I’ve been puzzling over something for a goodly time now, and have–defeated–thrown in the towel. At your mercy, I must ask for your indulgence, and assistance. In return, your questions too shall be addressed and, I hope, answered to your satisfaction.
What is my conundrum? Simply this: since the debut of my blog, the stats gathered by the WordPress servers consistently indicate large number of views for my post “Counting Ribs”, more than any other. Many, apparently, result from searches such as ‘how to count ribs,’ ‘counting ribs on chest x-ray,’ and the like. Of course, if you read that post you quickly realize that it isn’t really about the ribs, much less an instruction manual for how to count them. Seeing the stats month after month, and imagining the disgust or disappointment of those who find my offering deficient, I confess I feel no small twinge of guilt. Read on, and I will remedy the earlier deficiency. First, though, a few words about the ribs and their various afflictions.
Well, ok, first I need you to read the standard disclaimer: this site and blog post are not intended to provide medical advice, nor do they in any way represent the organization I work for. If you are having health issues you should seek the care of a medical professional–in person.
I can’t help but wonder why so many people seek this information. Do they have a rib fracture, or other problem? Do they know someone who does? Do they think the precise locus of this issue carries a unique, particular import? Has their doctor diagnosed a rib disorder, but not shown them its ghostly tracing on their x-ray? Are they having pain, or have they found a lump, and wonder which rib might be the offender?
In most cases, the exact site of a rib fracture matters relatively little. It makes no difference whether a fracture finds itself in the sixth rib, the eighth, or the fifth, or on the left side versus the right. An important exception concerns fractures of the first 3 ribs: these tight curved flutes, huddled close against the apex of the lung, are not easily disrupted. A break in one, or all, of them implies trauma to the chest sufficient to cause other, more serious damage–to the large arteries or veins in the chest, to the pleura (the lining of the chest cavity that surrounds the lung), or even to the heart. This generally occurs in high-speed car crashes, or falls from great heights, and is a well known sign of important chest injury. Every first-year radiology resident is taught to look for it, and to raise the red flag whenever it is found.
Another exception relates to other structures in the neighborhood that could be injured by the initial insult, or by the broken edges of a fractured rib. Fracture of the lower ribs, for example, can be associated with, or lead to, damage to the liver, spleen, or other organs. These too are often the result of major trauma, and aren’t as important in their own right as for what they signify. The number of ribs that are fractured can be important, as a string of five or more can cause the chest wall to break ranks when the patient tries to breathe, moving out when it should move in and vice versa–or not moving at all. This condition, known as flail chest, can cause major compromise of gas exchange. There’s also a high chance of pneumothorax, or punctured lung, when more than a single rib is broken.
Other things that can befall the ribs include a panoply of tumors, benign or malignant, infection, cysts and other non-tumorous growths, metabolic problems, and assorted other rarities. For most of these, their specific location isn’t important.
All that aside, the thing about counting ribs is that it’s tricky. First of all, not everyone has the same number of the things: twelve on each side is standard, but some of us have eleven, while others have 13….and there can be asymmetry between left and right sides. Extra ribs, if present, may be at the top or bottom end. For this reason, it’s most accurate–though also, potentially, most confusing–to start counting from the top, rather than the bottom if you really need to know exactly which rib is acting up. That’s harder because, as I noted earlier, the first few ribs are small and jammed together tightly in the upper chest. As a result, they overlap on chest x-rays, creating all manner of perplexing curves and shadows. The good news is that extra ribs at the upper end of the spine, so called ‘cervical ribs’, are easy to recognize and discount. That’s because they are generally very small and don’t look at all like the neighboring normal ribs.
Here are a few images of the ribs in various projections (degrees of obliquity), without and with annotations to show the count. Note that it’s best to start where each rib joins the spine and follow it outward (laterally). The initial portion of each rib is more or less straight, but they curve downward as you follow them around the side to the front of the chest–hence the apparent jumble and overlap of numbers in some areas. You may need to try it a few times, but just remember to start near the spine and work your way out from there. Give it a go….and leave me a comment about why you’re interested in counting ribs!
Well since you asked! I was searching for how to count ribs because in the past year I have developed chronic pain on one side that seems to originate with an intercostal muscle spasm (trigger point maybe) between two of the lower ribs. Well, the pain didn’t lead me straight to research rib counting, there have been many stops along the way in various online sessions here and there over past months. But tonight’s cyber-diagnostic wanderings led me to hit on a pain management discussion page/forum on a support site for sufferers of Ehlers-Danlos Syndrome (which I’d never heard of before, and no I don’t now think I have it) where someone threw out a question about intercostal injections. Someone (another EDS patient) responded at length and included some advice about how to learn the nerve mappings for the spasming muscles…had a link that led me, not here, but to a site (getbodysmart.com) where, I then find myself taking an axial skeleton quiz that talked about which rib numbers fell into true/false/floating ranges….which led to a brief and futile attempt to locate my own by touch (and a brief side trip to Wikipedia to find out if the clavicle is considered a rib), I then Googled “how to count ribs” and got to your original post…which as you mention, did not tell me how to count my ribs. As must be obvious, I am not a physician so you might think that the story wouldn’t mean too much to me but I actually found it rather poignant and applicable to other life/career situations so it wasn’t like I was irritated about not learning how to count ribs afterwards. So anyway, then I saw the link to this redux page and clicked on it. Am I learning the rib thing now as a result of reading your tutorial? No, but not because it wasn’t a fine lesson..it’s just that at this point I think I realized that what I was actually trying to figure out really would not require that I can properly designate rib numbers! Not to mention… what was I trying to figure out again?! Well there you have it…this may irritate you somewhat in that way that physicians I know tend to get when they hear about patients self-diagnosing after a consult with Dr. Google…but I hope it gave you a chuckle as well!
