Clinicians rely on X-ray examination(s) or procedure(s) to make a diagnosis on a pathology, to assess the area where the patient may be experiencing pain and to evaluate the treatment executed (1). Though various radiological examinations are available the choice of which examination to undergo depends on the area and purpose of the examination.

What Does Non-Accidental Injury (NAI) Mean?

  • Non-accidental injury or better known as NAI is defined as purposefully abusing someone physically or emotionally with the intent of causing harm (2).
  • The harm or abuse experienced by a vulnerable child or adult is not acceptable.

What Are The Categories Of Abuse That Is Experienced By A Vulnerable Individual?

There are four categories of abuse which are namely physical abuse, emotional abuse, sexual abuse and purposefully neglecting someone (3).

What Are The Common Signs And Symptoms Of NAI?

The common signs and symptoms would be the following (3):

  • Bruises and abrasions
  • Lacerations
  • Scratches
  • Soft tissue swelling
  • Haematomas (blood clot within the soft tissue)
  • Thermal burns and
  • Bites.

Is There Are Possibility That The Individual Suspected Of NAI May Actually Be Suffering From A Disease?

Yes, it is possible for individual suspected of NAI to be actually suffering from a disease.


 Figure 1: Fracture(s) caused by trivial trauma on a background of natural disease, in this case Rickets.

Source: www.forensicmed.co.uk (4)

What Is Skeletal Survey?

In order to determine whether the cases of injury experienced is NAI, the skeletal survey is performed;

  • An X-ray examination called skeletal survey is performed. It is a series of projections/ views requested by the requesting clinician to determine particular patterns of neglect in children.
  • Skeletal survey is performed on these patients with the intent of assessing and documenting the extent of previous skeletal injury (2).

What Are The Series Of Films/ Images Performed For A Skeletal Survey?

Basically a skeletal survey should comprise of the following (4):

  • AP/ Lateral skull x-ray
  • Lateral cervical and thoracolumbar spine x-ray.
  • Chest x-ray (CXR)
  • Ribs left/ right oblique
  • Abdominal X-ray (AXR)
  • AP humerus left/ right
  • AP forearm left/ right
  • AP hand left/ right
  • AP femur left/ right
  • AP tibia/ fibula left/ right
  • Dorsiplantar feet left/ right

Who Performs The Skeletal Survey X-ray Examination?

A radiographer performs the skeletal survey examination as he/ she is trained personnel in performing the above mentioned views.

Is There Any Preparation Required For A Patient Who Would Be Having A Skeletal Survey?

Before examination

  • Normally there is no special patient preparation is required.
  • However if the patient was a female of child bearing age, the LMP should be requested to determine that the patient is not pregnant and to avoid irradiating the foetus (6).

During examination

  • Essentially the patient is not required to do anything except follow the radiographers’ instruction during the X-ray examination.
  • As there are various views taken it is important for the patient to keep still during the examination.

After examination

  • On completion of the skeletal survey X-ray examination, the patient is asked to wait in the room.
  • The radiographer will evaluate the images taken before the patient is allowed to leave the department.
  • The result of the examination will be sent to the requesting clinician.


  1. Non-accidental injuries. Institute of medical Illustrators. 2013. Available online: http://www.imi.org.uk/document/non-accidental-injuries
  2. Non-accidental injuries. Radiopedia.org. Gaillard. F., & Bhattacharya, B., 2014. Available online: http://radiopaedia.org/articles/non-accidental-injuries
  3. Pediatric Forensic Pathology. (Image). Available online : https://www.google.com.my/search?q=non-Accidental+injury+in+paediatric&source=lnms&tbm=isch&sa=X&ei=qtjcU7qkBMS1uAS05YGACQ&ved=0CAYQ_AUoAQ&biw=1708&bih=841&dpr=0.8#facrc=_&imgdii=_&imgrc=vXttr6VN6a6dNM%253A%3BhF2d-nPOO_RQnM%3Bhttp%253A%252F%252Ffiles.forensicmed.webnode.com%252F200000 655-3786b38816%252Frickets.JPG%3Bhttp%253A%252F%252Fwww.forensicmed.co.uk%252F pathology%252Fpaediatric-forensic-pathology%252F%3B390%3B688
  4. Skin signs of non-accidental injury. Available online : http://www.dermnetnz.org/reactions/non-accidental-injury.html
  5. The 28 Day Rule. Available online : http://www3.ha.org.hk/qmh/department/Clinical%20 Department/Radiology/xray.htm
  6. X-ray Krans, B., 2014. Available online : http://www.healthline.com/health/x-ray#Overview


Last Reviewed : 2 June 2016
Writer : Pushpa Thevi Rajendran
Accreditor : Daud bin Ismail