1 Ribs 2010 pt 2 VERSION 2 POSITIOINING

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

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 • • • STERNUM RAO/LAO Lateral Upright/ Supine / X-table LPO - BILATERAL UPPER RIBS LPO BILATERAL LOWER RIBS

3

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

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

UNIT 3 RT 122 TECHNIQUE CONSIDERATION 6 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 m. As (ABD) • EXPIRATION

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

8 PA for Chest or Bilat RIBS (AD)

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

10 (AP) BILATERAL - AD

11 Deep Inspiration Why?

12 INSPIRATION vs EXPIRATION

13 Why do AP vs PA projection? PA AP

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

15 BILAT (BD) 11 X 14 CW OR 14 x 17 CW

16 OR Upright

17 AD SUPINE AP BILATERAL RIBS BD

18 AD – INSP BD - EXP

BILATERAL RIBS AP Same pt - routine AD & BD 19 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 AD – INSP BD - EXP

21 BILAT – OBLIQUES – (AD) RPO LPO CR ~ ½ way between MSP/MCP (side up) or ~ 2” lat to MSP (side up) & T 7 (AD) 14 x 17 (LW or CW)

22 RPO LPO

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

24 RPO LPO

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

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

27 AP Bilat – OBLIQUE (AD) Position? Demonstrates? CR ~ ½ way between MSP/MCP (side up) or ~ 2” lat to MSP (side up) & T 7 (AD)

28 PA Position LAO Projection VS AP RPO

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

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

31 LAO VS RPO

32 BILATERAL OBLIQUES (BD) RPO LPO CR ~ 2” lat to MSP (side up) & L 1 (BD) 14 x 17 ( CW)

33 BELOW THE DIAPHRAM LPO RPO Technique needs improvement

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

35 LPO

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

37 RPO

38 Routine: Unilateral RIBS Focus is on RT side or LT side Top & Bottom (AD & BD) • 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)

UNILATERAL – RT RIBS ( AP) AD & BD 39 when positioning the patient – do same position (upper & lower) 14 x 17 LW CR ~ ½ way between MSP/MCP & T 7 (AD) & L 1 (BD) 11 X 14 CW

40 UNILATERAL – RT RIBS ( AP) AD & BD

41 AP UNILATERAL (LT RIBS) AD BD CR ~ ½ way between MSP/MCP & T 7 (AD) L 1 (BD)

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

43 Unilateral - LT RIBS AD/BD

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

47 CR ~ ½ way between MSP/MCP (side down) &~ T 7 (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 Compare to RPO & LPO FOR ONE SIDE RPO FOR RT SIDE LPO FOR LT SIDE

49 UNILATERAL (LEFT RIBS) – BOTH AD & BD LPO –AXILLARY “side down” ribs MSP + T 7 Top of light 1” above shoulder Bottom of light ~ 10 rib MSP + L-1 (Bend of Rib) Top of light 1 – 2 “ above xyphoid Bottom of light 1 – 2 “ below IC

50 UNILAT – LEFT(LPO)

51 LPO/RAO – For LEFT Ribs RAO

52 LPO for BD Lt axillary

53 Comparison of OBL – BD BILAT VS UNILAT

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

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

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

UNILATERAL – RT RIBS LPO AD LPO BD 57 (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) &~ T 7 (AD) “frame with light” top light 1”above shoulder lat side 1” lat to ribs medial ~ 2 “ lat to msp bottom ~ 10 th 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 UNILATERAL – RT RIBS LPO AD LPO BD (for the posterior portion of ribs- articulation to spine)

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

60 Position? Demonstrating? AD T 7 or L 1 BD

61 End of Rib positioning Review Part 3 Image Review