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Chapter 10: Bony Thorax—Sternum and Ribs
Lampignano: Bontrager’s Textbook of Radiographic Positioning and Related
Anatomy, 9th Edition

MULTIPLE CHOICE

1. The jugular notch corresponds to the level of:

a. T2-3.
b. T1.
c. T4-5.
d. C7.
ANS: A REF: 356

2. The xiphoid process corresponds to the vertebral level of:

a. T7.
b. T9-10.
c. T4-5.
d. L1-2.
ANS: B REF: 356

3. What is the joint space between the manubrium and body of sternum called?
a. Sternal notch
b. Costocartilage
c. Sternal angle
d. SC joint
ANS: C REF: 356

4. At approximately what age does the xiphoid process become totally ossified?
a. 12 years old
b. 21 years old
c. 40 years old
d. The xiphoid process never becomes ossified.
ANS: C REF: 356

5. Which of the following structures connects the anterior aspect of the ribs to the sternum?
a. Costocartilage
b. Sternal tendons
c. Costovertebral joints
d. Costotransverse joints
ANS: A REF: 357

6. The sternal angle is a palpable landmark at the level of:

a. T4-5.
b. T2-3.
c. T7.
d. T9-10.
 ANS: A REF: 356

7. Which costocartilage attaches to the sternum at the level of the sternal angle?
a. First
b. Second
c. Third
d. Fourth and fifth
ANS: B REF: 357

8. In the erect adult bony thorax, the posterior or vertebral end of a typical rib is ____ higher
than or more superior to the anterior portion.
a. 1 to 2 inches (2.5 to 5 cm)
b. 3 to 5 inches (8 to 13 cm)
c. 6 to 8 inches (15 to 20 cm)
d. 10 to 12 inches (25 to 30 cm)
ANS: B REF: 357

9. Which of the following ribs is considered to be a false rib?

a. Seventh
b. First
c. Ninth
d. None of the above
ANS: C REF: 357

10. Which of the following statements is true about floating ribs?

a. They do not possess a head.
b. They do not possess a costovertebral joint.
c. They do not possess costocartilage.
d. They are ribs 8 through 12.
ANS: C REF: 357

11. The widest aspect of the bony thorax generally occurs at the level of:
a. the eleventh and twelfth ribs.
b. T7.
c. the sternoclavicular joints.
d. the eighth or ninth ribs.
ANS: D REF: 358

12. What is the joint classification and type of movement for the sternoclavicular joints?
a. Cartilaginous with diarthrodial (ginglymus) movement
b. Synovial with diarthrodial (gliding) movement
c. Synovial with amphiarthrodial, limited movement
d. Cartilaginous with synarthrodial or no movement
ANS: B REF: 358

13. What is the joint classification and type of movement for the costotransverse joint?
 a. Cartilaginous with diarthrodial (ginglymus) movement
b. Synovial with diarthrodial (plane) movement
c. Synovial with amphiarthrodial, limited movement
d. Cartilaginous with synarthrodial or no movement
ANS: B REF: 358

14. What is the name of the part labeled i in this figure?

a. Facet for the first rib

b. Body
c. Sternoclavicular joint
d. Sternal angle
ANS: C REF: 356

15. What is the name of the part labeled ii?

a. Xiphoid process
b. Body
c. Sternoclavicular joint
d. Sternal angle
 ANS: D REF: 356

16. The structure labeled iii is the costocartilage:

a. of the tenth rib.

b. portion of the first false rib.
c. of the last true rib.
d. of the sixth rib.
ANS: D REF: 357

17. What is the name of the part labeled iv?

a. Facet for the sternum attachment

b. Head of the sternum
c. Facet for the second rib attachment
d. Costocartilage for the first rib attachment
ANS: D REF: 357

18. What is the name of the structure labeled v?

 a. Head
b. Body
c. Manubrium
d. Xiphoid process
ANS: C REF: 356

19. Which aspect of the rib articulates with the thoracic vertebral body?
a. Neck
b. Tubercles
c. Head
d. Facets
ANS: C REF: 357

