Skeletal Survey — Dictation, Appropriateness, and Dose for Residents
What a Skeletal Survey Covers and What Attendings Look For
A skeletal survey is a comprehensive radiographic examination of the entire skeleton. It’s not a quick look; it’s a meticulous, systematic evaluation of dozens of images, often for high-stakes indications. Your attending isn’t just looking for a single fracture—they’re looking for a pattern of disease.
The two most common scenarios you’ll encounter are the workup for multiple myeloma in an adult and the evaluation for Non-Accidental Trauma (NAT) in a child under two. The required views and key findings differ significantly between them.
For an adult myeloma/metastasis survey, the standard protocol includes:
- Skull (AP/lateral)
- Spine (Cervical, Thoracic, Lumbar AP/lateral)
- Pelvis (AP)
- Humeri, Forearms, Hands (AP/PA)
- Femurs, Lower Legs, Feet (AP)
- Optional Chest (PA/lateral)
For a pediatric NAT survey in a child under 2, the protocol is more extensive, adding oblique rib views to look for highly specific posterior rib fractures and often including magnified skull views. A follow-up survey in two weeks is standard to catch occult healing fractures.
In either case, your attending expects a systematic, bone-by-bone description in your findings and a clear, concise synthesis in the impression that directly addresses the clinical question.
Radiology Report Template for Skeletal Survey
This template provides a structured framework for a comprehensive skeletal survey. Adapt the findings based on the specific indication (e.g., NAT vs. myeloma).
Technique
A radiographic skeletal survey was performed according to the ACR Practice Parameter, including the following views: [AP and lateral skull, AP and lateral cervical, thoracic, and lumbar spine, AP pelvis, AP of both humeri, femurs, and lower legs, and PA of both hands and AP of both feet]. [ADD if applicable: Oblique views of the ribs were also obtained.]
Findings
Head: The calvarium and facial bones are evaluated. No definite fracture is identified. The sutures are patent. [Describe any lytic/sclerotic lesions, e.g., “pepper-pot” skull in myeloma or complex fractures in NAT].
Spine: Vertebral body heights and alignment of the cervical, thoracic, and lumbar spine are maintained. No acute fracture or subluxation. [Describe any compression fractures, lytic lesions, or diffuse osteopenia].
Chest/Ribs: The ribs, clavicles, and scapulae are unremarkable. No acute fractures identified. The cardiomediastinal silhouette and lungs are clear. [Specifically comment on posterior rib fractures in NAT cases].
Pelvis: The pelvis and sacrum are intact. No fractures or lytic/sclerotic lesions. The sacroiliac joints and pubic symphysis are unremarkable.
Upper Extremities: The humeri, radii, ulnae, and bones of the hands are evaluated. No acute fractures, dislocations, or aggressive osseous lesions. [In NAT, look for classic metaphyseal lesions (CMLs) or fractures of varying ages].
Lower Extremities: The femurs, tibias, fibulas, and bones of the feet are evaluated. No acute fractures, dislocations, or aggressive osseous lesions. [In NAT, look for CMLs, “bucket-handle” fractures, or other signs of trauma].
Impression
Example 1 (Negative Myeloma Survey):
No radiographic evidence of multiple myeloma. Specifically, no discrete lytic lesions or pathologic fractures are identified to suggest myelomatous involvement. Mild diffuse osteopenia is noted.
Example 2 (Positive NAT Survey):
1. Acute fracture of the posterior aspect of the right 7th and 8th ribs.
2. Healing fracture of the distal left tibia with associated periosteal reaction.
3. Findings of multiple fractures of varying ages are highly concerning for non-accidental trauma.
Free Template Sources for Your Personal Library
Building a solid template library is a career-long project. While the template above is a great starting point, two great free repositories exist for you to pull from as you build your own macros. These are excellent, non-commercial resources maintained by and for radiologists.
- RadReport.org: Curated by the RSNA, this is one of the most comprehensive and authoritative sources for peer-reviewed templates across all subspecialties.
- Radiology Templates (AU): An excellent, straightforward library maintained by Australian radiologists with practical, clean templates that are easy to adapt.
The Next-Level Move: AI-Assisted Structured Reporting
Templates are static. They’re a great starting point, but they don’t adapt to your findings. The real bottleneck on call isn’t finding the template; it’s meticulously filling it out, making sure every positive finding is documented correctly, and then summarizing it all in a coherent impression without missing anything.
This is where AI-assisted dictation comes in. Instead of clicking through a rigid template, you can dictate your positive findings in free form—”punched-out lytic lesions in the lumbar spine and pelvis, classic for myeloma,” or “healing posterior rib fractures and a classic metaphyseal lesion of the distal femur, concerning for NAT.” The AI then takes your free-form dictation and generates a fully structured report. It organizes your findings into the right sections and populates the impression based on established frameworks. Tools like GigHz Precision AI are designed to streamline this process, turning your natural language into a clean, attending-ready report that follows ACR and SIR guidelines.
