RAD 113: Bony Thorax

A

clavicle

B

SC joints

C

manubrium

D

sternal angle

E

body of sternum

F

xiphoid process

A

right clavicle

B

sternum

C

left clavicle

D

right SC joint

E

left SC joint

costochondral unions

synarthrodial (immovable)

1st sternocostal joint

cartilaginous

synarthrodial

2nd-7th sternocostal joints

synovial

diathrodial

plane/gliding

sternoclavicular joints (SC)

synovial

diathrodial

plane/gliding

6th-9th interchondral joints

synovial

diathrodial

plane/gliding

1st-10th costotransverse joint

synovial

diathrodial

plane/gliding

1st-12th costovertebral joints

synovial

diathrodial

plane/gliding

1st rib fracture

• may cause injury to lungs/ cardiovascular structure

• associated with underlying arteries or veins

lower rib fractures

may be associated with injury to the spleen, liver, or kidney

flail chest

• A portion of the ribs are broken when the patient breathes, the lungs collapses & then reexpands

• Multiple adjacent ribs are broken in multiple places

sternal fracture

• caused by blunt trauma

• associated with underlying cardiac injury

pectus carinatum

• congenital deformity where the sternum & xiphoid process protrudes outward

• AKA: pigeon breast

pectus excavatum

• congenital deformity where the sternum caves inward

• AKA: funnel chest

metastases

• malignant rib lesions

• osteolytic, osteoblastic, combo

• nuclear medicine

osteolytic metastases

destructive lesions

osteoblastic metastases

increased bony density

combo metastases

• osteolytic & osteoblastic

• moth-eaten appearance of bone resulting from a mix of destructive & blastic lesions

osteomyelitis

• localized or generalized infection of bone & marrow

• bacterial infection is most common cause

RAO sternum

• patient erect facing Bucky & rotate 15-20° RAO

• IR = 1.5” above jugular notch

• perpendicular to mid sternum & to left of MSP

• orthostatic breathing

• evaluation

  • sternum superimposed on heart shadow

  • left clavicle & jugular notch

  • entire sternum

RAO sternum rotation

large chest = 15°

thinner chest = 20 °

why is the sternum done RAO?

to shift the sternum to the left of the vertebral column & superimpose it with the heart shadow

What if the patient cannot be prone? (RAO sternum)

LPO sternum

RAO sternum trauma modification

angle the tube 15-20° across the right side of the patient (right to left)

Lateral Sternum

• true lateral, hands clasped behind back with shoulders relaxed, MCP to IR

• perpendicular to mid sternum & anterior to MCP

• 60-72” SID

• full inspiration

• evaluation:

  • entire sternum

Lateral Sternum Trauma Modification

horizontal beam lateral done instead

PA SC joints

• patient prone with head & chin straight resting on sponge

• CR perpendicular to MSP & T2-T3

• expiration

• evaluation

  • bilateral left & right SC joints equal distance from the spine

  • lateral manibrium

  • medial clavicles

SC joint obliques (RAO/LAO)

• prone/erect with 10-15° rotation toward the side of interest, SC joints centered to IR

• side closest to IR is shown best

• CR perpendicular to T2-T3 & 1-2” lateral of MSP

• expiration

• evaluation

  • SC joint open & shifted away from

what if the patient cannot lie prone? (SC joint obliques)

can be done as an RPO/LPO with 10-15° rotation away from the side of interest with the CR 1-2” lateral to MSP

Why are PA CXRs included in a rib series?

To rule out pneumothorax & hemothorax or other internal injuries 

Upper Ribs bilateral

• CR

  • perpendicular to T7 & MSP

• 14×17 portrait

• 40 SID

• IR = 1.5 above shoulders

• full inspiration

• evaluation

  • posterior ribs 1-9 above the diaphragm

How to tell if the patient is rotated on the lateral sternum?

ribs projected anteriorly past sternum

posterior pain ribs

AP projection

anterior pain ribs

PA projection

Lower Ribs bilateral

• CR

  • side of interest centered on IR midway between MSP & lateral margin of thorax 

• expiration

• evaluation

  • ribs 10-12

Axillary Ribs (Obliques)

• patient erect rotated 45°

• Above diaphragm

  • CR to T7

  • full inspiration

• Below diaphragm

  • CR to midway between the xiphoid process & the lower rib margin

  • expiration

Axillary Ribs posterior pain

• LPO

  • left posterior rib pain

• RPO

  • right posterior rib pain

Upper Ribs unilateral

• CR

  • perpendicular to T7 & midway between MSP & outer margin of thorax

• 14×17 landscape

• 72 SID

• full inspiration

• 14×17

• evaluation

  • posterior ribs 1-9 above the diaphragm

Lower Ribs Unilateral

• CR

  • side of interest centered on IR midway between MSP & lateral margin of thorax

• expiration

• evaluation

  • ribs 10-12 below diaphragm

Axillary Ribs, anterior ribs

• LAO

  • right anterior rib pain

• RAO

  • left anterior rib pain

what 4 views would you do for a patient complaining of right, anterior rib pain?

• PA upper ribs

• PA lower ribs

• LAO

• CXR

what 4 views would you do for a patient complaining of left posterior rib pain

• AP upper ribs

• AP lower ribs

• LPO

• CXR

what 4 views would you do for a patient complaining of right posterior rib pain

• AP upper ribs

• AP lower ribs

• RPO

• CXR

what 4 views would you do for a patient complaining of left anterior rib pain

• PA upper ribs

• PA lower ribs

• RAO

• CXR

posterior obliques axillary ribs

• RPO/LPO

• elongates ribs closest to IR

anterior obliques axillary ribs

• RAO/LAO

• elongates side furthest away from IR

where does the 2nd costocartilage attach?

sternal angle

Why are 1-7 true ribs?

they attach to the sternum

Why are 8-10 ribs false ribs

they do not attach to the sternum

floating ribs (11-12)

no anterior attachment

Where is the widest part of the thorax

between 8th & 9th rib

posterior end of rib sits ___ to the anterior portion

3-5” superior

posterior obliques (RPO/LPO)

elongates closest to the IR

anterior obliques (RAO/LAO)

elongates side furthest away from IR