Periosteal reaction

periosteal reaction imaging , differential diagnosis and subtypes

1. Periosteal Reaction

2. Periosteal Reaction Periosteal reaction results when cortical bone reacts to one of many possible insults . Tumor , infection, trauma, certain drugs, and some arthritic conditions can elevate the periosteum from the cortex and form various patterns of periosteal reaction

3. thick irregular thin solid

4. perpendicular/ hair-on-end septated laminated (onionskin )

5. Codman triangle sunburst disorganized

6. Benign versus aggressive Periosteal reaction may be classified as benign or aggressive (note: not benign and malignant) based on the time course of the initiating process

7. Morphological classification of periosteal reactions single layer multilayered solid spiculated perpendicular (hair-on-end) divergent (sunburst) sloping (velvet) disorganised /complex Codman triangle

8. Single layer periosteal reaction premature infants for up to 6 months early fracture healing osteosarcoma osteomyelitis Langerhans cell histiocytosis metastasis osteoid osteoma aneurysmal bone cyst Ewing sarcoma giant cell tumour chronic venous insufficiency

9. Multilayered periosteal reaction osteosarcoma acute osteomyelitis Ewing sarcoma Langerhans cell histiocytosis (LCH) hypertrophic osteoarthropathy

10. Solid periosteal pattern osteoid osteoma osteomyelitis osteosarcoma chondrosarcoma fibrous dysplasia non-ossifying fibroma osteoblastoma osteofibrous dysplasia stress fracture Brodie abscess chondroblastoma giant cell tumour skeletal metastasis Ewing sarcoma simple bone cyst

11. Spiculated periosteal reaction Perpendicular (hair-on-end) Ewing sarcoma osteosarcoma Metastasis Focal slopping (velvet) chondrosarcoma Divergent (sunburst) osteosarcoma haemangioma osteoblastic metastasis prostatic bronchoalveolar carcinoid breast neuroblastoma ( paediatric age group) osteoblastoma

12. Disorganised or complex periosteal reaction osteosarcoma metastasis osteomyelitis chondrosarcoma Ewing sarcoma stress fracture malignant fibrous histiocytoma spindle cell sarcoma

13. Codman triangle periosteal reaction osteosarcoma Ewing sarcoma osteomyelitis active aneurysmal bone cyst giant cell tumour metastasis chondrosarcoma (especially juxtacortical chondrosarcoma) malignant fibrous histiocytoma

14. Onionskin periosteal reaction ( osteomyelitis ). Frontal radiograph shows localized laminated periosteal reaction (arrow) along lateral cortex of distal femur.

15. Hair-on-end periosteal reaction ( Ewing’s sarcoma ). Lateral radiograph of lower leg shows bony spicules emanating perpendicular to cortex (arrows). Hair-on-end periosteal reaction ( chronic osteomyelitis ). Axial CT image of shoulder shows spiculations (arrows) arising along posterior cortex of scapula .

16. Sunburst periosteal reaction ( osteogenic sarcoma complicating long-standing Paget’s disease ). A, Frogleg radiograph of femur shows sunburst and disorganized aggressive periosteal reaction (arrows).

17. Axial T2-weighted MR (B) and axial CT (C) images show extensive cortical thickening (arrowheads ) and large soft-tissue mass (arrows) surrounding diaphysis of femur.

18. Psoriatic arthritis . Frontal radiograph of hand shows thick solid periosteal reaction along proximal phalanx of long finger (arrows). Marginal erosions are seen at heads of middle and proximal phalanges ( arrowheads).

19. Codman triangle (prostate cancer ). Frontal radiograph of distal femur shows edge of periosteum ( thin arrow) lifted off cortex (arrowhead) at site of sclerotic metastasis (thick arrow).

20. Chronic osteomyelitis . Lateral radiograph of distal femur shows dense thick periosteal reaction ( involucrum , straight arrows) surrounding dead bone ( sequestrum , arrowheads).

21. Caffey disease . Lateral radiograph of lower leg of 2-month-old girl with left lower extremity pain shows extensive thick periosteal reaction along tibia and fibula (arrows).

22. Secondary hypertrophic osteoarthropathy . A and B, Bilateral frontal views of distal femur show thin and thick single layer periosteal reaction (arrows ) along femoral shafts bilaterally.

23. Fracture . A, Frontal radiograph obtained 7 days after injury shows disorganized aggressive periosteal reaction at site of fracture (arrow) involving neck of third metatarsal. B, Repeat radiograph obtained 4 weeks after injury shows smooth, thin, nonaggressive periosteal reaction at same site (arrow), consistent with healing.

24. Osteogenic sarcoma . Lateral radiograph of mid femur shows sunburst periosteal reaction with bone formation in divergent pattern (arrow).

25. Chondroblastoma . Radiograph shows laminated (arrow) and disorganized periosteal reaction along proximal humerus .

26. Leukemia . Frontal radiograph of femurs shows dense thick periosteal reaction along femoral shafts bilaterally.

27. Venous stasis . Periosteal new bone formation cloaks tibia and fibula

28. Aneurysmal bone cyst of the radius. an expansile , eccentric , cyst like lesion causes ballooning of the cortex and periosteal response.

29. Periosteal reactions – bilaterally symmetrical in adults Hypertrophic osteoarthropathy (HOA) Pachydermoperiostosis . Vascular insufficiency (venous, lymphatic or arterial). Thyroid acropachy . Fluorosis . Diffuse idiopathic skeletal hyperostosis (DISH; Forestier disease).

30. Periosteal reactions – bilaterally asymmetrical