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Learn How to Count Ribs on Ultrasound!

By Learn MSK Sono FEATURING Jamie Bie, RMSKS, RVT, RDMS

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July 4, 2023

Do you want to know how to scan the ribs using ultrasound?

Have you ever ...
read more ↘ wondered how it's possible to know which rib you are scanning without being able to see all the ribs in one image?

The good news is that it is possible to count the ribs on ultrasound, and it is a reliable modality for detecting pathologies such as fractures, costochondritis, or slipping rib syndrome. To do so, you must first be able to recognize which segment of the rib you are imaging, and at which level. Then, you can properly label the location where the patient may be having pain or a palpable abnormality.

Start your examination by placing your transducer in a Sagittal plane on the body, short axis to the medial aspect of the palpable clavicle.

The clavicle is an easy landmark to begin because you visibly see the way the bone runs and place your transducer perpendicular to it. If you start your exam too far lateral you will miss the first rib and your count will be off by 1.

When you visualize the first rib just inferior to the clavicle you can begin counting from 1-121.

1.Move the transducer from superior to inferior while gradually gliding laterally as you scan inferior
2.When you are scanning along the medial aspect of the rib cage, you are at the level of the costal cartilage
3. You must move laterally as you scan to see all 12 ribs. The true ribs are 1-7, the false ribs are 8-10, and the floating ribs are 11-12

The rib appears hypoechoic at the level of the costal cartilage and transitions into a hyperechoic ossified bone laterally.

To begin evaluation of a single rib in the long axis, place the transducer in a transverse plane on the body over the rib of interest and do a sweep from medial to lateral. Start at the level of the bony sternum and sweep laterally until the costal cartilage transitions into a bony rib. You must keep elongating the rib while moving upward and lateral to fully visualize it. It is easier to count the ribs in the short axis when you are in a sagittal plane of the body to get an accurate count, but you must visualize the rib in both planes to know which segment of the rib you are looking at!

Now you are ready to label the ribs properly and examine them for pathology!
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