20. Which ribs are considered to be true ribs?

a. First only
b. First through seventh ribs
c. First through ninth ribs
d. Eleventh and twelfth ribs
ANS: B REF: 357

21. Which of the following techniques is most effective in preventing lung markings from
obscuring the sternum on an oblique projection?
a. Use a high kV.
b. Oblique as much as needed to not superimpose the sternum over the hilum region.
c. Decrease the source image receptor distance (SID) to magnify the sternum.
d. Use an orthostatic (breathing) technique.
ANS: D REF: 359

22. Why is the RAO sternum preferred to the LAO position?

a. The RAO produces less magnification of the sternum.
b. The RAO projects the sternum over the shadow of the heart.
c. The RAO reduces dose to the thyroid gland.
d. The RAO projects the sternum away from the hilum and heart.
 ANS: B REF: 359 | 364

23. Which of the following statements is true about radiography of ribs located above the
diaphragm?
a. Suspend breathing upon inspiration.
b. Perform the study with the patient recumbent.
c. Use an analog kV range of 85 to 95.
d. Always include an anteroposterior (AP) projection as part of the routine.
ANS: A REF: 360

24. Which of the following positions will best demonstrate the axillary portion of the left ribs?
a. AP
b. Posteroanterior (PA)
c. Left posterior oblique (LPO)
d. LAO
ANS: C REF: 361

25. Which of the following positions will best demonstrate the axillary portion of the right ribs?
a. AP
b. PA
c. LAO
d. RAO
ANS: C REF: 361

26. Which of the following conditions may occur with trauma to the ribs?
a. Airway obstruction of the trachea
b. Pneumonia
c. Hemothorax
d. Pulmonary embolus
ANS: C REF: 361

27. What is the recommended degree of obliquity for an RAO projection of the sternum for an
asthenic (thin-chested) type of patient?
a. 20°
b. 15°
c. 30°
d. 10°
ANS: A REF: 364

28. Which position can replace the RAO of the sternum if the patient cannot lie prone?
a. LAO
b. Left lateral decubitus
c. LPO
d. RPO
ANS: C REF: 364
29. What is the recommended SID for the erect lateral sternum position?
a. 40 inches (102 cm)
b. 44 inches (113 cm)
c. 46 inches (117 cm)
d. 60 to 72 inches (152 to 183 cm)
ANS: D REF: 365

30. Where is the CR centered for a PA projection of the sternoclavicular joints?

a. At the level of the vertebra prominens (T1)
b. At the level of the sternal angle (T4-5)
c. Three inches (7 cm) distal to the vertebra prominens (T2-3)
d. At the level of the thyroid cartilage (T9)
ANS: C REF: 366

31. How much rotation and which oblique position are required to best demonstrate the left
sternoclavicular joints?
a. 10° to 15° LAO
b. 35° to 45° LAO
c. 10° to 15° RAO
d. 5° to 10° RAO
ANS: A REF: 367

32. Which two projections must be taken for an injury to the right anterior, upper ribs?
a. PA and LAO
b. PA and RAO
c. AP and RAO
d. AP and LPO
ANS: A REF: 361

33. Which two projections must be taken for an injury to the left posterior, lower ribs?
a. AP and LPO
b. AP and RAO
c. PA and LPO
d. PA and RAO
ANS: A REF: 361

34. What kV range (digital systems) is recommended for an AP projection of the ribs found below
the diaphragm?
a. 75 to 85 kV
b. 60 to 65 kV
c. 65 to 75 kV
d. 70 to 80 kV
ANS: A REF: 360

35. Which disease or condition may be associated with postoperative complications of open heart
surgery?
a. Spondylitis
 b. Osteoblastic metastases
c. Osteomyelitis
d. Flail chest
ANS: C REF: 363

36. Fracture of adjacent ribs in two or more places with associated pulmonary injury is known as
a(n) _____ rib injury.
a. compound
b. flail chest
c. acute
d. compression
ANS: B REF: 363

37. The radiographic appearance of the erosion of bony rib margins is a possible indication of:
a. osteomyelitis.
b. osteoblastic metastases.
c. spondylolysis.
d. osteolytic metastases.
ANS: A REF: 363

