RAO Position: Sternum
Clinical Indications Pathology of the sternum, including fractures
and inflammatory processes.
Technical Factors Minimum SID: 40 inches (102 cm) <br> - IR Size:
24 × 30 cm (10 × 12 inches), lengthwise <br> -
Use of grid <br> - 2- to 3-second exposure if
breathing technique is used <br> - Analog: 65 to
75 kV range <br> - Digital: 70 to 80 kV range
Patient Position Erect (preferred) or semiprone position with
slight rotation, right arm down by side, left arm
up.
Part Position Position patient oblique, 15° to 20° toward the
right side (RAO). <br> - Align the long axis of the
sternum to CR and to the midline of the
table/upright Bucky. <br> - Place top of IR about
4 cm (1.5 inches) above the jugular notch.
CR (Central Ray) Perpendicular to IR. <br> - Directed to center of
sternum (1 inch (2.5 cm) to left of midline and
midway between the jugular notch and xiphoid
process).
Respiration Orthostatic (breathing) technique can be
performed if patient can cooperate. <br> - If not
possible, suspend respiration on expiration.
<br> - Breathing technique requires a minimum
of a 2-second exposure time and low mA to
blurr overlying structures
Evaluation Criteria Anatomy Demonstrated: Sternum is visualized,
superimposed on heart shadow. <br> Position:
Correct patient rotation shown with
visualization of sternum alongside vertebral
column without superimposition by vertebrae.
<br> Exposure: Optimal contrast and density
showing outline of sternum through overlying
ribs, lung, and heart. Bony margins should
appear sharp, lung markings blurred if breathing
technique was used. No motion with suspended
respiration.
Notes 1. Rotation: A large, deep-chested thorax
requires less rotation than a thin-chested
thorax. Determine rotation by ensuring the
sternum and spinous processes are not
superimposed. <br> 2. Adaptation: If RAO is not
possible, an LPO position can be used, or angle
the CR 15° to 20° across the right side to
project the sternum lateral to the vertebral
column. A portable grid required and should be
placed crosswise on the stretcher or tabletop.
AEC not recommended
Lateral Position—Right or Left Lateral: Sternum
Clinical Indications Pathology of the sternum, including fractures
and inflammatory processes. <br> - Depressed
sternal fractures.
Technical Factors Minimum SID: 40 inches (102 cm). <br> - IR
Size: 24 × 30 cm (10 × 12 inches) or 30 × 35 cm
(11 × 14 inches), lengthwise.<br> - Use of grid.
<br> - Analog: 70 to 75 kV range. <br> - Digital:
75 to 80 kV range.
Patient Position Erect (preferred) or lateral recumbent.
Part Position Erect: <br> - Patient standing or seated with
shoulders and arms drawn back. <br> Lateral
Recumbent: <br> - Patient lying on side, arms
up above head, keeping shoulders back. <br> -
Place top of IR 4 cm (1.5 inches) above the
jugular notch. <br> - Align long axis of sternum
to CR and midline of grid or table/upright Bucky.
<br> - Ensure true lateral with no rotation.
CR (Central Ray) Perpendicular to IR. <br> - Directed to center of
sternum (midway between the jugular notch
and xiphoid process). <br> - Recommended SID:
60 to 72 inches (152 to 183 cm) to reduce
magnification. <br> - If SID is less than 60
inches, use a larger IR (30 × 35 cm) to
compensate for magnification. <br> - Center IR
to CR.
Respiration Suspend respiration on inspiration.
Notes Large, pendulous breasts may need to be
positioned with a wide bandage to avoid
obstruction. <br> - Adaptation: A horizontal
x-ray beam can be used with the patient in a
supine position if necessary. AEC not
recommended.
Evaluation Criteria Anatomy Demonstrated: Entire sternum with
minimal overlap of soft tissues. <br> Position:
Correct patient position with no rotation
indicates: <br> - No superimposition of humeri,
shoulders, or soft tissue on sternum. <br> -
Entire sternum with no superimposition of the
ribs. <br> - Lower aspect of sternum
unobscured by breasts. <br> - Collimation to
area of interest. <br> Exposure: Optimal
contrast and density to visualize the entire
sternum. <br> - No motion, indicated by sharp
bony margins.
PA Projection: Sternoclavicular Joints
Clinical Indications Joint subluxation or other pathology of the
sternoclavicular joints.
