1. Bony Thorax
Tanya Nolan

2. Bony Thorax Sternum 12 Ribs 12 Thoracic Vertebrae Function
Supports walls of pleural cavity & diaphragm
Volume of cavity able to change during respiration
Protects heart and lungs

3. Sternum Flat bone 6 in in length
Supports clavicles and provides attachment to 1st seven costal cartilages of ribs
T2-T3
Sternal Angle
T-10
Provides bony landmark for superior liver and inferior heart

4. 12 Rib Pairs True Ribs False Ribs Floating Ribs Number Variation 1-7
Attached to the Sternum
False Ribs
8-12
Do not attach directly to the sternum; attach to costal cartilage of 7th rib
Floating Ribs
11 and 12
Attached only to the vertebrae
Number Variation
Cervical Ribs
Articulate with C7 but rarely attach to sternum
Lumbar Ribs
Less Common

5. Ribs Angle Oblique plane slanting anteriorly and inferiorly
Anterior ends lies 3-5 inches below the level of the vertebral end.
Angle increases from the rib 1-9 then decreases 9-12.

6. Ribs Vary in breadth and length
Facet on head articulates with vertebrae
Trauma to ribs can damage these neurovascular structures, causing pain and hemorrhage. Rib fractures can cause a great deal of pain and hemorrhage because of the closely related neurovascular structures. Deeper inspiration will be attained if patient fully understands the importance of the expanding lungs.
Vertebral End
Costal Groove
Sternal End
Costal arteries, veins, and nerves

7. Erythropoiesis Production of red blood cells. Early Fetus
Mesodermal cells of yolk sac
3-4 Months to Adolescence
Spleen, Liver, and Skeletal involvement
Adulthood
Vertebrae, Sternum, Pelvis, and Ribs
Principal means of delivering oxygen to the body

8. Bony Thorax Articulations
8 Joints
Sternoclavicular
Costovertebral (1-12)
Costotransverse (1-10)
Costochondral (1-10)
Sternocostal (1-7)
Interchondral (6-10)
Manubriosternal
Xiphisternal

9. Sternoclavicular
Only points of articulation between the upper limbs and the trunk
Gliding Joints
Permit free movement
Manubriosternal
Joint
Xiphisternal
Joint

10. Costovertebral and Costotranverse
Synovial Gliding
Rib Head closely bound to the demifacets and 2 adjacent vertebral bodies
Costotransverse
Tubercle of rib articulates with transverse process of lower vertebra

11. Costochondral and Sternocostal
Cartilaginous Synchondosis
No Movement
Articulation between costal cartilages and true ribs
Costochondral
1st Rib: Cartilaginous Synchondosis
2-7: Synovial Gliding
Freely moveable
Articulation between rib costal cartilages and sternum
Sternocostal

12. Interchondral Between 6-9 Ribs Between 9-10 Ribs Synovial Gliding
Freely moveable
Between 9-10 Ribs
Fibrous Syndesmosis
Slightly moveable

13. Manubriosternal & Xiphersternal
Cartilaginous Synchondrosis
Little Movement
Manubriosternal Joint
Xiphisternal Joint

14. Respiratory Movement Quiet Respiration Deep Inspiration
Olique rib orientation changes little
Deep Inspiration
Degree of obliquity decreases
Ribs carried anteriorly, superiorly, and laterally while necks are rotated inferiorly
Deep Expiration
Degree of obliquity increases
Ribs carried inferiorly, posteriorly, and medially while the necks are rotated superiorly

15. Diaphram WHY? Ribs above diaphram best imaged through air filled lungs
Ribs below diaphram best imaged through upper abdomen
Difference in penetration required for the 2 regions, even density required
WHY?

16. Diaphram Location Changes with Body Position Repiratory Movement
Upright
Lowest
Supine
Highest
Anterior ends of ribs less sharply visualized in supine position
Repiratory Movement
1 ½ inches between deep inspiration and deep expiration
Less in hypersthenic
More in hyposthenic
Rib injury is very painful, and patients should be examined in the position in which they arrive in the radiology department

17. Oblique Projection of Sternum
Why must you do an oblique projection of the sternum versus an AP or PA projection?
Degree of angulation depends on the depth of the chest
Deep Chest
Less angulation
Shallow Chest
More angulation
Because sternum is directly anterior to the thoracic spine, AP and PA gives little useful diagnositic information.

