1. 1 PA -anterior side BEST SEEN AP -posterior side BEST SEEN Ribs 2010- pt 2 VERSION 2 POSITIOINING TEXT VERSION - PHOTOS HAVE BEEN REMOVED TO MAKE PRESENTATION SMALLER

2. 2 CLAVICLE AP LT CLAVICLE - UPRIGHT AXIAL LT CLAVICLE- UPRIGHT AP RT CLAVICLE - SUPINE AXIAL RT CLAVICLE- SUPINE A/C JOINTS A/C JTS – (BILATERAL) W/O WTS A/C JTS – (BILATERAL) WITH WTS LT - A/C JTS - W/O WTS LT - A/C JTS – WITH WTS SHOULDER (UPRIGHT OR SUPINE) NON- TRAUMA AP RT SHOULDER – INT ROT AP RT SHOULDER – EXT ROT LT SHOULDER – GRASHEY TRAUMA AP RT SHOULDER – NEUTRAL ROT LT SHOULDER – TRANSTHORACIC LAT RT SHOULDER – SCAPULAR Y SCAPULA (UPRIGHT OR SUPINE) AP, LAT – RT SCAPULA RIBS – (UPRIGHT OR SUPINE) UNILATERAL: AP (RT) UPPER & LOWER RIBS PA (RT) UPPER & LOWER RIBS OBLIQUE – FOR (RT) AXILLARY UPPER RIBS OBLIQUE – FOR (RT) AXILLARY LOWER RIBS OBLIQUE – FOR (RT) POSTERIOR UPPER RIBS (articulation to spine) OBLIQUE – FOR (RT) POSTERIOR LOWER RIBS (articulation to spine) BILATERAL: AP BILATERAL UPPER RIBS AP BILATERAL LOWER RIBS PA BILATERAL UPPER RIBS PA BILATERAL LOWER RIBS RPO - BILATERAL UPPER RIBS RPO BILATERAL LOWER RIBS LPO - BILATERAL UPPER RIBS LPO BILATERAL LOWER RIBS STERNUM RAO/LAO Lateral Upright/ Supine / X-table

3. 3

4. 4 RIBS (Projections & Positions) AP OBLIQUES LPO RPO (May also include PA CHEST for lungs) PA OBLIQUES RAO LAO Exam done : UNILATERAL or BILATERAL AD (above diaphram) & BD – (below diaphram)

5. 5 BEST SEEN - RIBS AP - posterior ribs (AD/BD) PA - anterior ribs (AD/BD) OBLIQUES – RAO / LPO : LT axillary ribs + RT post rib art w/spine – LAO / RPO RT axillary ribs + LT post rib art w/spine

6. 6 UNIT 3 RT 122 TECHNIQUE CONSIDERATION RIBS : UNILATERAL OR BILATERAL SHORT SCALE CONTRAST NEEDED BONY DETAIL AD – above diaphram – 60 – 70 KVP – INSPIRATION BD – below diaphram – 70 KVP + 3-4 x more mAs (ABD) EXPIRATION

7. 7 Routine: Bilateral RIBS AP or PA OBLIQUES LPO (RAO) RPO (LAO) (May also include PA CHEST for lungs) ↑ kVp for lungs (90-120)vs kVp bony ribs (60-80) Must include : BOTH sides (RT & LT) TOP & Bottom (AD & BD)

8. 8 PA for Chest or Bilat RIBS (AD)

9. 9 BILAT – AD (upright) 14 x 17 LW CW Centering – same as CXR MSP + T 7

10. 10 (AP) BILATERAL - AD

11. 11 Deep Inspiration Why?

12. 12 INSPIRATION vs EXPIRATION

13. 13 Why do AP vs PA projection? PA AP

14. 14 BILAT (BD) 11X14 CW OR 14 x 17 CW Centering – (similar to upper ABD) MSP + L-1 (Bend of Rib) Top of light 1 – 2 “ above xyphoid Bottom of light 1 – 2 “ below IC

15. 15 BILAT (BD) 11X14 CW OR 14 x 17 CW

16. 16 OR Upright

17. 17 SUPINE AP BILATERAL RIBS AD BD

18. 18 AD – INSP BD - EXP

19. 19 BILATERAL RIBS AP AD & BD Same pt - routine AD 14 x 17 LW 14 x 17 CW Centering – (similar to upper ABD) MSP + L-1 (Bend of Rib) Top of light 1 – 2 “ above xyphoid Bottom of light 1 – 2 “ below IC

20. 20 AD – INSP BD - EXP

21. 21 BILAT – OBLIQUES – (AD) RPO LPO CR ~ ½ way between MSP/MCP (side up) or ~ 2” lat to MSP (side up) & T7 (AD) 14x17 (LW or CW)

22. 22 RPO LPO

23. 23 RPO LPO RT AXILLARY RIBS LT POST ARTICULATION TO SPINE LT AXILLARY RIBS RT POST ARTICULATION TO SPINE

24. 24 RPO LPO

25. 25 If Taken “AP” Technique Used ? Position? Demonstrates? What determines an adequate rotation?

