periosteal reaction radiology review.pptx

Periosteal reactions, radiological review , types of reactions

1. PERIOSTEAL REACTION PRESENTATION BY DR MIRZA SANAULLA MODERATOR : DR VIDHYARANI R

2. WHAT IS PERIOSTEUM ? Fibrous connective tissue membrane that covers the external surfaces of all bones with the exception of joint surfaces, which are covered by articular cartilage. The periosteum has thick collagen fibers called Sharpey’s fibres which penetrate perpendicularly into the outer cortex, anchoring the periosteum to the underlying bone. Two layers: Outer fibrous layer. Inner cellular layer.

3. LAYERS OF PERIOSTEUM TWO LAYERS: Outer fibrous layer : Subdivided into deep and superficial- more collagenous matrix less cells –fibroblasts Superficial - rich in blood vessel ,nerves few elastic fibers Deep - many elastic fibers, few blood vessels Inner cellular layer /Cambium layer: Less collagenous matrix ,more cells. Osteogenic progenitor cells. Osteoblasts.

4. FUNCTIONS OF PERIOSTEUM Nourishment to outer cortex of bone Pain sensation New bone formation , bone remodeling , fracture healing

5. PERIOSTEAL REACTION? Formation of new bone in response to abnormal stimuli. Stimuli- infection , tumour , trauma , arthritic conditions , anyother inflammatory irritant. These cause subperiosteal extensions of blood, pus, or tumor. These migrate beneath the periosteum by way of the Haversian canals,and cause elevation of periosteum. The appearance of periosteal reaction is determined by the intensity, aggressiveness, and duration of the underlying insult. The periosteum in children is more active and less adherent to the cortex than in adults. Thus, periosteal reaction can occur earlier and appear more aggressive in children than in adults.

6. CAUSES OF PERIOSTEAL REACTION

7. TYPES OF PERIOSTEAL REACTION BENIGN AGGRESSIVE Shell -Laminated Solid - Spiculated Thick irregular *Perpendicular (hair on end) *Sunburst -Disorganized -Codman triangle

8. TYPES OF PERIOSTEAL REACTIONS-SOLID In this pattern, the reaction is localized, and caused by a focal insult. Usually its form is elliptical and dense, resulting in cortical thickening. It happens because of successive and gradual addition of compact bone to the surface, until merging of layers. CAUSES : chronic indolent Infections Benign neoplasms -osteoid osteoma Eosinophilic granuloma Hypertrophic pulmonary osteoarthropathy Low grade paraosteal osteosarcoma Non immobilized fractures

9. THICK IRREGULAR TYPE The presence of the thick irregular pattern of periosteal reaction may imply a more temporally and spatially heterogeneous process, such as chronic osteomyelitis. Venous stasis

10. SINGLE LAMELLA / THIN A single lamella is one sheet of new bone a millimeter or two away from the cortical surface. It may or may not join cortex at its extremes. . The single lamella reaction has been called the hallmark of a benign process Acute osteomyelitis , eosinophilic granuloma, storage disease (e.g., Gaucher’s )

11. SHELL TYPE This pattern is characterized by a continuous reaction, in which the cortical bone is reabsorbed as the new periosteal is formed . It is associated with cortex destruction, but also increasing bone width, because of the periosteal reaction. Seen in aneurysmal bone cyst ,GCT.

12. MULTIPLE LAMELLAR (ONION SKIN ) It is caused by repeated periosteal stimulation without time for incorporation into the cortex On plain films, it appears as multiple continuous lamellae with lucent zones between them, widening the bone contour Lamellated reactions indicate a rapidly progressive lesion and are usually seen with bone sarcomas, especially Ewings sarcoma and osteosarcoma. Acute osteomyelitis. Ocassionaly stress fractures

13. HAIR ON END / PARALLEL SPICULATED Denotes a more rapid underlying process The spicules are higher in the midzone of the reaction, decreasing in height proximally and distally Its configuration is actually an interconnected compartmental system resembling a honeycomb. Compartment walls lying parallel to the radiographic beam register as spicules , whereas walls crossed perpendicularly by the beam are inapparent . This pattern is seen in malignant tumors such as: Ewings sarcoma, osteosarcoma hyperplastic marrow in thalassemia This pattern favors a malignant tumor but may be stimulatedby certain inflammatory states like syphilis,myositis , and Caffey’s disease

14. SUNBURST / DIVERGENT SPICULATED Denotes malignant osteoid production and only partially consists of reactive bone. - It consists of streaks of variable thickness and orientation converging on an medullary epicentre. The rays are reactive bone,, and the space between rays in osteosarcoma is filled with neoplastic cells and tumor products, usually chondroid and myxoid highly suggestive of osteosarcoma may also be seen with blastic metastasis and osseous hemangioma, especially in the skull

15. CODMANS TRIANGLE The Codman triangle indicates a periosteal elevation caused by mass effect A Codman triangle is a cuff of reactive bone surrounding the upper and/or lower limits of a lesion on one or both sides of the shaft. - Radiographically , a triangle is formed at the transition between the normal periosteum and the adjacent elevated periosteum It has a triangular shape, caused by a space between the neoplastic mass or blood, for example, and the periosteal thin line usually seen with aggressive malignant tumors breaking out into the soft tissue, such as osteosarcoma and chondrosarcoma , but sometimes occurs as a defense against inflammation in acute osteomyelitis .