38. Which of the following conditions, if severe, often requires a decrease adjustment of manual
exposure factors?
a. Osteoblastic metastases
b. Osteomyelitis
c. Flail chest
d. None of the above
ANS: D REF: 363

39. A congenital defect characterized by anterior protrusion of the lower sternum and xiphoid
process is termed:
a. pectus excavatum.
b. flail chest.
c. pectus carinatum.
d. sternal protrusion.
ANS: C REF: 363

40. Which condition of the sternum is often termed “funnel chest”?

a. Pectus excavatum
b. Flail chest
c. Pectus eruptus
d. Pectus deforminens
ANS: A REF: 363

41. The condition flail chest is most commonly caused by:

a. pneumothorax.
b. emphysema.
c. blunt trauma.
 d. congenital heart defect.
ANS: C REF: 363

42. A radiograph of an RAO sternum reveals that it is partially superimposed over the spine.
What must be done to eliminate this problem during the repeat exposure?
a. Perform an LPO projection instead of an RAO.
b. Angle the CR 5° to 10° laterally to the sternum.
c. Increase rotation of the body.
d. Increase kV.
ANS: C REF: 364

43. A radiograph of a lateral projection of the sternum reveals that the patient’s ribs are
superimposed over the sternum. What needs to be done to correct this problem during the
repeat exposure?
a. Increase the SID.
b. Angle the CR 5° anterior.
c. Ensure that the patient is not rotated.
d. Increase the kV.
ANS: C REF: 365

44. A radiograph of an RAO projection of the sternum demonstrates excessive lung markings
obscuring the sternum. A 1-second exposure time and an orthostatic (breathing) technique
were used. Which of the following will produce a more diagnostic image of the sternum?
a. Ensure that the patient is not breathing during the exposure.
b. Increase the exposure time; decrease the mA.
c. Decrease the kV; increase the mA or time.
d. Initiate exposure on deeper inspiration.
ANS: B REF: 364

45. A PA radiograph of the sternoclavicular (SC) joints demonstrates unequal distance from the
SC joints to the midline of the spine. The left SC joint is farther from the sternum than the
right. What specific positioning error is present on this radiograph?
a. Slight right rotation (right side toward the image receptor)
b. Slight left rotation (left side toward the image receptor)
c. Tilt of the upper thorax
d. Excessive angulation of the CR
ANS: A REF: 366

46. A young female patient from the emergency department (ED) is brought to radiology for rib
examination. She is able to sit up or stand for the procedure. She indicates that the region of
pain is to the right anterior-to-mid axillary region. Which rib projections should be performed
to minimize the effective dose to this patient?
a. PA and RPO
b. AP and RPO
c. PA and RAO
d. PA and LAO
 ANS: D REF: 361

47. A patient enters the ED with an injury to the left anterior lower ribs. Which of the following
projections should be taken to demonstrate the involved area?
a. AP and LAO
b. PA and RAO
c. AP and LPO
d. PA and LAO
ANS: B REF: 371

48. An ambulatory patient enters the ED with a possible injury to the right upper posterior ribs.
Which of the following positioning routines should be taken to demonstrate the involved area?
a. Erect PA and LPO
b. Erect AP and RPO
c. Recumbent AP and RPO
d. Erect PA and LAO
ANS: B REF: 370-371

49. A patient enters the ED with blunt trauma to the sternum. The patient is in great pain and
cannot lie prone on the table or stand erect. Which of the following positioning routines would
be best for the sternum examination in this situation?
a. RPO and lateral recumbent projections
b. AP and horizontal beam lateral projections
c. LPO and horizontal beam lateral projections
d. LPO and lateral recumbent projections
ANS: C REF: 361 | 364

50. A patient enters the ED with trauma to the bony thorax. The initial radiographs reveal that
there are fractured ribs and a possible pneumothorax of the left thorax. The physician orders a
chest study to confirm the pneumothorax; however, the patient cannot stand. Which of the
following positions would best demonstrate the pneumothorax?
a. Left lateral decubitus
b. Right lateral decubitus
c. Ventral decubitus
d. Dorsal decubitus
ANS: B REF: 361