Technical Factors Minimum SID: 40 inches (102 cm). <br> - IR
Size: 18 × 24 cm (8 × 10 inches), crosswise.
<br> - Use of grid. <br> - Analog: 65 to 70 kV
range. <br> - Digital: 70 to 75 kV range.
Patient Position Patient prone with a pillow for the head turned
to one side, arms up beside head or down by
side (may also be taken PA erect).
Part Position Align midsagittal plane to CR and to midline of
grid or table/upright Bucky. <br> - Allow no
rotation of shoulders. <br> - Center IR to CR (3
inches (7 cm) distal to the vertebra prominens
at T2-T3).
CR (Central Ray) Perpendicular to the IR. <br> - Centered to level
of T2-T3, or 3 inches (7 cm) distal to the
vertebra prominens (spinous process of C7).
Respiration Suspend on expiration for a more uniform
density.
Evaluation Criteria Anatomy Demonstrated: Lateral aspect of the
manubrium and medial portion of the clavicles
visualized lateral to the vertebral column
through superimposing ribs and lungs. <br>
Position: No rotation of the patient shown by
equal distance of sternoclavicular joints from
the vertebral column on both sides, with
collimation to area of interest. <br> Exposure:
Optimal contrast and density to visualize the
manubrium and medial portion of the clavicles
through superimposing ribs and lungs. No
motion, indicated by sharp bony margins.
Anterior Oblique Positions—RAO and LAO:
Sternoclavicular Joints
Clinical Indications Joint separation, subluxation, or other
pathology of the sternoclavicular joints. <br> -
Best visualizes the sternoclavicular joint on the
downside, which is closest to the spine on the
radiograph.
Technical Factors Minimum SID: 40 inches (102 cm). <br> - IR
Size: 18 × 24 cm (8 × 10 inches), crosswise.<br>
- Use of grid. <br> - Analog: 65 to 70 kV range.
<br> - Digital: 70 to 75 kV range.
Patient Position Prone, with slight rotation (10° to 15°) of thorax;
upside arm in front of patient and opposite arm
behind.
Part Position Rotate patient 10° to 15° laterally. <br> - Align
and center spinous process 1 to 2 inches (3 to 5
cm) lateral (toward upside) to CR and the
midline of the grid/table/upright Bucky. <br> -
Center IR to CR. <br> - Collimate to area of
interest.
CR (Central Ray) CR is perpendicular to the level of T2 to T3 or 3
inches (7.5 cm) distal to the vertebra
prominens. <br> - CR should be centered 1 to 2
inches (2.5 to 5 cm) lateral (toward upside) to
midsagittal plane.
Respiration Suspend on expiration for a more uniform
density (brightness).
Adaptation Notes Option 1: Oblique images can be obtained using
a posterior oblique position with 10° to 15°
rotation.<br> - Option 2: An angle of 15° across
the patient can be used to project the SC joint
lateral to the vertebrae. A portable grid should
be placed crosswise on the stretcher or
tabletop to prevent grid cutoff.
Evaluation Criteria Anatomy Demonstrated: The manubrium,
medial portion of clavicles, and sternoclavicular
joint are best demonstrated on the downside.
The SC joint on the upside will appear
foreshortened. <br> Position: Correct patient
rotation shows the downside SC joint without
superimposition of the vertebral column or
manubrium. <br> Exposure: Ensure optimal
contrast and density to visualize the
sternoclavicular joints through overlying ribs
and lungs. No motion is indicated by sharp
bony margins.
AP Projection: Posterior Ribs (Above or Below
Diaphragm)
Clinical Indications Pathology of the ribs, including fractures and
neoplastic processes
Technical Factors Minimum SID: 40 inches (102 cm). <br> - A
72-inch (183 cm) SID can be used for bilateral
rib examinations to minimize magnification of
anatomy. <br> - IR Size: <br> - 35 × 43 cm (14 ×
17 inches), crosswise <br> - 30 × 35 cm (11 ×
14 inches), lengthwise. <br> - Use of grid. <br>
Above diaphragm: Analog: 65 to 75 kV range;
Digital: 75 to 85 kV range. <br> Below
diaphragm: Analog: 70 to 80 kV range; Digital:
80 to 90 kV range.
Patient Position Erect position preferred for above diaphragm if
the patient's condition allows. <br> - Supine
position for below diaphragm.
