Upper Extremities
Bone Survey (Skeletal Survey)
Anatomy
Anatomy & Key Landmarks
Includes the entire axial and appendicular skeleton — skull, spine, ribs, pelvis, upper and lower limbs.
Major anatomic landmarks vary by view: skull sutures and vault, vertebral alignment, rib contours, clavicles, pelvis and hip joints, long bone cortices, and epiphyses or physes in children.
Common Pathologies/Indications
- Nonaccidental Trauma (NAT): Used to identify occult fractures or injury patterns inconsistent with reported trauma, especially in infants or non-verbal children.
- Skeletal Dysplasias & Metabolic Disorders: Used to evaluate bone development, mineralization, and structural anomalies (e.g., osteogenesis imperfecta, rickets, metabolic bone disease).
- Neoplasms / Metastatic Disease: Used to assess for multifocal or widespread osseous metastases (e.g., prostate, breast, lung, or renal carcinoma).
- Baseline & Follow-Up Studies: For systemic bone disease, therapy monitoring, or pre-/post-treatment comparison.
Protocol Overview
General Principles
A skeletal survey is a systematic series of radiographs encompassing all or most of the skeleton, tailored to the indication (ACR).
Exams must be comprehensive yet efficient, minimizing motion and exposure.
Use immobilization when appropriate and apply gonadal shielding without obscuring diagnostic anatomy.
Technical Factors
- SID: 40 inches (102 cm) standard
- IR: Size varies by anatomy; full inclusion of regions of interest
- Exposure: 65–75 kV for digital systems (adjust for habitus and bone density)
- Grid: Not typically used for infants/small children; used for adults and thicker anatomy
- Patient Prep: Remove jewelry, metal, or clothing artifacts
Shielding: Use when possible without obscuring regions of interest
Representative Projections
Depending on indication, skeletal surveys may include:
Pediatric NAT / Dysplasia Protocols:
- AP and lateral skull
- AP and lateral spine
- AP chest (including ribs, clavicles, scapulae)
- AP pelvis and hips
- AP humeri, forearms, femora, tibiae/fibulae (bilateral when possible)
- Hands (PA, left by standard) and feet
Adult Metastatic Survey Protocols:
- Skull (AP and lateral)
- Cervical, thoracic, and lumbar spine (AP/lateral)
- Chest (AP or PA)
- Pelvis (AP)
- Upper and lower limbs (spot or long bone views, AP)
- Additional spot films as indicated by symptoms or prior findings
Bone Survey of the Lower Limbs
CR Location & Positioning
- SID: 40 inches (102 cm)
- Patient position: Supine (pediatric) or upright/supine (adult).
- Adjustments: Bilateral imaging may be obtained on a diagonal IR to include hips through feet.
- CR: Perpendicular to mid-limb region of interest.
- Pt. Instructions: Hold still; use immobilization or caregiver support as appropriate.
- Exposure: Shortest exposure possible to reduce motion.
Evaluation Criteria
- Coverage: All required anatomy included; verify joints at ends of long bones.
- Rotation checks: Symmetry of femoral condyles and limb alignment; for adults, consistent cortical margins.
- Motion checks: Cortical and trabecular details clearly defined.
- Technique checks: Appropriate penetration; visible soft tissue detail.
- Clinical aim: Demonstrate pathologic lesions, fractures, or systemic abnormalities.
Comparison of Skeletal Survey Indications (per ACR)
| Indication | Typical Patient Population | Primary Imaging Regions | Key Considerations |
|---|---|---|---|
| Nonaccidental Trauma (NAT) | Infants and young children (< 2 years) with suspected physical abuse | Entire skeleton: skull, spine, chest (ribs), pelvis, upper and lower limbs, hands, feet | Must be comprehensive; bilateral limbs for comparison; repeat in 10–14 days if needed; follow institutional child-protection protocols |
| Skeletal Dysplasias / Metabolic Disorders | Infants and children with abnormal growth, short stature, or suspected metabolic bone disease | Axial and appendicular skeleton including long bones, pelvis, and skull | Evaluate ossification centers, bone density, and shape; compare with age-matched references; monitor therapeutic response |
| Neoplasms (Metastatic Disease) | Adults or children with known/suspected primary malignancy or systemic metastases | Skull, spine, ribs, pelvis, proximal long bones; additional targeted regions per symptoms | Look for lytic, blastic, or mixed lesions; baseline for disease extent or therapy follow-up; may complement or precede nuclear medicine bone scan |
Protocol Customization Notes
Skeletal survey protocols should always be tailored to the clinical indication and patient population.
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For pediatric NAT or metabolic evaluations, a complete skeletal survey is required, including all long bones, skull, chest, spine, pelvis, hands, and feet—often with bilateral comparisons.
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For suspected skeletal dysplasia or metabolic bone disease, projection sets may be customized to emphasize growth plates, ossification centers, and long bone morphology, using lower exposure factors and careful collimation.
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For metastatic disease surveys in adults, the exam is often region-focused, emphasizing the axial skeleton and proximal long bones, as these are the most common sites of metastasis. Additional or follow-up spot views should be guided by symptoms or prior imaging.
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In all cases, standardized positioning, accurate labeling, and consistent technique are essential for reproducible comparison over time or between institutions.
Hows & Whys of Bone Survey Radiography
Anatomy
- Why is the left hand and wrist commonly used for assessing bone age or skeletal maturity?
Standardization allows comparison with reference atlases such as Greulich & Pyle or Tanner–Whitehouse, ensuring reproducibility. - Why must both appendicular and axial skeletons be imaged for a metastatic or NAT survey?
Metastases and occult fractures can occur anywhere in the skeleton — complete imaging ensures detection of multifocal or systemic involvement.
Positioning
- Why are infants kept supine for skeletal surveys rather than upright?
Supine positioning allows immobilization, consistency, and safety; upright positioning increases motion risk and potential distress. - Why should the IR be placed directly beneath the patient rather than using a pad or cushion?
Any separation increases OID and magnification, reducing image sharpness and spatial accuracy for measurement. - Technique & Image Evaluation (Reverse Questions)
How can you confirm adequate exposure for a bone survey image?
Cortical margins are well defined, trabecular patterns visible, and no burned-out or underexposed regions obscure diagnostic detail. - How can you differentiate true fractures from normal growth plates in pediatric surveys?
Growth plates are smooth, symmetric, and located at expected anatomic levels; fractures are irregular, angulated, or asymmetric.
Clinical Applications
- Why are follow-up skeletal surveys often performed 10–14 days after an initial NAT survey?
Healing callus formation can confirm or reveal additional fractures not initially visible. - Why are skeletal surveys used for metastatic workups instead of bone scans in some patients?
They provide direct anatomic detail and can better visualize lytic or sclerotic patterns, particularly in multiple myeloma or osteoblastic metastases.
