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Whole SkeletonDemonstration data

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.