Skeletal Survey

The skeletal survey is a standardised series of radiographs covering the whole skeleton, used to detect and map disseminated bone disease. In adults it is central to the assessment of multiple myeloma and metastatic disease, showing lytic or sclerotic lesions and pathological fractures. A dedicated high-detail paediatric protocol is the imaging cornerstone for suspected non-accidental (inflicted) injury, seeking fractures of differing ages and specific high-specificity injuries.

Indications

Suspected or known multiple myeloma or plasmacytoma for staging of bone involvement
Metastatic bone disease to map lytic and sclerotic deposits and assess fracture risk
Metabolic bone disease and dysplasias such as Langerhans cell histiocytosis or osteogenesis imperfecta
Suspected physical abuse in a child (non-accidental injury) using the dedicated paediatric protocol
Assessment of a suspected pathological fracture in a known primary

Contraindications & Cautions

No absolute contraindication; justify the collective radiation dose of the multi-region survey
Whole-body MRI or low-dose CT is now preferred to skeletal survey for myeloma detection where available
In children the survey must follow strict, high-detail protocols and be limited to appropriate clinical concern
Pregnancy requires justification and shielding, weighing benefit against fetal dose

Patient Preparation

No specific preparation is required
Explain the number of projections and the need for repositioning
Remove radiopaque objects from each field
In suspected non-accidental injury follow safeguarding pathways and document carefully
Provide analgesia and careful handling for painful pathological lesions or fragile bone

Technique & Parameters

Standard adult survey includes the skull (lateral and AP), cervical/thoracic/lumbar spine, chest, pelvis, both humeri and both femora, with forearms and lower legs added per protocol
Radiographs are optimised for bone detail with appropriate exposure and collimation
The paediatric non-accidental injury survey uses individually collimated, high-detail views of every region, including oblique rib views and dedicated views of the hands, feet and joints
Follow-up limited surveys at about two weeks in children increase detection of healing rib and metaphyseal fractures
A single whole-body babygram is inadequate and should not be used in place of the dedicated survey

Systematic Review

Review each bone systematically for lucent or sclerotic lesions
Assess lesion margins, endosteal scalloping, cortical breach and any soft-tissue component
Look for periosteal reaction and pathological fractures
In children specifically seek metaphyseal corner (bucket-handle) fractures, posterior rib fractures and fractures of differing ages
Correlate the distribution and appearance with the suspected diagnosis
Compare with any prior imaging and follow-up films

Key Findings & Significance

Multiple myeloma: multiple well-defined punched-out lytic lesions, diffuse osteopenia and endosteal scalloping
Osteolytic metastases (for example from lung, breast, renal or thyroid primaries): destructive lucent lesions
Osteoblastic metastases (for example prostate or treated breast): focal or diffuse sclerosis
Pathological fracture through a lytic lesion
In children: posterior rib fractures, metaphyseal corner fractures and multiple fractures of differing ages are highly specific for inflicted injury

Differential Considerations

Multiple lytic lesions: myeloma, metastases, lymphoma or brown tumours of hyperparathyroidism
Sclerotic lesions: osteoblastic metastases, treated lesions, osteopoikilosis or Paget disease
A solitary lytic lesion: plasmacytoma, metastasis, primary bone tumour or benign lesion
Diffuse osteopenia: myeloma versus osteoporosis or osteomalacia
In children: inflicted injury versus osteogenesis imperfecta, rickets or birth-related fractures

Pearls & Pitfalls

Skeletal survey underestimates myeloma burden; whole-body MRI or low-dose CT is more sensitive and now preferred
Lytic myeloma lesions are typically photopenic on bone scintigraphy, so the survey or cross-sectional imaging is required
In children a single babygram is unacceptable; a protocolised, individually collimated survey is mandatory
A follow-up limited survey at around two weeks improves detection of healing paediatric fractures
Correlate the lesion distribution with the likely primary and assess weight-bearing bones for impending fracture

Structured Report

List the regions and projections included in the survey
Describe the number, distribution and character (lytic or sclerotic) of lesions
Report any pathological fractures and impending fracture risk
In paediatric surveys detail each fracture, its specificity for inflicted injury and estimated age, within safeguarding processes
Give an impression and recommend cross-sectional imaging or follow-up as appropriate

References

ACR-SPR-SSR Practice Parameter for the Performance of Skeletal Surveys in Children
ACR-SPR-SSR Practice Parameter for Skeletal Surveys in Adults
Dutoit AP, Vanel D. Multiple Myeloma: Imaging. RadioGraphics
Royal College of Radiologists and Society and College of Radiographers: The Radiological Investigation of Suspected Physical Abuse in Children

Educational clinical decision support only. Protocols vary by institution and equipment; always confirm with a qualified radiologist and local guidelines before clinical use.

Skeletal Survey

📋 Indications

⛔ Contraindications & Cautions

🧑‍⚕️ Patient Preparation

⚙️ Technique & Parameters

🔎 Systematic Review

🩻 Key Findings & Significance

🧠 Differential Considerations

💡 Pearls & Pitfalls

📝 Structured Report

📚 References