Skeletal Survey or Bone Survey – Indications and Uses

A skeletal survey is a series of x-rays which are done to view the entire skeleton, performed systematically to cover the entire skeleton or the anatomic regions as per clinical indications.

Different clinical indications may demand a different set of x-rays. In the case of child abuse, which is a common indication, the local health protocols may differ slightly on the inclusion of different views of x-rays.

A bone survey takes X-rays of the:

• skull
• ribs
• spine
• pelvis
• long bones [forearm, humerus, leg, femur]
• any other bones that need to be looked at

A joint survey is often done along and includes views of wrist, elbow, shoulder, ankle, knee, hip and sacroiliac joints.

The aim of the skeletal survey is to identify focal or diffused abnormalities of the skeleton and in case of children to differentiate them from anatomic variations or developmental changes.

Indications of skeletal survey

• Child abuse [suspected or known]
• Widespread infections
• Skeletal dysplasias
• Bony Lesions
  • Multiple myeloma
  • Eosinophilic granuloma
  • Metastasis
• Paget’s disease
• Metabolic bone disease like hyperparathyroidism
• Rickets
• Scurvy
• Polyarticular arthropathy

It must be mentioned that barring child abuse, the survey is not required only when there are diagnostic difficulties.

Skeletal Survey in Child Abuse or Nonaccidental injury

• Skull  – AP and Lateral views
• Chest
  •  AP & Lateral in inspiration
  • Right and Left oblique for Ribs
    • Done in inspiration –
    • Include lower ribs.\
• Abdomen
• Pelvis
• Bilateral femora
• Both legs AP
• Both feet AP
• Coned view bilateral knees   AP
• Coned view bilateral ankles  AP
• Bilateral arms with hands –  AP
• Lateral view of spine

A follow-up survey is done after two 2 weeks.

The follow-up survey is usually the same as above except for skull, spine, and pelvis usually.

But if these were regions of concern previously, they should be included.

Skeletal survey for other Causes Such as Syndromes

Following is the list that generally encompasses most of the regions. But the x-rays to be done can be modified depending on the type of lesion and region of interest.

[While body CT is a more sensitive, faster and convenient investigation as compared to the skeletal survey. Availability, cost, and concerns for radiation dose are the drawbacks though]

• Skull AP and Lateral views
• Chest PA and Lateral views
• Abdomen including pelvis
• Left leg AP view
• Left-arm AP view
• Lateral view of the spine including the sacrum
• Bilateral wrists and hands AP view
• AP or dorsoplantar view of the foot

Skeletal Survey for Endocrine Lesions

• Skull 3 views
  • Anteroposterior
  • Townes view
  • Lateral view
• Chest X-ray
  • Posteroanterior view
  • Lateral view
• Abdomen including the pelvis and upper femora
• Both legs AP view
• Both feet dorsoplantar view
• Both arms anteroposterior view
• Lateral view of the spine

Skeletal Survey of Neonates

These are usually done in cases of syndromes and infection

X-rays in case of syndromes

• AP and lateral views of the skull
• Ap and lateral views of chest including thoracic spine
• Lateral views of the lumbar, sacral & cervical spine
• Abdomen including pelvis
• Left leg, foot, arm and hand
  • In case of asymmetries include both upper limbs

X-rays in case of Infections

• Babygram
  • Anteroposterior and lateral images of the child
  • Should include chest, abdomen, shoulders & hips
• Both arms AP views
• Both legs AP
• Views of the involved region if there is a local swelling or erythema.

Use of Skeletal Survey

X-rays are basic investigations and have widespread availability.

Skeletal survey, by the sheer number of x-rays included, requires preparations at all the fronts.

In the case of child abuse, the skeletal survey is mandatory in all cases of children younger than 2 years.

However, this screening is not found of much value in children older than 5 years.

The children between 2- to 5-year-olds must be considered individually.

For other ailments and lesions, whole body CT is a faster and convenient choice. But still, the skeletal survey is used as it is easily available.