Objectives: The radiographical process of projection of a complex human form onto a two-dimensional image plane gives rise to distortions and magnifications. It is important that any simulation used for educational purposes should correctly reproduce these. Images generated using a commercially available computer simulation widely used in radiography education (ProjectionVRTM) were tested for geometric accuracy of projection in all planes. Methods: An anthropomorphic skull phantom was imaged using standard projection radiography techniques and also scanned using axial CT acquisition. The data from the CT was then loaded into the simulator and the same projection radiography techniques simulated. Bony points were identified on both the real radiographs and the digitally reconstructed radiographs (DRRs). Measurements sensitive to rotation and magnification were chosen to check for rotation and distortion errors. Results: The real radiographs and the DRRs were compared by four experienced observers and measurements taken between the identified bony points on each of the images obtained. Analysis of the mean observations shows that the measurement from the DRR matches the real radiograph +1.5 mm/−1.5 mm. The Bland Altman bias was 0.55 (1.26 STD), with 95% limits of agreement 3.01 to −1.91. Conclusions: Agreement between the empirical measurements is within the reported error of cephalometric analysis in all three anatomical planes. The image appearances of both the real radiographs and DRRs compared favourably. Advances in knowledge: The commercial computer simulator under test (ProjectionVRTM) was able to faithfully recreate the image appearances of real radiography techniques, including magnification and distortion. Students using this simulation for training will obtain feedback likely to be useful when lessons are applied to real-world situations.
