The role of radiography in skeletal surveys
A skeletal radiographic examination (skeletal survey) aims to accurately identify and date bone injuries. It allows for the differentiation of true fractures from normal variants of growth or metabolic bone diseases.
In cases of suspected abuse (non-accidental trauma), the examination is performed according to strict protocols. The most critical rule is that high-quality, targeted radiographs of each anatomical region must be taken separately. Performing a single full-body overview image ("babygram") is strictly prohibited.
Standard radiographic projections
To properly assess the skeletal system in young children, a standardized set of positioning views is used:
- Skull: anteroposterior (AP) and lateral projections. When occipital bone trauma is suspected, a Townes view (Townes view) is added.
- Spine: lateral views of the cervical, thoracic, and lumbar spine.
- Chest: AP projection (including the clavicles) and oblique projections for detailed visualization of the ribs.
- Abdomen and pelvis: AP projection including the hip joints.
- Extremities: AP projections of the humeri, forearms, femora, lower legs, and feet, as well as posteroanterior (PA) projections of the hands.
Follow-up studies and additional methods
In some cases, initial radiographs may fail to show an acute fracture. Therefore, repeat (follow-up) examinations are ordered:
- At 11–14 days: to detect occult rib fractures (initially up to 2/3 of such injuries are missed) and metaphyseal injuries.
- At 2 weeks: to assess the healing of metaphyseal injuries.
- At 5–6 weeks: for definitive differential diagnosis between trauma and growth plate irregularities (normal variant).
If radiographic findings are equivocal but clinical suspicion remains high, bone scintigraphy may be used, as it has high sensitivity for periosteal injuries and acute diaphyseal or rib fractures. MRI and ultrasound play only an adjuvant role in the routine diagnosis of bone injuries in infants.
Differential diagnosis of injuries
Radiography helps distinguish accidental injuries from non-accidental ones (resulting from abuse).
Accidental fractures are more common in older children (peak at 10–14 years). Typical locations include the bones of the forearm and, in toddlers learning to walk, the bones of the lower leg. Multiple fractures are uncommon in this group.
Non-accidental trauma (NAT) predominates in children under 2 years of age. Although no single fracture type is 100% proof of abuse, there are major indicators ("red flags"). These include posterior rib fractures and metaphyseal fractures of long bones, especially if the child is not yet walking. Any fracture in an infant under 18 months of age requires a thorough exclusion of non-accidental trauma.
To remember the mandatory projections for a skeletal survey: "S-S-C-A-E" (Skull, Spine, Chest, Abdomen/pelvis, Extremities). Each region is imaged separately—no "babygrams"!
Class and exam questions
Why is it forbidden to take a single full-body X-ray of a child?
A full-body overview image ("babygram") does not provide sufficient spatial resolution or the correct beam angle for each region, leading to missed small but critically important fractures (e.g., metaphyseal or rib fractures).
When is it appropriate to schedule repeat radiography in suspected trauma?
Follow-up images are usually taken at 11–14 days. This time is required for radiographic signs of callus formation to appear, allowing for the detection of occult fractures, especially of the ribs.
Which fractures in infants are considered most suspicious for child abuse?
The highest suspicion is raised by rib fractures (especially posterior rib fractures) and metaphyseal fractures of long bones in children who are not yet walking.
What else to study on this topic
- Principles of computed tomography and the evolution of CT scanners
- The role of MRI and ultrasound in the diagnosis of non-accidental trauma in children
- Shaken baby syndrome (pathogenesis and triad of signs)
- Imaging anatomy and pathology of the sinonasal cavity (CT and MRI)
- Neonatal neurosonography (assessment of brain structures)
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