Skeletal survey (non-accidental injury)

A skeletal survey in NAI 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 prior to 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 paediatric radiology opinion and review during the study.

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

• torso
  • chest AP
  • ribs (oblique) (left and right)
  • abdomen and pelvis AP
  • spine (whole spine lateral)
• upper limbs (each)
  • humerus AP
  • elbow lateral
  • forearm AP
  • wrist lateral
  • hand DP
• lower limbs (each)
  • femur AP
  • knee (lateral)
  • tib/fib AP
  • ankle lateral
  • foot DP

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 1 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.

Practical points

• skeletal surveys are technically and emotionally demanding, they require specially trained radiographers with a clear understanding of the process
• often centres require a minimal of two radiographers with specialised training in the room at all times, with the use of anatomical markers (rather than digital) ¹
• quality images, free from motion artefact are important, use of appropriate immobilisation techniques should be considered including the use of adults to assist holding the patient, if this is done, all parties involved must be documented