Bony Thorax
1
STERNUM
1. PA OBLIQUE PROJECTION “RAO”
-
For trauma patients obtain LPO or AP Oblique
projection
SID: 30 inch (76 cm) to blur the posterior ribs
PP:
- prone/upright, RAO position to use the heart for contrast.
- Have support the body on the forearm and flexed knee.
- Elevation of the left shoulder and hip to prevent
superimposition of the vertebrae and sternum.
- The average rotation is about 15 to 20 degrees.
- Place the top of the IR about 1 ½ inches (3.8) above the
jugular notch.
CR: 丄 to IR
RP:
- elevated side of posterior thorax at the level of T7 and
approximately 1 inch (2.5 cm) lateral to the midsagittal
plane.
SS:
- Slightly oblique projection of sternum.
- entire sternum from jugular notch to tip of xiphoid
process.
- Sternum projected over the heart, but free of
superimposition from the thoracic spine.
- Blurred pulmonary markings, if a breathing technique was
used.
R:
Breathing motion. Instruct patient to take slow, shallow
breaths during the exposure. When a short exposure time is
to be used, instruct the patient to suspend breathing at the
end of expiration to minimize the visibility of the
pulmonary vasculature.
2. PA OBLIQUE PROJECTION “MOORE
METHOD” MODIFIED PRONE POSITION
-
The alternate positioning method for ambulatory
patient, which employs a modified prone position,
makes it possible to produce a high-quality
sternum image in a more comfortable manner.
SID: 30 inch (76 cm) to blur the posterior ribs
PP:
- Place the IR crosswise in the Bucky tray.
- The xray tube is positioned oved the patient's right side.
- bend at the waist, and place the sternum in the center of
the table.
- arms above the shoulders and the palms down on table.
- true prone position and that the midsternal area is at the
center of Rtable.
CR: 25 degree from the right side
Note: the angulation places the sternum over the lung to
maintain maximum contrast of the sternum.
Less angulation - large patients
More angulation - thin patients
RP:
- level of T7 and approximately 2 inchs (5cm) to the right of
spine.
SS:
- Slightly oblique projection of sternum.
- entire sternum from jugular notch to tip of xiphoid
process.
- Sternum projected free of superimposition from the
thoracic spine.
- Blurred pulmonary markings, if a breathing technique
was used.
- blurred posterior ribs
R:
Shallow breathing technique. Instruct patient to take
slow, shallow breaths during the exposure. A low mA
setting and an exposure time of 1 to 3 secs. If cannot
employ, instruct the patient to suspend breathing at the
end of expiration to minimize the visibility of the
pulmonary vasculature.
Bony Thorax
2
3. LATERAL POSITION “R OR L POSITION”
STERNOCLAVICULAR ARTICULATIONS
1. PA PROJECTION
-
SID: 72 inch (183cm) reduce magnification and distortion of
sternum.
PP:
- upright or recumbent. Dorsal decubitus may be used cause
of a patient's condition.
- sternum to the midline of the grid.
UPRIGHT:
- True lateral position so that the broad surface of the sternum
is perpendicular to the plane of IR.
- rotate shoulder posteriorly, lock hands behind, midsagittal
is vertical.
- Large breasts should be drawn to the sides and held in
position w/ a wide bandage so tha shadow do not obscure
the lower portion of the sternum.
RECUMBENT:
- Arms over head to prevent overlapping the sternum.
- rest head (arms or pillow)
- put support under the lower thoracic region to position the
long axis of the sternum horizontally.
CR: 丄 to IR
RP:
- Lateral border of midsternum
SS:
- lateral image of entire length of the sternum shows the
superimposed sternoclavicular joints and medial ends of the
clavicles.
- Manubrium free of superimposition by the soft tissue of
the shoulders.
- Sternum free of superimposition by ribs.
R: Suspend deep inspiration. This provides sharper
contrast b/w posterior surface of the sternum and the
adjacent structures.
This position may be difficult to perform on
trauma patients. Use upright if patient is able.
SID:
PP:
- prone/upright, midsagittal plane of body to midline of
grid.
