Sternum and Ribs

What makes up the bony thorax

Sternum

12 Thoracic Vertebrae

12 pairs of ribs

What is the function of the bony thorax?

-Protects vital orgaans

-Attachment to shoulder, chest, and back muscles (protect)

-Support bones of the shoulder girdle

-Contract and expand during respiration

What is the sternum also known as

the breast bone

What type of bone is the sternum

Flat

How many inches long is the sternum

6''

Manubrium

The superior portion of the sternum

Contains the jugular notch (T2-T3)

Jugular notch

T2-T3

Widest portion

Articulate with the first rib

Also known as the sternal notch, suprasternal notch

What is another name for the body of the sternum?

Gladiolus or corpus

Body/gladiolus

Inferior to manubrium and strongest part of the sternum

Formed by 4 fused segments

4''

Sternal angle

Rests at T4-T5

Articulates with the second pair of ribs

Joint of body and manubrium form

Xiphoid process

lower, narrow portion of the sternum

rests at T9-T10

Does not ossify till 40, about 1''

Where does the xiphoid process lay?

At T9-T10

Superior portion of the liver

Inferior border of the heart

Which ribs are true ribs?

1-7

Which ribs are false ribs?

8-12

Which ribs are floating ribs?

11-12

What do the intercostal spaces do when breathing?

Increase and decrease

Rib anomalies

Cervical rib off of C7

or

Lumbar (rib coming off lumbar)

Which rib is the shortest and broadest?

1st rib

The length of the ribs increase till about

the 7th rib

Which rib is the longest

7th

What happens to the ribs after the 7th pair?

The rib length decreases

Width decreases with

each inferior rib

as we go down width decreases

Which ribs are the widest side to side

8th and 9th

What are the parts of a typical rib?

Head (facet + demifacet, vertebral end)

Flattened neck

Tubercle

Body (projects anteriorly, medially, then curves down inferiorly)

Angle

Costal groove

Sternal end (ventral/anterior surface)

What is the "angle" part of a rib?

Point at which the rib curves forward

What is the costal groove on a rib?

The inferior internal border

Blood vessels and nerves here

What does the 11th and 12th rib not have?

A head or neck

Costovertebral joints are in what ribs

1-12

Costovertebral joint

Articulation of the head of the rib with the body of the vertebra

Costovertebral joint classifications

Synovial

Gliding/plane

Diarthrodial (freely movable)

Costotransverse joints are in what ribs

1-10

Costotransverse joints

Articulation of TUBERCLE of the rib with the TRANSVERSE process of the vertebrae

Costotransverse joint classification

Synovial

Gliding/plane

Diarthrodial (freely movable)

Costochondral joints are in what ribs

1-10

Costochondral joints

Sternal extremity of the rib articulates with the costocartilage

Costochondral joint classification

Cartilaginous

Synchondroses

Synarthrodial (immovable)

Sternocostal joint (1st)

1ST ARTICULATION of the manubrium with the costocartilage

Sternocostal joint (1) classification

Cartilaginous

Synchondrosis

Synarthordial (immovable)

Sternocostal joint (2-7)

Articulation of the manubrium or body of the sternum with costocartilage

Sternocostal joint (2-7) classification

Synovial

Plane/gliding

Diarthrodial (freely movable)

Interchondral joint

Costocartilage articulation with adjacent rib cartilage

Interchondral (6-9) joint classification

Synovial

Plane/gliding

Diarthrodial (freely movable)

Interchondral (9-10) joint classification

Fibrous

Syndesmosis

Amphiarthrodial (slightly movable)

Sternoclavicular joint

Articulation between sternum and clavicle

Sternoclavicular joint classification

Synovial

Plane/gliding

Diarthrodial (freely movable)

Manubriosternal joint

Articulation of cartilage between manubrium and body of sternum

Manubriosternal joint classification

Cartilaginous

Symphsis

Amphiarthrodial (slightly movable)

Xiphisternal joint

Articulation of cartilage between body of sternum and xiphoid process (around T9-T10)

Xiphisternal joint classification

Cartilaginous

Synchondroses

Synarthrodial (immovable)

Most movement in ribs for

hyposthenic patients

Least movement in ribs for

hypersthenic patients (breathing is not going to change a lot)

What position of the patient is preferred for upper ribs?

Erect

Gravity pushing diaphragm down

What position of patient is preferred for lower ribs?

Recumbent/laying

Diaphragm comes up

When a chest + rib trauma comes in

Image in the position the patient arrives

Get decub for free abdomen in air/pneumothorax

PA Oblique Sternum RAO

Patient: prone or upright

RAO 15-20 degrees

Top of IR 1.5'' above jugular notch

Shield gonads

Shallow breathing/orthostatic breathing

CR for RAO sternum

T7 and 1'' left of MSP

How much do you rotate the patient for RAO sternum?

15-20 degrees

Sternum RAO critique

-Entire sternum from jugular notch to xiphoid tip

-good visibility

-minimally rotaated sternum and thorax

-sternum projected free of superimposition by vertebral column

-minimally oblique vertebrae to prevent rotation of sternum

-lateral portion of manubrium and SC joints free of superimposition

-sternum projected over the heart

If sternum is over the vertebral body

Body is not rotated enough

If sternum is more than 1'' from vertebral body

Overotated

Sternum Lateral (R/L)

Upright or recumbent

Erect: patient ARCHES BACK

Supine: use sponge to support and elevate middle of thoracic area

Top of IR 1.5'' above jugular notch

Shield gonads

SUSPEND ON INSPIRATION

If supine for lateral sternum

Use sponge to support and elevate middle of thoracic area

Lateral sternum can also be done

Dorsal decubitus or lateral recumbent if unable to stand

Lateral sternum critique

-Manubrium free of superimposition of shoulders

-Sternum free of superimposition by the ribs

-Lower portion not superimposed by breasts of female patient (another more pentrated image may be done if breasts cannot be moved out of the way)

PA Sternoclavicular joints

Prone or upright

MSP centered to IR

Shield gonads

Suspend on EXPIRATION

Where is the central ray for PA sternoclavicular joints?

