Skeletal Survey
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Direct answer
A skeletal survey is a fixed battery of radiographs — skull frontal and lateral, chest, spine frontal and lateral, pelvis, and bilateral humeri, femora, forearms and lower legs — performed for two reasons: staging a disease that seeds bone diffusely, and documenting non-accidental injury in children. In multiple myeloma it maps the classic punched-out lytic lesions of the skull vault ("raindrop" or pepper-pot skull) and long bones, remembering myeloma is the great mimic, sometimes sclerotic in POEMS syndrome. Metastasis surveys read lytic primaries (lung, breast, thyroid, kidney, gut), blastic primaries (prostate, breast, carcinoid, Hodgkin lymphoma) and mixed patterns. The paediatric survey is a forensic exercise hunting classic metaphyseal lesions, posterior rib fractures and fractures of different ages, reported with the whole clinical team.
What you must remember
- Standard film set: skull AP and lateral, chest, spine AP and lateral, pelvis, and bilateral full-length humeri, forearms, femora and tibiae-fibulae — every film complete, because a missing film is a missed lesion.
- Myeloma signature: well-defined, uniform punched-out lytic lesions without reactive sclerosis — skull pepper-pot or raindrop lesions, endosteal scalloping of long bones, vertebral compression; a negative survey never excludes myeloma (diffuse marrow disease is invisible), which is why whole-body MRI or low-dose CT and the PET-CT era have overtaken it in sensitivity.
- Lytic versus blastic metastases: lytic — kidney, thyroid, lung, breast, gastrointestinal; blastic — prostate classically, plus breast, carcinoid, Hodgkin lymphoma, medulloblastoma; mixed — breast and lung. Only about two-thirds of prostate metastases are purely blastic.
- Vertebral metastasis clues: pedicle and posterior element involvement (think metastasis) contrasts with haemangioma's coarse vertical trabeculae; disc space preserved until late.
- Brown tumours and hyperparathyroidism: subperiosteal resorption of the radial aspects of the middle phalanges and eroded terminal tufts distinguish it, with salt-and-pepper skull mimicking myeloma — check the hands, which the survey includes or adds.
- Non-accidental injury set (children): classic metaphyseal lesions (corner or bucket-handle fractures), posterior rib fractures near the costovertebral junctions, spiral long-bone fractures in non-ambulant infants, and healing fractures of different ages — with a repeat survey after about two weeks, per child-protection protocols.
- When not to survey: a single suspected bone lesion is biopsied or imaged focally; whole-body low-dose CT or PET-CT has largely replaced the myeloma survey where available.
Two surveys, adult and child
A 64-year-old with back pain, anaemia and a monoclonal spike has a survey showing innumerable sharply marginated lytic lesions across the skull vault, an L1 compression fracture and endosteal scalloping of the femoral shafts. Punched-out lesions without sclerosis plus the electrophoretic band is multiple myeloma; the survey stages the burden and flags vertebrae at risk of cord compression. The follow-on conversation is modernisation — whole-body low-dose CT or MRI detects marrow disease the plain survey misses, and Indian practice is migrating accordingly.
A 7-month-old, drowsy with a swollen thigh, has a survey showing a spiral femoral fracture, healing posterior rib fractures of different ages, and a corner fracture at the distal radius. None fits the reported fall from a bed; together they are the radiological signature of non-accidental injury. The radiologist's duty is documentation, a repeat survey in two weeks, ophthalmology for retinal haemorrhages, and reporting under child-protection law — in India, mandatory reporting provisions under the Protection of Children from Sexual Offences Act and the Juvenile Justice Act apply to serious suspected abuse, a responsibility the exam expects you to know exists.
Where students slip
First, calling every lytic skull lesion metastasis: myeloma's uniform punched-out lesions with a monoclonal band beat metastasis, and brown tumours of hyperparathyroidism complete the lytic skull triad — the vignette's calcium and PTH settle it. Second, forgetting the pedicle sign: metastasis destroys the pedicle early while multiple myeloma and tuberculosis spare it relatively. Third, the myeloma survey's low sensitivity — a normal survey in a symptomatic patient pushes to MRI, not to reassurance. The paediatric trap: single findings such as a clavicle fracture happen in genuine accidents; it is the pattern — lesions of different ages, posterior ribs, metaphyseal corners, an inconsistent story — that carries the diagnosis, and "pattern, not single fracture" is the distinction answer.
Frequently asked questions
Which radiographs constitute a standard skeletal survey?
Skull AP and lateral, chest, entire spine AP and lateral, pelvis, and bilateral humeri, forearms, femora and lower legs — a complete named set for systemic bone disease.
What is the characteristic skeletal lesion of multiple myeloma?
Sharply demarcated punched-out lytic lesions without reactive sclerosis — the pepper-pot skull and endosteal scalloping of long bones.
Which primary tumours give lytic and blastic metastases?
Kidney, thyroid, lung, breast and gastrointestinal cancers are typically lytic, while prostate, breast, carcinoid and Hodgkin lymphoma are typically blastic or mixed.
Which fractures suggest non-accidental injury in an infant?
Classic metaphyseal corner or bucket-handle lesions, posterior rib fractures near the costovertebral junctions, spiral fractures in non-ambulatory infants, and fractures of different healing ages.
Why can a normal skeletal survey not exclude myeloma?
Diffuse marrow infiltration without cortical destruction is radiographically invisible, so whole-body MRI, low-dose CT or PET-CT is more sensitive in symptomatic patients.