26. 26 Some of the challenges with RIBS >>>>>>>>>>>>>>

27. 27 AP Bilat – OBLIQUE (AD) Position? Demonstrates? CR ~ ½ way between MSP/MCP (side up) or ~ 2” lat to MSP (side up) & T7 (AD)

28. 28 Projection PA AP Position LAO VS RPO

29. 29 PA Bilat – OBLIQUE (AD) Move both arms out of the way This position not tested in lab

30. 30 RAO (LOOKS THE SAME AS LPO) BILATERAL OBLIQUE - AD

31. 31 LAO VS RPO

32. 32 BILATERAL OBLIQUES (BD) RPO LPO CR ~ 2” lat to MSP (side up) & L1 (BD) 14x17 ( CW)

33. 33 BELOW THE DIAPHRAM LPO RPO Technique needs improvement

34. 34 Review :BILATERAL – LPO AD & BD when positioning the patient – do same position (upper & lower) Remember to change the tech ~ same kVp, go up 3 to 4 x in mas

35. 35 LPO

36. 36 Review BILATERAL – RPO AD & BD when positioning the patient – do same position (upper & lower)

37. 37 RPO

38. 38 Routine: Unilateral RIBS AP or PA (area of injury) 1 or 2 OBLIQUES ex: RT RIBS RPO for RT side (AD & BD) & LPO for RT side (AD & BD) Focus is on RT side or LT side Top & Bottom (AD & BD)

39. 39 UNILATERAL – RT RIBS ( AP) AD & BD when positioning the patient – do same position (upper & lower) 14 x 17 LW CR ~ ½ way between MSP/MCP & T7 (AD) & L1 (BD) 11 X 14 CW

40. 40 UNILATERAL – RT RIBS ( AP) AD & BD

41. 41 AP UNILATERAL (LT RIBS) AD BD CR ~ ½ way between MSP/MCP & T7 (AD) L1 (BD)

42. 42 UNILATERAL – LT RIBS AP AD BD 14 x 17 LW 14 x 17 cw

43. 43 Unilateral - LT RIBS AD/BD

44. 44 OBLIQUE Unilateral RIBS 1.AP or PA 2.AP OBLIQUES RT RIBS = RPO for RT side (AD & BD) (“turn pt towards side that hurts”) 3. Additional oblique is LPO for RT side (AD & BD) And/or “cone down” with marker

45. 45 UNILATERAL Ribs DONE FOR ONE SIDE ONLY AP/PA – (? Injury on the back or front?) AP OBLIQUE – (ribs elongated) – side of problem turn toward the IR = axillary AP (OTHER) OBLIQUE – (ribs foreshortened) – side of problem turn away from the IR (see post art to spine and anterior portion of the rib best – they are superimposed) –Keep your centering on the correct side of the injury

46. 46 UNILATERAL (LEFT RIBS) – AD doing BOTH Obliques for one side LPO –AXILLARY RPO –LT POST ART “side down” ribs“side up” ribs

47. 47 CR ~ ½ way between MSP/MCP (side down) &~ T7 (AD) “frame with light” top light 1”above shoulder lat side 1” lat to ribs medial ~ 2 “ lat to msp (side up) bottom ~ 10 th rib

48. 48 Compare to RPO & LPO FOR ONE SIDE RPO FOR RT SIDE LPO FOR LT SIDE

49. 49 UNILATERAL (LEFT RIBS) – BOTH AD & BD LPO –AXILLARY “side down” ribs MSP + L-1 (Bend of Rib) Top of light 1 – 2 “ above xyphoid Bottom of light 1 – 2 “ below IC MSP + T7 Top of light 1” above shoulder Bottom of light ~ 10 rib

50. 50 UNILAT – LEFT(LPO)

51. 51 LPO/RAO – For LEFT Ribs RAO

52. 52 LPO for BD Lt axillary

53. 53 Comparison of OBL – BD BILAT VS UNILAT

54. 54 UNILATERAL – RT RIBS RPO AD RPO BD (for the axillary portion of ribs) When positioning the patient – do same position (upper & lower)

55. 55 UNILATERAL – RT RIBS RPO AD RPO BD (for the axillary portion of ribs)

56. 56 LAO/RPO for the RT RIBS UPSIDE = PA AWAY DOWNSIDE = AP TOWARD (SIDE OF PAIN)

57. 57 UNILATERAL – RT RIBS LPO AD LPO BD (for the posterior portion of ribs- articulation to spine) when positioning the patient – do same position (upper & lower) Aka “side up” ribs “extra view” CR ~ ½ way between MSP/MCP (side up) &~ T7 (AD) “frame with light” top light 1”above shoulder lat side 1” lat to ribs medial ~ 2 “ lat to msp bottom ~ 10th rib CR ~ ½ way between MSP/MCP (side up) + L-1 (Bend of Rib) Top of light 1 – 2 “ above xyphoid Bottom of light 1 – 2 “ below IC

58. 58 UNILATERAL – RT RIBS LPO AD LPO BD (for the posterior portion of ribs- articulation to spine)

59. 59 OBLIQ - (LEFT RIBS) – AD RPO –LT POST ART

60. 60 Position? Demonstrating? AD BD T7 or L 1

61. 61 End of Rib positioning Review Part 3 Image Review