Skeletal (osseous) survey

Why and when

A skeletal survey, also called an osseous or bone survey, is a planned set of radiographs that covers most of the skeleton. The three main reasons are suspected non-accidental trauma (NAT) in a young child, a cancer that destroys bone such as multiple myeloma, and suspected skeletal dysplasia (an inherited bone growth disorder). Each reason has its own list of views, but the rules are the same: every region is a separate, tightly collimated image with a lead marker, taken with enough detail to show a tiny fracture line.

The child abuse survey

For suspected abuse the survey is routine in children under 2 and selective from 2 to 5. Following the ACR protocol, the axial skeleton is a frontal and lateral skull, frontal and lateral cervical spine, AP and lateral thorax, right and left oblique ribs, AP pelvis and lateral lumbar spine. The appendicular skeleton is an AP of each humerus, forearm, femur and tibia, a PA of each hand and an AP of each foot. That is about 20 images. Fractures that raise concern are posterior rib fractures (from squeezing the chest), classic metaphyseal lesions at the ends of long bones (corner or bucket-handle fractures), scapula, sternum and spinous process fractures, and several fractures of different ages. A follow-up survey about 2 weeks later finds fractures that only show once they start to heal. The skull is usually left out of it, because skull fractures do not form callus.

Adult surveys

In adults, a myeloma survey covers the bones that hold red marrow. A typical set is a PA chest, lateral skull, AP and lateral cervical, thoracic and lumbar spine, AP pelvis, and AP humeri and femurs. Myeloma lesions are lytic (punched-out holes), with little new bone forming, so a nuclear medicine bone scan can miss them. Many centers now use whole-body low-dose CT instead, but the radiographic survey is still on the exam. A metastatic survey is less common now, because a bone scan finds blastic metastases from prostate or breast cancer more easily. A dysplasia survey adds views such as a PA left hand for bone age and a lateral thoracolumbar spine.

Doing it well

A whole-body babygram is never acceptable. Beam divergence distorts the edges of the field, and one exposure cannot be right for both the skull and the feet. Use a small focal spot, a technique set for each part, and the smallest field that covers it. Check every image for rotation and clipped joints before the patient leaves, since a repeat days later can miss findings. Myeloma patients have fragile bones, so move them slowly and let them help. With a child, stay neutral and kind with the family, record who was present and anything you saw, and follow facility policy and state law for reporting. Never discuss suspected abuse with the caregivers yourself.