51. Initial PA projections of the SC joints indicate a possible bony defect involving the right SC
joint. The vertebral column is preventing a clear view of it. Which of the following
projections will demonstrate the right SC joint without superimposition over the spine?
a. Horizontal beam lateral
b. LAO
c. RAO
d. Erect lateral projection
ANS: C REF: 367
 52. What is the minimum number of ribs that must be demonstrated for a unilateral rib study
above the diaphragm?
a. Ribs 1 through 6
b. Ribs 1 through 8
c. Ribs 1 through 9
d. All ribs must be demonstrated.
ANS: C REF: 370

53. A radiograph of an RAO projection of the ribs demonstrates the left axillary ribs are
foreshortened, whereas the right side is elongated. Which of the following is the most likely
reason for this radiographic outcome?
a. The patient requires more rotation to the right.
b. An LAO was performed rather than the RAO position.
c. The technologist should have performed a PA projection to demonstrate the left
axillary ribs, not an RAO.
d. CR angulation was incorrect.
ANS: B REF: 371-372

54. A patient with metastatic disease in the ribs comes to radiology following a nuclear medicine
scan. The radiologist orders a right, upper posterior rib study. Which of the following
positioning factors should be followed for this specific study?
a. Perform positions erect if the patient’s condition permits.
b. Exposure on full expiration.
c. Include the RPO position as part of the positioning routine.
d. Both A and C are correct.
ANS: D REF: 360 | 371-372

55. Which of the following positioning considerations does NOT apply for a study of the lower
ribs?
a. Perform positions recumbent.
b. Use a digital kV range between 65 and 70 kV.
c. Exposure on full expiration.
d. Both A and B are incorrect.
ANS: B REF: 360

56. Which of the following landmarks can be palpated to locate the upper margin of the sternum
on the obese patient?
a. Vertebra prominens
b. Sternal angle
c. Jugular notch
d. Thyroid cartilage
ANS: C REF: 362

TRUE/FALSE

1. The tubercle portion of a typical rib articulates with the vertebral facet/demifacet.
 ANS: F REF: 357

2. The only bony connection between the shoulder girdle and the bony thorax is the
acromioclavicular joint.

ANS: F REF: 356

3. The degree of rotation for the right anterior oblique (RAO) projection of the sternum is
dependent on the size of the thoracic cavity.

ANS: T REF: 359

4. The left anterior oblique (LAO) position of the sternum provides the best frontal image of the
sternum with it superimposed over the heart.

ANS: F REF: 361

5. A right or left side marker may be taped over the area of interest to indicate the location of the
trauma to the ribs.

ANS: F REF: 361

6. It is a safe practice to decrease the SID to 30 inches (77 cm) for the oblique sternum
projection.

ANS: F REF: 364

7. Both nuclear medicine and magnetic resonance imaging (MRI) studies can be performed to
evaluate metastatic rib lesions before conventional rib radiographic examination.

ANS: F REF: 362

8. Multiple myeloma is seen often in the flat bones of the bony thorax.

ANS: T REF: 363

9. Both bony and soft tissue anatomy may be evaluated by CT for pathology involving the
sternum or the sternoclavicular joints.

ANS: T REF: 363

10. The use of 125 kV is recommended for AP and PA projections of the ribs to reduce skin dose.

ANS: F REF: 368-371

11. An erect lateral projection of the sternum requires that respiration be suspended on expiration.

ANS: F REF: 365

Another random document with
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 Liinan huoneessa oli liian kuuma. Kalle siirtyi saliin ja alkoi kävellä
edes takaisin. Levottomista liikkeistä saattoi arvata hänen
mielessään liikkuvan jotakin outoa. Näin hän ajatteli:

