Skeletal survey (non-accidental injury)

A skeletal survey in non-accidental injury is a defined set of images that are obtained to assess the majority of the bones in the child. Referral for a skeletal survey in this context will usually come from a member of the child protection team, and there should be a thorough discussion about their concerns before the study being performed. In most cases, this study should only be performed in an institution where the radiographers have appropriate training and where there is access to pediatric radiology opinion and review during the study.

United Kingdom

In the UK, a skeletal survey is composed of ¹:

• torso

  • AP chest

  • ribs (oblique) (left and right)

  • AP abdomen and pelvis

  • whole lateral spine

• upper limbs (each)

  • AP humerus

  • lateral elbow

  • AP forearm

  • lateral wrist

  • DP hand

• lower limbs (each)

  • AP femur

  • lateral knee

  • AP tib/fib

  • lateral ankle

  • DP foot

The humerus and forearm may be imaged as a single AP if the quality is appropriate. This is also true of the femur and tib/fib. 

In all under one year old and in all children where there is neurology or encephalopathy, a CT head should be performed. Where a CT is not performed, skull radiographs should be performed.

Australia and New Zealand

In Australia and New Zealand, the primary skeletal survey is comprised of ²:

• head, chest, spine and pelvis

  • AP and lateral skull (if CT has not been performed)

  • AP chest (including the shoulders)

  • ribs (oblique) (left and right)

  • AP abdomen and pelvis

  • whole lateral spine

• upper limbs (each)

  • AP arm (centered at the elbow)

    • if the child is too large

      • AP humerus, including the shoulder and elbow

      • AP forearm, including the wrist and elbow

  • lateral elbow

  • lateral wrist

  • PA hand and wrist

• lower limbs (each)

  • AP lower limb hip to ankle

    • if the child is too large

      • AP femur

      • AP tibia and fibula

  • lateral knee

  • lateral ankle

  • mortise ankle

  • AP knee

  • DP foot

Practical points

• a single radiograph of the entire patient, i.e. a 'babygram', is not a recommended nor appropriate exam for the assessment of suspected non-accidental injuries ^1,2

• skeletal surveys are technically and emotionally demanding, they require specially trained radiographers with a clear understanding of the process

• often centers require a minimal of two radiographers with specialized training in the room at all times, with the use of anatomical markers (rather than digital) ¹

• quality images, free from motion artifact, are important. Use of appropriate immobilization techniques should be considered, including the use of adults to assist holding the patient; if this is done, all parties involved must be documented