When Should You Order a Skeletal Survey? ACR Appropriateness Criteria
The American College of Radiology (ACR) provides evidence-based guidelines to help clinicians choose the right study for the right reason. For a skeletal survey, the indications are quite specific.
Based on the ACR Appropriateness Criteria for Suspected Physical Abuse-Child, a skeletal survey is rated as “Usually Appropriate” and is the first-line imaging modality for a child 24 months of age or younger with concern for physical abuse. This is true whether injuries are clinically apparent or not. It remains “Usually Appropriate” for the follow-up imaging at 10-14 days to detect occult healing fractures. For children older than 24 months, its appropriateness can vary, and other modalities may be considered.
For oncologic staging, the role is more nuanced. According to the criteria for Malignant or Aggressive Primary Musculoskeletal Tumor-Staging And Surveillance, a skeletal survey may be appropriate for evaluating diseases like multiple myeloma, where bone scans are often falsely negative due to the purely lytic nature of the lesions. However, for most other malignancies, whole-body bone scintigraphy, PET/CT, or whole-body MRI are generally preferred for detecting osseous metastases.
How Much Radiation Does a Skeletal Survey Deliver?
A skeletal survey involves a large number of individual radiographs, so the cumulative dose is a valid consideration, especially in pediatric patients. The total estimated effective dose for a complete skeletal survey is typically in the range of 0.5-2.0 mSv.
To put this in perspective, this is a relatively low dose, falling into the ACR’s ☢☢ (0.1-1 mSv) relative radiation level category for many of its components, though the cumulative total can exceed this. It is significantly less radiation than a whole-body CT scan but more than a single chest X-ray. The diagnostic yield in the correct clinical setting, such as suspected NAT or myeloma, far outweighs the radiation risk.
| Imaging Study | Typical Effective Dose (mSv) |
|---|---|
| Skeletal Survey (complete) | 0.5 – 2.0 mSv |
| Chest X-ray (2 views) | ~0.1 mSv |
| Whole-Body Low-Dose CT | ~5 – 10 mSv |
| Annual Natural Background Radiation | ~3 mSv |
Source: Protocol data curated by practicing radiologists and cross-referenced with ACR RRL guidelines.
Skeletal Survey Imaging Protocol — Views and Pitfalls
The success of a skeletal survey depends entirely on the quality and completeness of the images obtained. A standard protocol, as recommended by the ACR, is crucial for a diagnostic study. The protocol consists of approximately 20-25 individual views designed to cover all major bones without significant overlap or omission.
| Anatomic Region | Standard Views | Key Considerations |
|---|---|---|
| Skull | AP, Lateral | Look for lytic lesions (myeloma) or complex fractures (NAT). |
| Spine | AP, Lateral (Cervical, Thoracic, Lumbar) | Assess for compression fractures and vertebral body lesions. |
| Chest/Ribs | AP Chest; Oblique Ribs (Pediatric NAT) | Oblique views are critical for detecting posterior rib fractures. |
| Pelvis | AP | Good view for lytic lesions and fractures of the femoral necks. |
| Long Bones | AP (Humeri, Forearms, Femurs, Lower Legs) | Systematically evaluate for fractures, periosteal reaction, CMLs. |
| Hands/Feet | PA Hands, AP Feet | Small bones can harbor subtle fractures or lesions. |
A common pitfall is an incomplete study. If any of the standard views are missing or are of non-diagnostic quality due to motion or improper technique, the sensitivity for detecting pathology drops significantly. It’s crucial to communicate with the technologists to ensure the full, high-quality protocol is performed every time.
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Free GigHz Tools That Pair With This Article
Three free tools that complement the material above:
- ACR Appropriateness Criteria Lookup — Type an indication or clinical scenario in plain language and get the imaging studies the ACR rates for it, with adult and pediatric radiation levels. Built directly from 297 ACR topics, 1,336 clinical variants, and 15,823 procedure ratings.
- GigHz Imaging Protocol Library — A searchable library of 131 imaging protocols with the physics specs surfaced and the matching ACR Appropriateness Criteria alongside. Plain-English narratives readable in 60 seconds, organized by modality.
- GigHz Radiation Dose Calculator — Pick the imaging studies a patient has had and see total dose in millisieverts (mSv) with comparisons to natural background radiation, transatlantic flights, and chest X-rays. Useful for shared decision-making.
Frequently Asked Questions
Is it HIPAA-compliant?
Yes. The platform is designed for de-identified workflows by default. It operates on the de-identified text of your report and does not require access to patient-identifiable information or your PACS system.
Do I need my hospital’s IT department to set this up?
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Does this replace PowerScribe or other dictation systems?
No, it works alongside them. You can dictate as you normally would, then copy-paste your free-form text into the tool to get a structured report back in seconds. You then paste the final, polished report back into your PACS/RIS.
Can I use this on my phone or iPad?
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Can I customize the templates?
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What happens after my residency or fellowship ends?
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Reviewed by Pouyan Golshani, MD, Interventional Radiologist — May 7, 2026