"Näin pitkälle sitä siis nyt on jouduttu. Voi minua poloista vieläkin.
Jos ilkeäisin itseltäni, niin raastaisin Liinan tukasta, tänne… ja
selvittäisin nyrkkipuheella, mikä hän on ja miksi hän on tehnyt
minutkin. Mutta tokkopa hän ymmärtää sittekään. Tuskin vain!… No,
onhan tuota syytä itsessänikin, miksi rupesin juomaan, niin miksi?
Heikko olen ollut, mutta sen tiedän, jos minulla olisi ollut kunnon
vaimo, en nyt tällainen olisi. Sen verran minussa toki on vielä häpyä,
että en viitsikään olla joka viilekkeen pilkattavana. Vai meillä muka ei
ole leipää sen tähden, että meillä ei ole emäntää, joka paistaisi! Ja
minäkö pidän eukkoani vain nukkena lasikaapissa? Totta totisesti
niin onkin; mutta kuka tuota viitsii kuulla syrjäisiltä, en minä
ainakaan. Loppu tästä elämästä pitää tulla tavalla tai toisella… Ja
loppuhan tästä tuleekin ihan itsestään. Pankkiin olisi huomenna
lähetettävä rahan, kauppiaalla on tuomio ja hän vaatii rahaa, leipään
tarvittaisiin rahaa ja isälle pitäisi toimittaa rahaa siitä tuonnoisesta
summasta, jonka vain vähäksi ajaksi lainasin. Rahaa, rahaa, rahaa,
eikä minulla penniäkään… Pahin pula on syömisestä. Rupeavat
palvelijatkin näljissään haukkumaan… Liinasta en välittäisi, nähköön
vähän nälkää, eikö sitte oppisi jotain tekemään. Ja lapsista kyllä isä
pitää huolen, sen tiedän ihan varmaan. Itse minä kyllä elän missä
hyvänsä… Voi sentäänkin, kun en alussa ollut jyrkempi Liinalle ja
pakottanut häntä ihmiseksi. Mutta kuka tuota jaksaa nähdä akkain
itkua ja vaikerrusta, ja säälihän tuota oli ajaakin herrasihmistä heti
läävään, kun muutenkin tuntui elämä olevan hänestä niin vaikea. Ja
se appiukko, rikkaaksi häntä kaikki luulivat, se se juuri minutkin petti,
kun tyttö vielä lisäksi oli niin vietävän suloinen… se ukko jätti meidät
ihan paljain käsin. Kutti, parahiksi, Kalle! kuka käski olemaan sokea
ja kosimaan herrasneittä? Ei kukaan muu kuin oma herruuteni. Nyt
olen hyväkin herra!… Peijakas kun rupee nälkä hiukomaan omaakin
vatsaani; se vain ei katso herruutta eikä narreutta! Mutta loppu tästä
pitää tulla!"

Kauan hän sillä tavalla mietiskellen käveli välistä hitaammin,

välistä taas kiireemmin, mikäli ajatukset milloinkin sujuivat. Unta ei
kuulunut. Aamu jo ehti valjeta hänen yhä astuskellessaan.

Viimein hän teki päätöksensä, pukeutui päällysvaatteihinsa, meni

tampuurin kautta ulos, valjasti hevosen, saman, jolla oli tullut kotiin ja
läksi ajamaan.

Liina yhä nukkui ja vasta hetkisen kuluttua heräsivät palvelijatkin,

tottuneet kun ajan pitkään olivat hekin enemmän makaamaan kuin
työtä tekemään! Renki kiepsahti vähän sukkelammin tavallista ylös
ja alkoi torua piikoja: "nyt teidät hukka perii, kun näin makaatte
selvään päivään asti, vaikka isäntä on kotona!" Mutta karjapiika,
käytyään elukoita katsomassa ja huomattuaan, että isännän hevosta
ei ollut tallissa eikä rekeäkään kotosalla, alkoi tupaan palattuaan
pilkata renkiä, että hän näljissään näki vain unia päivälläkin. Ja
siihen uskoon piiat jäivät, vaikka renki kuinka olisi vakuuttanut
käyneensä yöllä riisumassa isännän hevosen.