- center IR at thelevel of the spinous process of 3rd thoracic
vertebra, lies posterior of the jugular notch.
- arms along the side, palms up. Shoulders lie on the same
transverse plane.
- For bilateral examination, rest the patients head on the
chin, midsagittal is vertical.
- For unilateral projection, ask patient to turn the head to
face the affected side and rest the cheek on the table.
- turning the head rotates the spine slightly away from the
side being examined and provides better visualization of
the lateral portion of the manubrium.
CR: 丄 to IR
RP: - T3
SS:
- PA projection shows the sternoclavicular joints and
medial portions of the clavicles.
- No rotation present on bilateral; slight rotation on
unilateral.
R: - suspend at the end of expiration
Bony Thorax
3
2. PA OBLIQUE PROJECTION “BODY ROTATION
METHOD” RAO OR LAO POSITION
- This position may be difficult to perform on trauma
3. PA OBLIQUE PROJECTION “CENTRAL RAY
ANGULATION METHOD” NON BUCKY
- joint is closer to IR, less distortion is obtained than body
patients. Use upright if patient is able.
rotation method. IR on tabletop to project minimal distortion.
SID:
PP:
- prone on IR under upper chest.
- to avoid grid cutoff, place grid on radiographic table with
its long axis running perpendicular to long axis of table.
- arms along the side, palms up.
- rest head on chin toward the side being radiographed.
CR: 15 degrees from the opposite side being examined
toward the midsagittal plane.
(if the CR enters the right side, the left sternoclavicular joint is
shown, and vice versa)
SID:
PP:
- prone/upright (seated)
- keeping the affected side adjacent to IR, oblique angle to
project the vertebrae well behind the sternoclavicular joint
closest to the IR.
- 10 to 15 degrees
- shoulders lie in the same transverse plane.
CR: 丄 to sternoclavicular joint closest to IR.
(if the CR enters the right side, the left sternoclavicular joint is
shown, and vice versa)
RP: - level of T2-3 about 3 inchs (7.6 cm) distal to the
vertebral prominens and 1 to 2 inches (2.5 to 5cm) lateral
from the midsaggital plane.
SS:
- open sternoclavicular joint space
- exposure sufficient to demonstrate sternoclavicular joint
through the superimposing rib and lung fields.
R: - suspend at the end of expiration
RP: - enters at the level of T2-3 about 3 inchs (7.6 cm)
distal to the vertebral prominens and 1 to 2 inches (2.5 to
5cm) lateral from the midsagittal plane.
SS:
- open sternoclavicular joint space
- exposure sufficient to demonstrate sternoclavicular joint
through the superimposing rib and lung fields.
R: - suspend at the end of expiration
RIBS
IR 14x17 inch (35 x 43 cm) should be used to identify
ribs involved and determine the extent of trauma or
the pathologic condition.
IR 11 x 14 inch (28 x 36 cm) may be used with smaller
patients.
Anterior ribs often examined w/ patient facing IR (PA
projection)
Posterior ribs patient facing xray tube (AP projection)
Axillary portion best shown in oblique projection.
Bony Thorax
4
UPPER ANTERIOR RIBS
1.
PA PROJECTION
POSTERIOR RIBS
1. AP PROJECTION
SID:
PP:
- upright or recumbent; diaphragm descends to its lowest
level in upright position. The upright position is valuable
for showing fluid levels in chest.
- IR 1 ½ iniches (3.8 cm) above the upper shoulders.
- rest patient’s hands against the hips w/ the palms turned
outward to rotate the scapula away from the rib cage.
- If prone, rest the head on chin and adjust midsagittal
plane to be vertical.
- To image affected ribs unilaterally, use 11 x 14 inch (28 x
35 cm) collimator size to improve image quality.
- for hypersthenic patients w/ wide rib cages, move them
laterally to include entire lateral surface of affected rib area
on radiograph.
CR: 丄 to IR/ 10 to 15 degrees caudad ( for showing 7th,
8th, and 9th ribs)
RP: - at the level of T7
SS:
- best shows the anterior ribs above the diaphragm.
Anterior rib closest to IR.