18. Which Oblique Position???
RAO or LAO?
Why?
Answer: RAO
Angulation of the body or the central ray to project the sternum to the right of the thoracic vertebrae clears the sternum of the vertebrae but superimposes it over the posterior ribs and the lung markings. If the sternum is projected to the left of the thoracic vertebrae it is also projected over the heart and other mediastinal structures which allows for use of the homogeneous density of the heart.

19. What technique?
Why?
Pulmonary structures, particularly in elderly persons and heavy smokers, can cast confusing markings over the sternum unless the motion of shallow breathing is used to eliminate them. Use breathing technique. If a breathing technique is not used, make sure exposure is made at the end of expiration to obtain a more uniform density

20. PA Oblique Projection (RAO) Sternum
Estimate body rotation by placing one hand on patient’s sternum and the other hand on the thoracic vertebrae to act as a guide
Top of IR 1.5 inches above jugular notch
Average body rotation is degrees

21. PA Oblique Projection (RAO, LPO) Sternum
Minimal rotation
Sternum projected free from superimposition of the spine
Sternum projected over the heart
Answer: When the patient must stay supine (trauma)
When would you use an LPO Position?

22. Lateral Projection (Upright) Sternum
Rotate patients hands posteriorly
Lock hands behind back
Film 24 x 30 cm lengthwise
IR 1.5 inches above jugular notch
Suspend deep inspiration

23. Lateral Projection (Supine) Sternum
Bring hands above head
Film 24 x 30 cm lengthwise
IR 1.5 inches above jugular notch
Suspend deep inspiration

24. Lateral Projection Sternum

25. Pectus Excavatum Sunken or “caved in” chest
Most common congenital chest wall abnormality in children.
Severity ranges from a moderate indentation to constriction of the internal organs.
Sunken chest appears to be a problem with the sternum or ribs, but the problem is with the cartilage piece that connects each rib to the sternum. This costal cartilage connector is deformed, pushing the breastbone inward.

26. PA Projection Sternoclavicular Articulations
T3 (just posterior to jugular notch)
Arms rest by side of patient with palms up
Turn head toward affected side
Rotates spine slightly away from side being examined
Better visualization of lateral manubrium
Suspend at end of expiration
Use upright position when possible.

27. Sternoclavicular Articulations
Bilateral Unilateral
No Rotation Slight Rotation

28. PA Oblique Projection (RAO, LAO) SC Joints
Rotate patient degrees
CR perpendicular to SC Joint closest to the IR (T2-T3)
You may also angle the tube 15 degrees toward the side of interest with the patient prone. S
LAO: Left side of interest
RAO: Right side of interest L R 15

29. PA Oblique Projection (RAO, LAO) SC Joints

30. Ribs Localize Point of Interest Anterior Ribs Posterior Ribs
PA Projection
Posterior Ribs
AP Projection
Axillary Portion of Ribs
Best demonstrated in oblique projection
lateral projection results in superimposition of both sides

31. Respiration

32. Upper Anterior Ribs PA Projection
It may be useful to angle tube degrees caudad when demonstrating ribs 7-9 (depress diaphram)
Do you use the same technique as you would for a chest x-ray?

33. Posterior Ribs: AP Projection
Ribs above diaphram
1.5 inches above shoulders
Full Inspiration
Ribs below diaphram
Lower edge of IR at iliac crest
Full Expiration

34. Posterior Ribs AP Projection

35. Axillary Ribs AP Oblique Projection (RPO, LPO)
45 degree Oblique
Place affected side closest to the IR
Center affected side midway between midsagittal plane and lateral surface
Abduct arm of affected side and elevate to carry scapula away from rib cage

36. Axillary Ribs AP Oblique Projection (RPO, LPO)
2 x distance between vertebral column and lateral border affected side visualized
Axillary ribs free of superimposition

37. Axillary Ribs PA Oblique Projection (RAO, LAO)
45 degree oblique
45 degree oblique
Answer: Side up
Which is the side
of interest?
Why?

38. Axillary Ribs PA Oblique Projection (RAO, LAO)