Ribs & Sternum- positioning notes/ demo

Sternum views

RAO (pa oblique) & lateral

sternum RAO technique

81 kVp, 3.2 mAs, center cell

sternum RAO overview

• 40” SID

• 11×14 LW collimation

• centering

  • place top of IR 1 ½” above jugular notch (3 fingers)

  • enter around T7 & 1” (2 fingers) lateral to MSP (left)

• Breathing= suspended EXPIRATION

• 15-20 degree oblique

Sternum RAO evaluation criteria

1. sternum projected over the heart, but free from superimposition from the thoracic spine

• sternum JUST FREE of superimposition from vertebral column

• minimally oblique vertebrae to prevent excessive rotation of sternum

• lateral portion of manubrium & SC joints free of superimposition by vertebrae

4. blurred pulmonary markings

5. 15-20 degree oblique to prevent superimposition of vertebrae & sternum (sternum is centered to midline of IR)

STERNUM RAO- MERRILLS SUGGESTIONS

• 30” SID (to blur out posterior ribs & lung markings)

• 10 ×12 LW collimation

• slow, shallow breathing (to blur ribs & lung markings)

• for recumbent patients unable to lie prone…

  • obtain this projection w/ the patient LPO (resulting in AP oblique projection)

rotation in sternum RAO

• Over rotated= SC joints are touching, SC joint over manubrium

• Under rotated= sternum still on spine, SC joint NOT off spine

sternum lateral technique & unilateral upper ribs

81 kVp, 10 mAs, center cell

sternum- lateral- overview

• 72” SID

• 10×12 LW collimation

• centering

  • 1 ½” light above jugular notch (3 fingers)

  • CR should enter in lateral border of sternum

• Breathing= SUSPENDED INSPIRATION (to really puff chest out)

Sternum Lateral- evaluation criteria

1. Sternum entirely

2. Manubrium free of superimposition by soft tissue of the shoulders

3. Sternum is free of superimposition by the ribs

4. Lower portion of the sternum unobscured by the breast of a female

   • If have big boobies, have pt move them back & away

Ribs note for BB

should be placed on pt’s skin to mark pain (if specific to one area)

RIBS views for right anterior pain

PA & LAO

RIBS views for left anterior pain

PA & RAO

ribs views for right posterior pain

AP & RPO

ribs views for left posterior pain

AP & LPO

Ribs- PA

side of interest AWAY from IR

(anterior rib pain)

Ribs- AP

side of interest TOWARDS the IR 

(posterior rib pain)

Ribs views for pain on both sides & anterior

AP, LAO, RAO

Ribs views for pain on both sides with posterior pain

PA, LPO, RPO

ribs w/ chest views to do

PA chest

unilateral ribs (AP/PA) technique- upper

81 kVp, 10 mAs, center cell (grid)

unilateral ribs/ BILATERAL ribs (AP/PA) technique- lower

85 kVp, 12.5 mAs, center cell (grid)

unilateral ribs (AP/PA & obliques) overview:

• SID

  • 72” for erect

  • 40” for supine

• Collimation

  • 14X17 LW (must collimate side to side)

  • If lower overlap image is required, collimate to maximum of 14x11 CW

• Centering

  • Place IR 1.5” (3 fingers) above the shoulders

  • CR around T7

    • & halfway between MSP & lateral aspect of ribs

• Breathing= upper= inspiration; lower= expiration

Unilateral ribs (AP/PA) if image does NOT include the lower ribs, then….

• take another exposure, ensuring overlap. Bottom of light field should be at top of crest with proper collimation

NOTE for PA lower images for unilateral ribs

10-15 DEGREE CAUDAL ANGLE MUST BE USED TO PLACE LOWER RIBS BELOW DIAPHRAGM!!!