Kalle ajoi suoraa päätä Notkolaan. Vaikealta hänestä tuntui mennä

isäänsä yhä kiusaamaan ja vielä vaikeampi hänen oli kuulla isän
suusta jyrkkä vastaus, että oli turha ruveta kahta taloa hävittämään
yhden tähden. Kalle mielessään kuitenkin tunnusti isän olevan
oikeassa, hänhän oli itsekin koko aamun ajatellut samaa, ja nyt hän
ilmasi äsken tekemänsä päätöksen.
 Kauan siinä keskusteltiin ja punnittiin asiaa kaikilta puolin.
Notkolan isäntä, huomattuaan poikansa nyt viimeinkin palaavan
väärältä tieltä, kehoitti Kallea vielä koettamaan pitää taloansa
pystyssä, vaan Kalle ei uskaltanut, hänellä kun ei enää ollut
luottamusta itseensäkään.

Aamiaisen syötyä läksi Kalle ajamaan omia teitänsä, ei kuitenkaan

kapakkaan, kuten ennen. Isänsä huusi hänelle vielä jäljestä: "ole
huoletta, kyllä minä korjaan lapset!" ja kyyneliä kiilsi nyt jo
vanhanpuoleisen miehen silmissä.

Mäkelässä palvelijat kyllästyivät odottamaan olematonta aamiaista

eivätkä ilenneet enää mennä lainailemaankaan, vaan karkasivat.
Niinpä Notkolan isäntä päivemmällä tapasi Liinan yksinään lasten
kanssa ja vei heidät kotiinsa. Mäkelän kartanot lukottiin ja elukat
korjattiin myöskin nälkää näkemästä Notkolaan toistaiseksi. Aikaa
myöten otti pankki saatavastaan talon haltuunsa ja irtaimiston veivät
muut saamamiehet.

*****

Tähän nyt kertomus oikeastaan saisi päättyä, sillä johan

arvaamme, että päähenkilöt, joiden elämän vaiheita olemme
seuranneet, olivat auttamattomasti elämänsä mukaista kylvöä
niittämässä ja että heidän lapsensa joutuivat hyviin käsiin. Kuitenkin
huvittanee vielä katsahtaa muutamia vuosia, ehkäpä
kymmenkunnankin eteen päin.

Silloin istui Liina huononpäiväisessä torpassa. Hän näet ei ollut

viihtynyt Notkolassa, jossa toisten uutteruus oli ikäänkuin ainaisena
pahana omanatuntona häntä rasittamassa, vaikka häntä ei
kovuudella kohdeltukaan, ja hän sen tähden oli lähtenyt omaan
vapauteensa. Huonoa hänen toimeentulonsa sitte oli ja ehkäpä hän
saamattomuudessaan olisi kuollut nälkäänkin, ell'eivät torpan
asukkaat, johon hän asettui elämään, olisi toimittaneet hänelle
syötävää ensin Notkolasta ja sitte kunnan vaivaisvaroista, kuin
Notkolan vanhukset kuolivat ja tila joutui Liinalle vieraampien
haltuun. Työhön oppimisesta ei nytkään tullut mitään. Torpanväen
kätkyitä hän vain kiikutteli ja muisteli ennen nuorempana lukemiansa
romaaneja.

Kallesta kuultiin sen verran, että hän toisissa pitäjissä piti

päällysmiehen ammattia tukin ajoissa ja uitoissa ja ansaitsi rahaa
runsaasti. Mutta Liinalle hän ei lähettänyt penniäkään, sillä viina oli jo
tullut hänelle niin rakkaaksi, että sen alttarille hän uhrasi joka
roponsa. Humalapäissään hän kuitenkin joskus kiroeli omaa
tyhmyyttänsä; koko tuo naimisissa olon aika häilyi hänen mielessään
vain pahana unena. Toimen miestä hänestä ei enää koskaan tullut,
siksi oli hänen oma tahtonsa jo vallan uupunut, ja oikea avun lähde,
niin se häneltä oli unhottunut jo ammoin ennen, kuin hän
herrasmaisuuden ja himon orjaksi joutuikaan.
 *** END OF THE PROJECT GUTENBERG EBOOK JUTELMIA ***

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