Sternum and Ribs (2/12/2024 & 2/14/2024)

What is Aurora’s sternum routine?

lateral and RAO

What is a common indication for a sternum x-ray?

MVA

What size IR is used for sternum images?

10 × 12 LW (with grid)

What is SID for the RAO sternum image?

40”

Explain patient and CR position for the RAO sternum image

patient

• prone or erect

• rotate 15-20^o into RAO

  • places sternum to the left of the spine

  • large chest needs less rotation

  • small chest needs more rotation

CR

• perpendicular to mid sternum

• 1 inch to the left of the spine

• top of IR 1½ inches above jugular notch

Why do we do an RAO instead of an LAO?

to put the sternum into the uniform density heart shadow

What are breathing instructions for an RAO sternum image? Why?

shallow breathing to utilize long exposure time (3 sec) to blur lung markings and ribs

(on expiration if pt is unable to do shallow breathing)

What needs to be demonstrated on an RAO sternum image (film eval)?

• slight oblique of sternum utilizing heart shadow

• any fractures or inflammatory processes

• collimation side to side

• marker (L because the right side of the body is not even on the image)

• oriented as if person is standing in front of you

What is done in place of an RAO sternum for a trauma patient?

• trauma oblique sternum

• patient supine

• 15-20^o tube angle from right to left or LPO position

  • angled tube: center at sternum

  • LPO: centered 1 inch lateral to sternum on left side (side down)

• mark left side

Explain patient and CR positioning for a lateral sternum

patient

• erect

  • lateral position (R or L)

  • seated or standing

  • shoulders and arms drawn backward

• recumbent

  • lateral position (R or L)

  • true lateral

  • arms raised above head, shoulders back

CR

• perpendicular to mid-sternum entering lateral border

• top of IR 1½ inches above jugular notch

Explain the trauma lateral sternum

• recumbent

• dorsal decubitus position

• raise arms above head (if possible)

What are breathing instructions for a lateral sternum? Why?

full inspiration; to get high contrast between posterior surface of sternum and lungs

What is SID for lateral sternum images?

Erect: 72”

Recumbent: 40”

Trauma shoot-thru: 40-72”

What needs to be demonstrated on a lateral sternum image (film eval)?

• lateral view of entire sternum

• any fractures or inflammatory processes

• marker placed anterior for side down (usually L)

• collimation anterior to posterior

• oriented how you took the image

What pathology is shown?

pectus excavatum

What pathology is shown?

pectus carinatum

What SID is used for ribs?

40”

What is the Aurora routine for ribs?

AP/PA upper

AP/PA lower

AP/PA oblique upper

AP/PA oblique lower

What size IR is used for ribs?

upper: 14×17 LW

lower: 11×14 LW

What are some complications that can occur with rib fractures?

• pneumothorax

• hemothorax

• atelectasis

What determines whether ribs are done AP or PA?

location of the pain (area in pain is closer to IR)

Explain patient and CR position for AP/PA upper ribs

patient

• AP or PA

  • no rotation

• erect (preferred)

  • to lower the diaphragm

  • supine if patient cannot stand

• raise chin

• abduct affected arm

CR

• perpendicular 3-4 inches below jugular notch

• midway between lateral rib cage and mid-sagittal plane

• top of IR 1½ inches above shoulder

What are respiration instructions for AP/PA upper ribs?

full inspiration (to lower diaphragm)

What needs to be demonstrated on an AP/PA upper rib image?

• ribs 1-10

• any fractures, neoplastic processes, pathologies

• posterior ribs in detail

• marker on affected side

• collimate (make sure to include past jugular notch/spine)

• oriented as if person is standing in front of you

Explain patient and CR position for AP/PA lower ribs

patient

• AP or PA

• supine recumbent preferred

  • raises diaphragm

• abduct arm

CR

• perpendicular to level of T12

  • midway between xiphoid and lower rib cage

• midway between lateral rib cage and MSP

• bottom of IR at crest

What are respiration instructions for AP/PA lower ribs?

on expiration

What needs to be demonstrated on an AP/PA lower rib image?

• ribs 8-12

• any fractures, neoplastic processes, other pathologies

• posterior ribs in detail

• marker on affected side

• collimate (make sure to include all the way through the spine)

• oriented as if person is standing in front of you

Explain patient and CR position for oblique upper ribs

patient

• AP or PA

• erect preferred

  • to lower diaphragm

  • otherwise supine recumbent

• rotate 45^o oblique

  • AP - affected side down

  • PA - affected side up

• abduct affected arm

CR

• perpendicular 3-4 inches below jugular notch

• top of IR 1½ inches above shoulder

• midway between spine and lateral border of rib cage

What are respiration instructions for oblique upper ribs?

on full inspiration

What needs to be demonstrated on an oblique upper rib image?

• axillary portion of ribs (not seen on AP or PA)

• any fractures, neoplastic processes

• ribs 1-10

• marker placed on affected side

• oriented as if person is standing in front of you

• collimate (make sure to include spine)

Explain patient and CR position for oblique lower ribs

patient

• AP or PA

• supine recumbent preferred

  • to raise diaphragm

• 45^o oblique

  • AP - affected side down

  • PA - affected side up

• abduct arm

CR

• perpendicular to level of T12

  • midway between xiphoid and lower rib cage

• midway between spine and lateral border of rib cage

• bottom of IR slightly below rib cage or at top of crest

What are respiration instructions for oblique lower ribs?

on expiration

What needs to be demonstrated on an oblique lower rib image?

• axillary ribs (not seen on AP or PA)

• any fractures or neoplastic processes

• ribs 8-12

• marker on affected side

• oriented as if person is standing in front of you

• collimate (make sure to include spine)

What are techniques for an RAO sternum image?

80 kVp @ 16-20 mAs (breathing technique)

What are techniques for a lateral sternum image?

85-90 kVp @ 25-32 mAs

What are techniques for upper ribs?

AP: 70 kVp @ 16-20 mAs

Obl: 70 kVp @ 25-32 mAs

What are techniques for lower ribs?

AP: 80 kVp @ 20-25 mAs

Obl: 80 kVp @ 25-32 mAs