Unilateral ribs (AP/PA) evaluation criteria

• 1st-9th ribs above diaphragm for upper

• 8th-12th ribs below diaphragm for lower

• Ribs visible through lungs/ abdomen

• No rotation

• Erect indicator

ANTERIOR RIB PAIN=

PA (shows ANTERIOR ribs good)

POSTERIOR RIB PAIN=

AP (shows POSTERIOR ribs good)

Unilateral Ribs- AP or PA oblique (RPO/LPO or RAO/LAO)

technique- upper

81 kVp, 16 mAs, center cell

Unilateral Ribs- AP or PA oblique (RPO/LPO or RAO/LAO)

technique- LOWER

85 kVp, 16 mAs, center cell

Unilateral Ribs- AP or PA oblique (RPO/LPO or RAO/LAO)

Overview:

• SID

  • 72” for erect

  • 40” for supine

• Collimation

  • 14X17 LW (must collimate side to side)

  • If lower overlap image is required, collimate to maximum of 14x11 CW

• Centering

  • Place IR 1.5” (3 fingers) above the shoulders

  • CR around T7

    • CR should be halfway between MSP & lateral aspect of rings

• Breathing

  • Upper- inspiration; lower- expiration

Unilateral Ribs- AP or PA oblique (RPO/LPO or RAO/LAO)

pt position

• Patient position

  • If initial image was PA (anterior rib pain)

    • Rotate body 45 degrees w/ affected side AWAY from IR (RAO/LAO)

    • Shoulders relaxed. Arm of affected side up & out of way to carry the scapula away from ribs

  • If initial image was AP (posterior rib pain)

    • Rotated body 45 degrees with affected side TOWARDS the IR (RPO/LPO)

    • Shoulders relaxed. Arm of affected side up & out of way to carry the scapula away from ribs

Unilateral Ribs- AP or PA oblique (RPO/LPO or RAO/LAO)

if image does NOT include lower ribs….

• take another ensuring overlap. Bottom of light field should be at top of crest w/ proper collimation

Unilateral Ribs- AP or PA oblique (RPO/LPO or RAO/LAO)

evaluation criteria

• Erect indicator

• Axillary portion of the ribs free from superimposition w/ thoracic spine

• 1st-9th ribs above diaphragm for upper

• 8th-12th ribs below diaphragm for lower

• Ribs visible through lungs/ abdomen

• Axillary portion of side of interest well visualized w/ adequate obliquity & elongation

Unilateral Ribs- AP or PA oblique (RPO/LPO or RAO/LAO)

rotation

• Proper rotation

  • Demonstrated when the sternal end is just slightly off spine and inferior sternal body is positioned midway between the spine & the lateral rib surface

• Under rotated

  • Sternal end of opposite clavicle overlies the spine, inferior sternal body runs along the spine

• Over rotated

  • Sternal end of opposite clavicle overlies the manubrium of the sternum and the inferior sternal body shifts towards the lateral rib surface

ON RPO/LPO unilateral ribs, the axillary portion of the ribs __ to the IR is projected free & ____ ribs are well shown

CLOSEST; POSTERIOR

On RAO/LAO unilateral ribs, the axillary portion of the ribs ____ from the IR is projected free & ____ ribs are well shown

FARTHEST; ANTERIOR

Bilateral Ribs- AP/PA

technique- UPPER

81 kVp, 10 mAs, 2 outer cells

Bilateral Ribs- AP/PA

technique- LOWER

85 kVp, 12.5 mAs, center cell

Bilateral Ribs- AP/PA

Overview

• SID

  • 72” for erect

  • 40” for supine

• Collimation

  • 17x14 CW for initial image (collimate side to side)

  • If lower overlap image is required, collimate to maximum of 17x11 CW

• Patient position

  • Arms at sides, slightly abducted so not in anatomy

  • Shoulders are relaxed

• Centering

  • Place IR 1.5” (3 fingers) above the shoulders

  • CR around T7

    • & halfway between MSP & lateral aspect of ribs

• Breathing

  • Upper= inspiration; Lower= expiration

Bilateral Ribs- AP/PA

for PA lower images=

 10-15 DEGREE CAUDAL ANGLE MUST BE USED TO PLACE LOWER RIBS BELOW DIAPHRAGM!!!

Bilateral Ribs- AP/PA

evaluation criteria

• 1st- 9th ribs above diaphragm for upper

• 8th-12th ribs below diaphragm for lower

• Ribs visible through lungs/abdomen

• No rotation