Routine Projections (ARRT Required)

PA or AP Ribs (Above Diaphragm)

CR Location & Positioning

• SID: 72 inches preferred (minimizes magnification; improves detail)
• Patient position: Upright preferred; PA for anterior pain, AP for posterior pain
• Adjustments: Affected area closest to IR; MSP centered; shoulders rolled forward if PA
• CR: Perpendicular to IR at level of T7 (≈ 3–4″ below jugular notch or 7–8″ below vertebra prominens); top of IR ~1.5″ above shoulders
• Pt. Instructions: Deep inspiration; hold breath
• Exposure: On full inspiration

Evaluation Criteria

• Coverage (what anatomy must be included and how you verify it’s complete): Ribs 1–9 visualized above diaphragm
• Rotation checks (how symmetry or alignment tells you if positioning is correct): Sternoclavicular joints equidistant from spine
• Motion checks (how sharpness confirms patient cooperation/exposure timing): Sharp diaphragm and heart margins
• Technique checks (what contrast, density, soft tissue visibility, and artifacts to look for): Adequate penetration of ribs through lung fields
• Clinical aim (what contrast, density, soft tissue visibility, and artifacts to look for): Demonstrate upper ribs and lung apices for trauma or pain localization

PA or AP Ribs (Below Diaphragm)

CR Location & Positioning

• SID: 40–44 inches preferred
• Patient position: Supine preferred (elevates diaphragm)
• Adjustments: Affected area closest to IR; MSP centered
• CR: Perpendicular midway between xiphoid process and lower rib margin; bottom of IR at iliac crest
• Pt. Instructions: Full expiration; hold breath
• Exposure: On full expiration

Evaluation Criteria

• Coverage: Ribs 10–12 clearly demonstrated
• Rotation checks: Lateral rib margins equidistant from spine
• Motion checks: Sharp diaphragm margins; no blurring
• Technique checks: Ribs visualized through abdominal organs
• Clinical aim: Demonstrate lower ribs and costophrenic angles for trauma or pain below diaphragm

Oblique Ribs (Anterior or Posterior Obliques)

CR Location & Positioning

• SID: 72 inches for upper ribs; 40 inches acceptable for lower
• Patient position: Upright for upper ribs; supine for lower if needed
• Adjustments: Rotate patient 45°
  • PA obliques (RAO/LAO): Affected side closest to IR
  • AP obliques (RPO/LPO): Affected side away from IR
    Raise arm on elevated side above head; opposite arm down and behind torso
• CR:
  • Upper ribs: Perpendicular at T7 (≈ 3–4″ below jugular notch)
  • Lower ribs: Midway between xiphoid and lower rib margin; bottom of IR at iliac crest
• Pt. Instructions: Full inspiration for upper ribs; full expiration for lower ribs
• Exposure: On correct breathing phase

Evaluation Criteria

• Coverage:
  • Upper obliques: Ribs 1–10 demonstrated
  • Lower obliques: Ribs 8–12 demonstrated
• Rotation checks: Affected-side ribs appear twice as far from spine as opposite side
• Motion checks: Sharp axillary rib borders; no blur
• Technique checks: Diaphragm included; uniform brightness
• Clinical aim: Demonstrate axillary and lateral rib portions free of superimposition

Supplemental Projections

Cross-Table Lateral (Trauma or Pneumothorax Assessment)

CR Location & Positioning

• SID: 40 inches
• Patient position: Supine (trauma); dorsal decubitus with side of interest closest to IR
• Adjustments: Elevate arms above head if possible; ensure IR positioned to include area of trauma
• CR: Horizontal beam, perpendicular to IR, centered midway between midaxillary line and region of interest
• Pt. Instructions: Suspend respiration to minimize motion
• Exposure: On inspiration for upper ribs, expiration for lower ribs

Evaluation Criteria

• Coverage: Entire side of interest from sternum to posterior ribs
• Rotation checks: Posterior ribs superimposed; spine lateral
• Motion checks: Sharp diaphragm margins; lung markings clear
• Technique checks: Sufficient contrast to visualize ribs through thoracic structures
• Clinical aim: Evaluate displaced rib fragments, pleural air (pneumothorax), or fluid (hemothorax) without patient rotation

Oblique Chest (Steep 60° RAO/LAO)

CR Location & Positioning

• SID: 72 inches preferred
• Patient position: Upright preferred; rotate 60° from PA position
• Adjustments: Affected anterior ribs closest to IR; arms raised above head; shoulders rotated anteriorly
• CR: Perpendicular to IR at level of T7 (≈ 3–4″ below jugular notch or 7–8″ below vertebra prominens)
• Pt. Instructions: Full inspiration; hold breath
• Exposure: On full inspiration

Evaluation Criteria

• Coverage: Sternum and anterior ribs demonstrated with minimal overlap of vertebral column
• Rotation checks: Adequate 60° obliquity evident by lateral ribs well separated from spine
• Motion checks: Clear lung markings and sharp diaphragm
• Technique checks: Ribs visualized through lung fields without overexposure
• Clinical aim: Evaluate anterior rib fractures near sternum or costal cartilage region

PA Chest (Adjunct View for Rib Trauma)

CR Location & Positioning

• SID: 72 inches
• Patient position: Upright facing IR; MSP centered
• Adjustments: Chin raised; shoulders rolled forward and down; arms at sides
• CR: Perpendicular to IR at level of T7 (≈ 7–8″ below vertebra prominens or inferior angle of scapula)
• Pt. Instructions: Deep inspiration; hold breath
• Exposure: On full inspiration

Evaluation Criteria

• Coverage: Entire lungs from apices through costophrenic angles
• Rotation checks: SC joints equidistant from spine
• Motion checks: Sharp vascular markings; clear diaphragm
• Technique checks: Heart and mediastinum faintly visible through lung fields
• Clinical aim: Evaluate associated lung pathology such as pneumothorax, hemothorax, or contusion from rib injury