Part Position Align midsagittal plane to CR and to midline of
grid or table/upright Bucky. <br> - Rotate
shoulders anteriorly to remove scapulae from
lung fields. <br> - Raise chin to avoid
superimposition of upper ribs; look straight
ahead. <br> - Ensure no rotation of thorax or
pelvis.
CR (Central Ray) Above diaphragm: <br> - CR perpendicular to IR,
centered 3 to 4 inches (8 to 10 cm) below the
jugular notch (level of T7). <br> - Center the IR
to the level of CR (top of IR about 4 cm above
the shoulders). <br><br> Below diaphragm: <br>
- CR perpendicular, centered to level of xiphoid
process. <br> - Center the IR to the CR (lower
margin of IR at iliac crest).
Respiration Suspend respiration on inspiration for ribs
above the diaphragm. <br> - Suspend
respiration on expiration for ribs below the
diaphragm.
Note For bilateral rib examinations, use IR crosswise
for larger patients to ensure that lateral rib
margins are not cut off. A 72-inch (183 cm) SID
can also minimize magnification. Unilateral rib
studies or narrower chest dimensions allow use
of a smaller IR lengthwise.
Evaluation Criteria Anatomy Demonstrated: <br> - Above
diaphragm: Ribs 1 through 10 should be
visualized. <br> - Below diaphragm: Ribs 9
through 12 should be visualized. <br><br>
Position: Ensure there’s no evident rotation of
thorax. <br> - Collimation to area of interest.
<br><br> Exposure: Optimal contrast and
density (brightness) to visualize ribs through
the lungs and heart shadow (above diaphragm)
or through dense abdominal organs (below
diaphragm). Ensure no motion indicated by
sharp bony markings.
PA Projection: Anterior Ribs Above Diaphragm
Clinical Indications Pathology of the ribs, including fracture or
neoplastic processes. <br> - Injuries to ribs
below the diaphragm are generally to posterior
ribs; therefore, AP projections are indicated.
Technical Factors Minimum SID: 40 inches (102 cm). <br> - For
bilateral rib examinations, a 72-inch (183 cm)
SID can be used to minimize magnification of
anatomy. <br> - IR Size: <br> - 35 × 43 cm (14 ×
17 inches), crosswise <br> - 30 × 35 cm (11 ×
14 inches), lengthwise. <br> - Use of grid. <br>
Analog: 65 to 70 kV range; <br> Digital: 70 to 80
kV range.
Patient Position Erect position preferred, or prone if necessary,
with arms down to the side.
Part Position Align midsagittal plane to CR and to midline of
grid or table/upright Bucky. <br> - Rotate
shoulders anteriorly to remove scapulae from
lung fields. <br> - Ensure no rotation of thorax
or pelvis.
CR (Central Ray) CR is perpendicular to IR, centered to T7 (7 to 8
inches (18 to 20 cm) below the vertebra
prominens, as for PA chest). <br> - Center IR to
level of CR (top of IR about 4 cm above the
shoulders).
Respiration Suspend respiration on inspiration.
Note A common rib routine series includes an erect
PA and lateral chest projections with lung
exposure techniques to rule out respiratory
trauma or dysfunctions, such as pneumothorax
or hemothorax, which may accompany rib
injuries. <br> - Unilateral study of ribs or narrow
chest dimensions allows use of smaller IR
lengthwise.
Evaluation Criteria Anatomy Demonstrated: Ribs 1 through 10
visualized above the diaphragm. <br> Position:
No rotation of the thorax; collimation to area of
interest. <br> Exposure: Optimal contrast and
density (brightness) to visualize ribs through
the lungs and heart; no motion, indicated by
sharp bony markings.
Unilateral Rib Study: AP-PA Position
Clinical Indications This projection is taken to demonstrate specific
trauma to one side of the thoracic cavity.
Technical Factors Minimum SID: 40 inches (102 cm). <br> - IR
Size: <br> - 35 × 43 cm (14 × 17 inches) or <br> -
30 × 35 cm (11 × 14 inches), lengthwise. <br> -
Use of grid. <br> - Above diaphragm: Analog: 65
to 75 kV range; Digital: 75 to 85 kV range. <br> -
Below diaphragm: Analog: 70 to 80 kV range;
Digital: 80 to 90 kV range.
Patient Position Erect position preferred for above diaphragm (if
the patient's condition allows). <br> - Supine
position for below diaphragm.
