Skeletal Survey
A skeletal survey is a systematic set of radiographs of the whole skeleton, with separate coned views of each region, used to detect and document bone disease in more than one site.
The main uses are:
- Suspected child physical abuse (non-accidental injury), where it detects fractures that are clinically occult and defines their number, age and pattern.
- Suspected skeletal dysplasia and metabolic bone disease (rickets, osteogenesis imperfecta, hypophosphatasia, scurvy), congenital infections (syphilis, rubella and cytomegalovirus) and bone marrow disease.
- Myeloma and metastatic disease (where low dose whole body CT or MRI has replaced the skeletal survey in many centres, because of higher sensitivity).
- Documentation in unexplained or multiple fractures.
The effective dose depends on the number of views and the age of the child (about 0.2 to 1 mSv in infants, higher in adults).
In suspected child abuse, a survey is performed in all children under 2 years with suspicious injuries. Judgement is used for children aged 2 to 5 years (when verbal history and examination direct the need for imaging). It is rarely performed over age 5, when targeted views are used. Fractures are found in up to 20 to 30% of surveys in suspected abuse.
The survey is also done for siblings under 2 years of an abused child, and for the twin of an affected infant. A follow up survey 11 to 14 days later increases detection of healing fractures by 10 to 20% and clarifies equivocal findings. A single "babygram" (one image of the whole infant) is not acceptable, because of poor detail.
Indications. Suspected physical abuse in a child under 2 years (unexplained fractures, bruising, subdural haemorrhage, abdominal or head injury, inconsistent history). Siblings or contacts under 2 years of an abused child. Suspected skeletal dysplasia (short stature, disproportion, bowing, multiple fractures).
Suspected osteogenesis imperfecta, rickets or other metabolic bone disease. Congenital infection with bone changes. Myeloma and suspected multifocal bone metastases, where whole body CT or MRI is not available. Multiple unexplained fractures at any age. Sudden unexplained infant death (post-mortem survey). Not for routine investigation of isolated fractures with a clear accidental history.
Contraindications and precautions. No absolute contraindication. Pregnancy: avoid in an adult unless essential.
The survey is performed by trained radiographers with a child specific technique, immobilisation and the smallest dose consistent with quality, interpreted by a paediatric radiologist, with a documented reason for imaging, consent from the person with parental responsibility, and safeguarding procedures followed.
Do not delay treatment, safeguarding or child protection referral to obtain imaging when the child is seriously injured.
Preparation and technique. For a young child, the usual set is about 20 to 22 views:
- Skull (anteroposterior and lateral, with a Towne view as indicated).
- Cervical spine (lateral).
- Thoracolumbar spine (lateral).
- Chest (anteroposterior, and both obliques or coned views of the ribs).
- Abdomen and pelvis (anteroposterior).
- Humeri, forearms, femora, lower legs (each anteroposterior, with lateral views of any area with abnormality).
- Hands (posteroanterior).
- Feet (anteroposterior or dorsoplantar).
Each limb is imaged separately, with the joint on each side. For adults, the myeloma survey includes skull (lateral and anteroposterior), spine (lateral cervical, thoracic and lumbar), ribs, pelvis, humeri and femora.
