The big rib sign: localization of basal pulmonary pathology in lateral projection utilizing differential magnification of the two hemithoraces

The vertical displacement sign: a technique for differentiating between left and right ribs on the lateral chest radiograph

AIM

To evaluate a new approach to the differentiation of the right and left ribs, the vertical displacement sign, and to compare its efficacy with the big rib sign.

MATERIALS AND METHODS

One hundred and nine lateral chest radiographs that clearly showed both the gastric air bubble sign and the cardiac silhouette sign were retrospectively reviewed by two radiologists. Each study was evaluated by consensus. Each radiograph was assessed for suitability of reading with each technique. Suitable radiographs were then reviewed using both the big rib sign and vertical displacement sign independently.

RESULTS

Applicability of the vertical displacement sign [107 of 109 (98%)] was greater than that of the big rib sign [95 of 109 (87%)] (P = 0.0017). The accuracy of the vertical displacement sign [105 of 107 (98%)] was higher than that of the big rib sign [74 of 95 (78%)] (P < 0.001).

CONCLUSION

The vertical displacement sign seems to be a reliable technique for the differentiation of right and left ribs on the lateral chest radiograph and can be used as a complementary technique when the big rib sign is not applicable.

The ribs: anatomic and radiologic considerations

The ribs are essential structures of the osseous thorax and provide information that aids in the interpretation of radiologic images. Techniques for making precise identification of the ribs are useful in detection of rib lesions and localization of lung lesions. The big rib sign and the vertical displacement sign can be used to differentiate the right and left ribs on lateral chest radiographs. The clavicle, the xiphoid process, and the sternal angle may be used as anatomic landmarks for rib counting on computed tomographic scans. For rib counting on lateral chest radiographs, the sternal angle or the 12th rib may be used. Anatomic rib variants include developmental deformities, cervical rib, and short rib and may mimic true rib diseases. Detection of thoracic deformities such as funnel chest (pectus excavatum) and barrel-shaped thorax requires an awareness of the strong correlation between the transverse appearance of the thorax and costal shape. Shadows around the rib cage (eg, rib companion shadows, sharp lines along the lower margin of the ribs, rib overlying shadows) may mimic pleural and extrapleural disease on frontal chest radiographs. It is imperative that the radiologist be familiar with normal rib anatomy, normal rib variants, and the radiologic appearance of the ribs to prevent misdiagnosis.