- 1st - 7th ribs from both sides, in their entirety and above
the diaphragm.
R: - suspend at full inspiration to depress the diaphragm
as much as possible.
SID:
PP:
- Facing xray tube, upright or recumbent.
- Upright position to image ribs above the diaphragm
- Supine position to image ribs below the diaphragm to
permit gravity to assist in moving the patient's diaphragm.
RIBS ABOVE DIAPHRAGM
- Place the IR lengthwise 1 ½ inches above the upper border
of relaxed shoulders.
- Hands palm up against the hips. Alternatively, extend
the arms to the vertical position with the hands under the
head.
- shoulders rotate forward to draw the scapulae away
from the rib cage.
RIBS BELOW DIAPHRAGM
- IR crosswise in Bucky tray, centered to a point halfway
b/w the xiphoid process and the lower rib margin. Lower
edge of IR near at the level of the iliac crests.
- place arms in a comfortable position.
CR:
丄 to IR
RP: - above the diaphragm and below diaphragm
SS:
- posterior rib above and below diaphragm. Posterior rib
closest to IR.
- for ribs above the diaphragm, 1st - 10th ribs from both sides
in their entirety
- for ribs below the diaphragm, 8th- 12th posterior ribs on
both sides in their entirety.
R: RIBS ABOVE DIAPHRAGM
Suspend at full inspiration to depress the diaphragm as
much as possible.
RIBS BELOW DIAPHRAGM
Suspend at full expiration to elevate the diaphragm.
Bony Thorax
5
AXILLARY
1. AP OBLIQUE PROJECTION “RPO OR LPO
POSITION”
2. PA OBLIQUE PROJECTION “RAO OR LAO
POSITION”
SID:
SID:
PP:
- Facing xray tube, upright or recumbent.
- Upright position to image ribs above the diaphragm
- Supine position to image ribs below the diaphragm to
permit gravity to assist in moving the patient's diaphragm.
- Place the affected side closest to the IR.
- body position 45 degree AP oblique projection using RPO
and LPO position.
- center the affected side on a longitudinal plane drawn
midway between the midsagittal plane and lateral surface
of the body.
- If recumbent. Support the elevated hip. Abduct the arm
of the affected side, and elevate it to carry the scapula away
from the rib cage.
- If upright, rest the patient's hand on the head. Abduct the
opposite limb with the hand on the hip.
- Center the IR with the top 11 2 inches (3.8 cm) above the
upper border of the relaxed shoulder to image ribs above
the diaphragm or to a point halfway between the xiphoid
process and the lower rib margin to image ribs below the
diaphragm.
CR:
R:
- Suspend at the end of full inspiration for ribs above the
diaphragm and at the end of deep expiration for ribs below
the diaphragm.
丄 to IR
RP: center of IR
SS:
- In these images, the axillary portion of the ribs closest to
the IR is projected free of superimposition with the
thoracic spine. The posterior ribs closest to the IR are also
well shown.
- First through tenth ribs visible above the diaphragm for
upper ribs
- Eighth through twelfth ribs visible below the diaphragm
for lower ribs
PP:
- upright or recumbent.
- Upright position to image ribs above the diaphragm
- Supine position to image ribs below the diaphragm to
permit gravity to assist in moving the patient's diaphragm.
- position the body 45 degree PA oblique projection using
RAO or LAO position. Place the affected side away from
the IR. Align the body so that the longitudinal plane drawn
midway between midline and lateral surface of the body
side up is centered to the midline of the grid.
- Center IR with the top 1 1/2 inches (3.8 cm) above the
upper border of the shoulder to image ribs above the
diaphragm or to a point halfway between the xiphoid
process and the lower rib margin to image ribs below the
diaphragm.
CR:
丄 to IR
RP: - center of IR
SS:
- In these images, the axillary portion of the ribs farthest
from the IR is projected free of bony superimposition
with the thoracic spine.
- The anterior ribs farthest from the IR are also shown.
R: RIBS ABOVE DIAPHRAGM
Suspend at the end of full inspiration
RIBS BELOW DIAPHRAGM
Suspend at the end of full expiration