T3

or T2/T3, 3'' distal to vertebral prominens

What is the breathing instructions for PA SC joints/PA Oblique SC joints?

Suspend on EXPIRATION

PA SC Joint Critique

Both SC joints

Collimate 2'' beyond sides of vertebral column

PA Oblique SC Joint (RAO/LAO)

Prone or upright

10-15 degree rotation

Shield gonads

Suspend on EXPIRATION

Central Ray for PA oblique SC Joints (RAO/LAO)

T2/T3 and 1-2'' from MSP on elevated side

PA Oblique SC joint critique

demonstrates DOWNSIDE SC JOINT

SC Joint RAO

Right SC joint

SC joint LAO

Left SC joint

Rib procedure

14x17 crosswise or lengthwise

Recumbent (below diaphragm)

Erect/standing (above diaphragm)

Trauma: how they arrive in ER

Anterior pain (posterior projection)

Posterior pain (anterior projection)

Mark site of injury

Chest if needed for air fluid levels

Ribs above diaphragm

Erect

Inspiration

Ribs below diaphragm

Recumbent

Expiration

(increase kVp?)

PA Ribs

Shows ANTERIOR RIBS

Recumbent or erect

MSP in middle of IR

Hands on hips with shoulders rolled forward

Top of IR 1.5'' above shoulder

Shield gonads

Suspend on INSPIRATION

What is the central ray for PA ribs?

T7 and MSP

With hypersthenic patients for PA ribs

to demonstrate more of ribs 7, 8 and 9 below diaphragm,

move tube 5'' above center and angle caudal until CR enters at midline of IR

PA Ribs Above Diaphragm Evaluation

-Upper 1-9 ribs above diaphragm

-1-7 anterior ribs visible

-Sternoclavicular joints symmetrical

-Ribs clearly seen without overexposure through the heart and lungs

AP Ribs

SHOWS POSTERIOR RIBS

Upright or recumbent

MSP in center of IR, shoulders rolled forward

Top of IR 1.5'' above shoulders for ABOVE

1'' of bottom of IR below iliac crest for BELOW

Shield gonads

CR for AP ribs above diaphragm

T7 and MSP

ON INSPIRATION

CR for AP Ribs below diaphragm

Midway between xiphoid process and lower rib margin and MSP

ON EXPIRATION

AP Ribs Above Diaphragm Eval

-Upper 8 to 10 posterior ribs (1-10)

-Sternoclavicular joints symmetrical

-Ribs clearly seen without overexposure through the heart or lungs

AP Ribs Below Diaphragm Eval

-Lower posterior 4-6 ribs and top of iliac crests (so like 8-12 or 9-12)

-Bilateral exams, ribs symmetricaal, spine not rotaated

-Ribs clearly seen without overexposure of abdomen

Axillary Ribs AP Obliques (RPO/LPO)

Upright or recumbent

Patient in 45 degree RPO or LPO

Raise arm of side against detector above head and rest on table

Place arm of elevated side behind thorax

Top of IR 1.5'' above shoulders

shield gonads

Central ray for AP oblique of ribs (RPO/LPO)

Upper:

T7 and midway between spine and lateral border

-INSPIRATION

Below:

CR midway between xiphoid process and lower rib margin and midway between spine and lateraal border (more on down side)

-EXPIRATION

Why is it necessary to obtain both obliques of affected side?

TO see entire length of ribs, from their sternal to vertebral ends

LPO (AP oblique ribs), you see:

L posterior ribs

RPO (AP OBlique ribs), you see:

R posterior ribs

AP Oblique eval

Above diaphragm:

-upper 10 ribs

-distaance between the lateral maargin of the ribs aand spine of the side of interest should be approximately twice as greast as that of the unaffected side

-axillary ribs not superimpossed

-ribs clearly seen without overexposure through heaart and lungs

Below diaphragm:

-lower 4-6 ribs and top of crest

-distance between the lateral margin of the ribs and spine of the side of interest should be approximately twice as great as that of unaffected side

-axillary ribs not superimposed

-ribs clearly seen without overexposure through heart and lungs

Axillary Ribs PA Obliques (LAO/RAO)

Upright or recumbent

Patient in 45 degree RAO or LAO (affected side away from IR)

Rest arm of side down by body and raise arm away on elevated side

Top of IR 1.5'' above shoulder

Shield gonads

CR for PA OBliques (LAO/RAO)

Upper:

T7 and midway between spine and lateral border (more on elevated side)

-INSPIRATION

Below:

CR midway between xiphoid process and lower rib margin and midway between spine and lateraal border (more on elevated side)

-EXPIRATION

PA Rib RAO shows

L anterior ribs

PA Rib LAO shows

R anterior ribs

PA Oblique Rib Eval

2x the distance between vertebral column aand lateral border of ribs on the affected side

Axillary portion of the ribs free of superimposition

1-10 ribs for above diaphragm

8-12 for below

Flail Chest

Fracture of adjacent ribs in two or more places caused by blunt trauma

Pectus carinatum

Congentinal defect

Anterior protrusion of lower sternum and xiphoid process