Thanks for the info….not annoying at all–I’m a big believer in patients being active participants in their care and decision-making. However, it must be said that seeking medical advice on the internet can be perilous, and not all sites purporting to offer help are legitimate or accurate. There’s no substitute for an old-fashioned history and physical exam, face to face, and the opportunity to have a conversation. As with so much else in life, context is key….and medical info online fails on that score.
Reason for searching for how to count ribs is simply because I’m a medical student entering my clinical years and always find it a chore to count them. The first three are the ones that are tricky. Thanks for the post!
I’m here for the exact same reason Julian is, being a UK medical student. I always have difficulty counting the ribs on the patient without being overly forceful when doing so and wondered if there was any tips and tricks online that I was missing.
Thanks for the blog post anyway, t’was a good read.
I am a Radiologic Technologist, i read your post to learn more about how others count ribs, because I often count them to measure inspiration on chest radiographs. @Julian in my experience the first rib always curves around much more extremely and that is a great indication of which one it is. Great radiograph on the cervical ribs, thanks.
2nd year med student – realized i dont really know to properly count and identify the top few ribs. Thank you!
Humourous post. I am a 5th year medical student studying at the University of Cape Town in South Africa, and whilst studying for end of year trauma exams, I suddenly found myself asking where one starts counting ribs from on a chest Xray. Hence I found myself here after reading the previous post. That post on counting ribs wasn’t necessarily irritating to read, but you found yourself eagerly anticipating the end of the “touchy feely” stuff that doctors and medical students sometimes avoid so that one could get to the meat of the matter. In any event, your post did clarify my previous quandaries with regards to counting ribs on an xray. I just hope I can now remember how to do it!
Am a surgeon, just had a patient with 9th rib crack, a junior doc asks me what rib it was and my answer to him in the presence of the patient was. ” it doesn’t matter , just treat the patient.” that was a little over reaction, wasn’t it? I did make the correct entry as the 9th rib though, and canceled the patient a little earlier of its insignificant consequence…. i’m glad you did point out that ‘it relatively mattered little’ ..why am i here? just browsing,,, i do the counting slightly in a different manner; i do count them as each rib negotiates with the ’roundabout’ towards the sternum … rib 11, 12 are usually invisible and should be specifically ordered to be included if necessary.
otherwise, this is a great post, good job!
Hey there just wanted to give you a quick heads up.
The text in your content seem to be running off the screen in Opera.
I’m not sure if this is a format issue or something to do with browser compatibility but I thought I’d post to let you know.
The layout look great though! Hope you get the problem solved soon.
Many thanks
Just to help your curiosity, I found your blog because I am revising for my cardiorespiratory physiotherapy exams.
Thank you for your information, I was in a car accident and was told I have a broken sternun and two broken ribs, 11 and 12. It did not make sense to me that the 11 and 12 ribs were broken, because my pain is on the upper chest not in the lower part of my ribcage.
Since the routine views for a chest xray are PA and Lateral, why don’t you show how to count ribs from these views? The anterior view is somewhat helpful, but the oblique view really serves little purpose. Thanks!
Its like you read my mind! You seem to know so much about this,
like you wrote the book in it or something.
I think that you can do with a few pics to drive the
message home a little bit, but instead of that, this is great blog.
A fantastic read. I’ll definitely be back.
I’m a PA student studying for my radiology block! Thanks a lot!
I count ribs because I am a spine pain physician. I use them as landmarks. I have run into cases where a patient had a sacralization of the 5th lumbar vertebra, but his was missed because the patient was also missing the T12 ribs. I was wanting to find a way to count them without having to order an x ray of the complete spine to count vertebra. Counting ribs on a CXR can be tricky especially since the view often doesn’t contain the whole rib cage. Why be concerned over a sacralized L5 vertebra? What if the disc between last lumbar vertebra and the sacrum is herniated? this would normally be L5/S1 what if this is really L4/5 and the disc is a small to medium herniation that does not appear to encroach the nerve roots? what if the patient has a significant sciatica with a calf weakness? What may actually be a sciatica involving a piriformis syndrome or an SI joint dysfunction may get operated on at the L4 disc because it is the incorrectly identified as L5/S1 when it is really L4/5? What if the sx’s donot imporove with the disc surgery? The patient may then undergo a fusion at this level which may make the sciatica even worse. The point I’m trying to make is that the neurological levels determined by the bony level needs to be consistent with the neurological level determined by the exam.
Thanks a lot…
Funny, and how good of you to both watch your stats and react accordingly. Google is pretty good about determining what your “content domain authority” is, but a scattered blog including an, apparently, highly sought after but ill-represented subject matter and one that is, in your case, well annotated and juicy with keywords is surely to rise and remain at the top. Note also that maybe others may have, as did I, stumble across your page not just in google but specifically in google image: Your numbered ribs pic is among a sea of numberless ribs! 😀
In my particular case, I was so happy to have my original xrays but was so lost to find anything that looked like a break… or anything that didn’t! ha. It’s almost easier to read a sonogram!
Cheers
thanks; glad you enjoyed the annotated pics! the blog is scattered, very true; been meaning to split it up for better focus….life gets in the way, alas.