2/10/2020

COSTAE AND
STERNUM

Susi Tri Isnoviasih, SST, M.Tr.Kes

BASIC ANATOMY

• The function of the bony thorax is to protect the heart and lungs and
allow respiration
• It is made up of sternum, 12 pairs of ribs and 12 thoracic vertebrae.
• The 1st 7 ribs attach directly to the sternum via the costal cartilage (true
ribs)
• The costal cartilage of the 8th to 10th ribs attach to the costal cartilage of
the 7th rib (false ribs)

1
 2/10/2020

BASIC ANATOMY

• The 11th and 12th ribs are only attached at their posterior end
to the vertebrae (floating ribs).
• The space between the ribs is called the intercostal spaces.
• The ribs slant down from the spine. The anterior end is 7-
12cm below the posterior end of the rib

2
 2/10/2020

BASIC VIEW

• PA (ANTERIOR RIBS)
• AP (POSTERIOR ABOVE OR BELOW DIAPHRAGM )
•

PA PROJECTION

• PATIENT POSITION
• Erect preferred or prone if necessary, with arms down to the side.
• OBJECT POSITION
• Align midsagittal plane to CR and to midline of grid or table/upright
Bucky.
• Rotate shoulders anteriorly to remove scapulae from lung felds.
• Allow no rotation of thorax or pelvis.

3
 2/10/2020

PA PROJECTION

• Minimum SID Minimum SID of 40 inches (102 cm)

• When performing a bilateral rib examination, 72-inch (183-cm)
can be used to minimize magnifcation of the anatomy.
• IR size—35 × 43 cm (14 × 17 inches), crosswise or 30 × 35 cm
(11 × 14 inches), lengthwise

PA PROJECTION

• CR perpendicular to IR, centered to T7 (7 to 8 inches [18 to 20

cm] below vertebra prominens as for PA chest)
• IR centered to level of CR (top of IR 1,5 inches [4 cm] above
shoulders)
• Respiration Suspend respiration on inspiration

4
 2/10/2020

PA PROJECTION

PA PROJECTION

• Anatomy Demonstrated: Ribs 1 through 10 visualized above the

diaphragm.
• Position: • No rotation of the thorax. • Collimation to area of interest
• Exposure: • Optimal contrast and density (brightness) to visualize ribs
through the lungs and heart.
• no motion, as bony markings

10

5
 2/10/2020

BASIC VIEW

• PA chest is always performed to:

• a) Show the ribs
• b) Show the lungs to demonstrate any pathology e.g. pnemo or haemothorax.
• If after looking at the PA chest you think there may be a pneumothorax then expiration
and lateral chest views are performed.

11

• Rib fractures can be extremely painful.

• Explain to the patient it is very important to breath in as deeply

as possible to get a good quality image.

12

6
 2/10/2020

AP PROJECTION

• PATIENT POSITION
• Erect position is preferred for above diaphragm if patient’s condition allows and
supine for below diaphragm
• OBJECT POSITION
• Align midsagittal plane to CR and to midline of grid or table/upright Bucky.
• Rotate shoulders anteriorly to remove scapulae from lung felds.
• raise chin to prevent it from superimposing upper ribs; look straight ahead.
• Allow no rotation of thorax or pelvis

13

AP PROJECTION

• Above diaphragm
• CR perpendicular to IR, centered to 3 or 4 inches (8 to 10 cm) below jugular notch
(level of T7)
• IR centered to level of CR (top of IR should be about 1,5 inches [4 cm] above shoulders)

• Below diaphragm
• CR perpendicular, centered to level of xiphoid process
• IR centered to CR (lower margin of IR at iliac crest)

14

7
 2/10/2020

• Minimum SID of 40 inches (102 cm).

• IR Size 35 x 43 cm
• Respiration : Suspend respiration on inspiration for ribs above
the diaphragm and on expiration for ribs below the diaphragm.

15

16

8
 2/10/2020

17

IMAGE CRITERIA

• Anatomy Demonstrated:
• above diaphragm: Ribs 1 through 10 should be visualized.
• Below diaphragm: Ribs 9 through 12 should be visualized.

• Position: Rotation of the thorax should not be evident.

• Collimation to area of interest
• Exposure: Optimal contrast and density (brightness) to visualize ribs through the lungs
and heart shadow or through the dense abdominal organs if below the diaphragm.
• No motion, as demonstrated by sharp bony markings

18

9
 2/10/2020

SPECIAL PROJECTION

19

STERNUM

• Midline of anterior thorax

• 15cm long
• 3 parts-manubrium, body and xiphoid process
• Supports clavicles and provides points of attachment for costal
cartilages of the first 7 rib pairs

20

10
 2/10/2020

21

• Can be very difficult to show satisfactorily

• To separate vertebrae and sternum can rotate the body or
angle the x-ray tube across the body
• Degree of angulation depends on depth of chest.
• Deep chest requires less angulation than a shallow
chest

22

11
 2/10/2020

18cm
chest

23

24cm
chest

24

12
 2/10/2020

• If you angle the body by raising the left side (RAO) the sternum will be projected over
the heart which can be used like a filter in giving an even exposure

25

PA OBLIQUE (RAO)

• Patient facing erect bucky, raising the left side away from the bucky,
15- 20 degrees depending on thickness of chest
• Centre the sternum to the centre of the bucky
• 24 x 30cm IR vertical
• Top of IR 4cm above jugular notch
• Central beam approx. 2.5cm to the raised side (left) of t-spine at
level of T7

26

13
 2/10/2020

27

IMAGE CRITERIA

• Show entire sternum

• Blurred lung markings, still sternum
• Away from spine
• Not too much obliquity
• Sternum projected over heart

28

14
 2/10/2020

LATERAL PROJECTION

• Patient, seated or standing, turned side on to erect bucky

• Hands clasped behind their back and shoulders pulled back
• Centre sternum to centre of bucky
• Top of IR 4cm above jugular notch
• Central ray entering lateral border of sternum
• 24 x 30cm IR vertical. Held inspiration

29

30

15
 2/10/2020

IMAGE CRITERIA

• Entire sternum seen

• Manubrium seen free of shoulders and ribs
• No rotation

31

32

16