Part Position Align left or right side of thorax to CR and to
midline of grid or table/upright Bucky. <br> -
Raise chin to prevent superimposition of upper
ribs; look straight ahead. <br> - Ensure no
rotation of thorax or pelvis.
CR (Central Ray) Above diaphragm: <br> - CR perpendicular to IR,
centered midway between midsagittal plane
and outer margin of thorax. <br> - Center IR to
level of CR (top of IR about 4 cm above
shoulders). <br><br> Below diaphragm: <br> -
CR perpendicular to IR, centered to CR with the
bottom of the IR at the iliac crest.
Respiration Suspend respiration on inspiration for ribs
above the diaphragm. <br> - Suspend
respiration on expiration for ribs below the
diaphragm.
Evaluation Criteria Anatomy Demonstrated: <br> - Above
diaphragm: Ribs 1 through 10 should be
visualized. <br> - Below diaphragm: Ribs 9
through 12 should be visualized. <br><br>
Position: Ensure rotation of the thorax is not
evident. <br> Exposure: Optimal contrast and
density (brightness) to visualize ribs through
the lungs and heart; no motion indicated by
sharp bony markings.
Posterior or Anterior Oblique Positions: Axillary
Ribs (Above or Below Diaphragm)
Clinical Indications Pathology of the ribs, including fracture and
neoplastic processes. <br> - Oblique positions
will demonstrate the axillary portion of the ribs
not well seen on AP-PA projections. <br> -
Posterior-lateral injury: Use posterior oblique
positions, affected side toward IR. <br> -
Anterior-lateral injury: Use anterior oblique
positions, affected side away from IR.
Technical Factors Minimum SID: 40 inches (102 cm). <br> - For
bilateral rib examinations, a 72-inch (183 cm)
SID can be used to minimize magnification.
<br> - IR Size: <br> - 35 × 43 cm (14 × 17 inches)
or <br> - 30 × 35 cm (11 × 14 inches),
lengthwise. <br> - Use of grid. <br> Above
diaphragm: Analog: 65 to 75 kV range; Digital:
75 to 85 kV range. <br> Below diaphragm:
Analog: 70 to 80 kV range; Digital: 80 to 90 kV
range.
Patient Position Erect position preferred for above diaphragm (if
the patient's condition allows). <br> - Supine
position for below diaphragm.
Part Position Rotate patient into a 45° posterior or anterior
oblique position, with affected side closest to
the IR on posterior oblique and affected side
away from IR on anterior oblique (rotate spine
away from the site of injury). <br> - Raise
elevated side arm above head; extend opposite
arm down and behind the patient away from
thorax. <br> - If recumbent, flex the knee of
elevated side to maintain the position. <br> -
Support body with positioning blocks if needed.
<br> - Align a plane of the thorax midway
between the spine and the lateral margin of the
thorax on side of interest to the CR and to
midline of the grid or table/Bucky. Ensure that
side of interest is not cut off.
CR (Central Ray) CR is perpendicular to IR, centered midway
between the lateral margin of ribs and spine.
<br> Above diaphragm: CR to level 3 or 4 inches
(8 to 10 cm) below jugular notch (T7) (top of IR
approximately 4 cm above shoulders). <br>
Below diaphragm: CR to level midway between
xiphoid process and lower rib cage (bottom of
cassette at about the level of iliac crest).
Respiration Suspend respiration on inspiration for
above-diaphragm ribs. <br> - Suspend
respiration on expiration for below-diaphragm
ribs.
Note To demonstrate the axillary portion of the right
ribs, perform a right posterior oblique (RPO) or
LAO position. <br> - To demonstrate the axillary
portion of the left ribs, perform an LPO or RAO
position. <br> - Additional Collimated
Projection: Some departmental routines include
one well-collimated projection of the region of
injury taken on a smaller IR.
Evaluation Criteria Anatomy Demonstrated: <br> - Above
diaphragm: Ribs 1 through 10 should be
included and seen above the diaphragm. <br> -
Below diaphragm: Ribs 9 through 12 should be
included and seen below the diaphragm; the
axillary portion of the ribs under examination is
projected without self-superimposition. <br>
Position: An accurate 45° oblique position
should demonstrate the axillary ribs in profile
with the spine shifted away from the area of
interest; collimation to area of interest. <br>
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 indicated by sharp bony markings.
