Katie Mckinnon. Skeletal survey for NAI, Don't Forget the Bubbles, 2019. Available at:
In November 2018 the revised edition of “The radiological investigation of suspected physical abuse in children” was released in the UK. This was written by the Royal College of Radiologists and the Society and College of Radiographers, and endorsed by the Royal College of Paediatrics and Child Health. It produced guidance on the process of skeletal surveys and how and when to perform them.
The management of non-accidental injury is an area of fear for many paediatricians. The increasing guidance in this area helps to take some of the variation in practice out of the process.
What is a skeletal survey?
Skeletal surveys are a set of radiological images to assess for further evidence of injury in cases of possible non-accidental injury. It is particularly used in those under 24 months old, who are less able to give a history or demonstrate localised pain/injury on examination.
The skeletal survey can also include computed tomography (CT) head scan, particularly in those under 12 months. It is also part of the greater process of safeguarding assessment, which will include full assessment with body map documentation, ophthalmology assessment, and discussion between the hospital team and safeguarding services.
A whole article could be written on when to consider non-accidental injury. Once this concern has been raised, a senior paediatrician will decide on the need for a skeletal survey. Specific factors to consider are concerning injuries and fractures.
What’s new in the 2018 RCR imaging guidance?
One area raised by the new guidance is consideration of other children in the household (apart from the index case).
They specify that all multiple birth siblings under 24 months of age should be screened in the same way and the index patient, and that other children in the same household under 24 months old should also be considered.
Other key practical elements are highlighted by the new RCR guideline, for example that parents should be given information about the imaging, and written consent obtained.
Which children with fractures should have a skeletal survey?
In the context of suspected NAI, a skeletal survey should be carried out in children under 24 months with a fracture and any of the following:
- Confessed abuse/injury during domestic violence
- Delayed attendance (>24 hours in a child with obvious distress)
- History of impact from a toy or other object causing a fracture
- Other injuries on assessment that are not related to the fracture
- No trauma history to explain fracture (not an exception is made for ambulatory children >12 months old with a distal buckle fracture of the radius/ulna, or a distal spiral or buckle fracture of the tibia/fibula)
A skeletal survey should be carried out in children 12-23 months with any of the following fracture types:
- Rib fracture
- Classic metaphyseal lesion
- Complex or ping-pong skull fracture
- Humeral fracture with epiphyseal separation attributed to a short (≤3 feet) fall
A skeletal survey should be carried out in all children 0-11 months old with any fracture except the following (with no additional concerns):
- Distal radius/ulna buckle fracture or toddler fracture of tibia/fibula in a cruising child≥9 months old with a history of fall.
- Linear, unilateral skull fracture in a child >6 months with a history of a significant fall (height >3 feet or fall with caregiver landing on the child).
- Clavicle fracture likely due to birth trauma (acute fracture in baby <22 days old or healing fracture in baby <30 days old.
What about children with intracranial haemorrhage?
In children under 24 months old with an intracranial haemorrhage (ICH) – a skeletal survey should be considered in the following cases.
All children <6 months old with ICH
All children 6-11 months old with ICH except in the following (and with no additional concerns)
- Well children with a history of a high fall (≥3 feet) and a tiny haemorrhage under a fracture.
- Well child with a history of a high fall (≥3 feet) and an extradural haemorrhage.
Children 12-23 months old with ICH (subdural or extradural) with any of the following
- Any subdural except for a tiny subdural under a fracture
- Clinically unwell patients with no history of trauma or a low fall (<3 feet).
Children <24 months old with ICH and any of the following
- History of witnessed or confessed abuse causing the ICH.
- History of ICH occurring during domestic violence.
- Additional injuries on examination suggestive of abuse
Note this applies only if there is no verifiable mechanism of trauma that can be corroborated by witnesses, no underlying bleeding disorder, and no clear history of birth trauma to account for the injury.
Which other specific injuries should trigger a skeletal survey?
Serious injury due to suspected NAI:
- Burns >5% total BSA
- Traumatic brain injury
- Intra-abdominal/intrathoracic injury
- Injuries requiring PICU admission
Which views make up a skeletal survey?
Skull – AP and lateral
Chest – AP and oblique
Abdomen and pelvis – AP
Whole spine – lateral
Whole arm – AP
Elbow and wrist – coned lateral
Hand and wrist – PA
Whole leg – AP
Knee and ankle – coned lateral
Ankle – coned AP
Foot – DP
CT head – if <1 year or neurological concerns or evidence of head trauma
What about follow-up imaging?
A further skeletal survey should be carried out 11-14 days (and no later than 28 days) after the initial skeletal survey. This is to reduce the risk of missing acute occult injuries. Both skeletal surveys should be reported by two appropriately trained radiologists.
- Royal College of Paediatrics and Child Health. 2013. Child Protection Companion.
- Royal College of Radiologists, The Society and College of Radiographers. 2018. The radiological investigation of suspected physical abuse in children, revised 1st
- Weirich Paine, C, et al. 2016. Development of guidelines for skeletal survey in young children with intracranial haemorrhage. Pediatrics. 137:1-8
- Wood, JN, et al. 2014. Development of guidelines for skeletal survey in young children with fractures. Pediatrics. 134:45-53