16. INTERUPPTED TYPES -BUTTRESS This periosteal reaction a solid-appearing wedge of reactive bone can be seen at the lateral extraosseous margin. It is usually associated with rapid aggressive lesions, which suddenly stops its progression in the bone cortex A buttress may be formed at the lateral margin of a shell-type periosteal reaction seen with lesions such as aneurysmal bone cyst or periosteal chondroma , or may be created by central destruction of a previous continuous solid reaction rising suspicion of a malignant tumor

17. Periosteal Reaction Causes: 32 Drugs - Fluorosis - Hypervitaminosis A - Prostaglandins Tumors - Osteosarcoma - Ewing’s sarcoma - Chondroblastoma - Eosinophilic granuloma - Osteoid osteoma - Leukemia and lymphoma Infection Genetic - Caffey disease Vascular - Venous stasis Arthritis - Psoriatic arthritis - Reactive arthritis Metabolic - Hypertrophic pulmonary osteoarthropathy - Thyroid acropathy Congenital - Pachydermoperiostosis - Periosteal reaction of newborn Trauma - Stress fracture - Fracture

18. Psoriatic arthritis It is a seronegative spondyloarthropathy with inflammatory changes involving the skin and joints. Bone proliferation is an important feature of psoriatic arthritis, and periostitis can occur along the phalangeal shafts. Periostitis may manifest as thin or thick periosteal new bone formation or cortical thickening, particularly at the radial margin of the proximal and middle phalanges . Fluffy periostitis. Additional radiographic findings include juxtaarticular osteopenia, soft-tissue swelling, loss of cartilage, and marginal erosions. 33 Frontal radiograph of hand shows thick solid periosteal reaction along proximal phalanx of long finger . Marginal erosions are seen at heads of middle and proximal phalanges

19. Reactive arthritis It is another seronegative spondyloarthropathy, Localized periosteal reaction develops that is indistinguishable from psoriatic arthritis but more commonly affects the lower extremities (such as the calcaneus and metatarsals). The periosteal reaction may result in fluffy bone formation along the shaft and metaphyses . 35

20. Pachydermoperiostosis It is an autosomal-dominant inherited disorder characterized by marked thickening of the skin of the extremities, face, and scalp. It is also known as primary hypertrophic osteoarthropathy because it is not due to a secondary cause such as lung disease. It is a self-limited disease that most commonly affects adolescent boys and progresses for several years before stabilizing. The generalized and symmetric periosteal reaction in pachydermoperiostosis tends to blend with the cortex and primarily involves the distal ends of the radius, ulna, tibia, and fibula. 36

21. Hypertrophic pulmonary osteoarthropathy Patients can present with the classic triad of clubbing, periostitis, and synovial effusions  . It most frequently arises in patients with primary intrathoracic neoplasms, especially non–small cell lung cancer. Periosteal reaction occurs at the metaphysis and diaphysis of the long bones and tubular bones of the hands. The thickness corresponds to the duration of disease activity. Associated findings are periarticular osteoporosis, soft tissue swelling, joint effusions and clubbing of fingers. Painful condition. Bilaterally symmetrical 38

22. Physiologic Periosteal Reaction of the Newborn It is typically symmetric and occurs in infants up to 6 months old, most commonly between 1 and 4 months old. The rapid growth of the infant and loosely adherent periosteum may account for this finding. The usual appearance is a single-layered, thin periosteal reaction (< 2 mm) involving one aspect of the long bones, especially in the femurs and tibias . 40 Fr ontal radiograph of both femurs show smooth, single-layer periosteal reaction on lateral aspects of both femoral shafts

23. Caffey disease It is also known as infantile cortical hyperostosis It is a rare self-limiting inflammatory disease of infancy that is characterized by hyperirritability, soft-tissue swelling, and cortical hyperostosis and particularly involves the mandible and facial bones. The disease is believed to be an autosomal-dominant disease related to type 1 collagen mutation. Caffey disease almost always occurs before 6 months and is characterized by a laminated periosteal reaction affecting the mandible, scapula, clavicle, and ulna and, less frequently, the ribs . Soft tissue swelling, hyper-irritability and cortical hyperostosis involving mandible and facial bones. 42 Lateral radiograph of lower leg of 2-month-old girl with left lower extremity pain shows extensive thick periosteal reaction along tibia and fibula

24. Flourosis / Voriconazole It is known to stimulate osteoblasts and can cause a solid periosteal reaction, most often in tubular bones in a symmetric distribution, especially at sites of muscle and ligament attachment. Associated findings are calcified tendons and ligaments (posterior longitudinal, iliolumbar, sacrotuberous , and sacrospinous) and dense skeletal sclerosis (most prominent in vertebrae and the pelvis). Solid, irregular asymmetric ,multifocal periosteal reaction along the tubular bones 43

25. Hypervitaminosis A Retinoids are commonly used to treat children and teens with severe acne, psoriasis, and burn injuries. Overuse can lead to hypervitaminosis A, which results in solid periosteal reaction along the long bones, growth retardation, and premature closure of growth plates. The periosteal reaction occurs greatest near the center of the shaft and tapers toward the ends of the bone. Unlike Caffey disease, the periosteal reaction rarely involves the mandible. The ulna, lower leg, metatarsals, and clavicle are the most common locations. 45

26. Prostaglandins Prostaglandins can be used to maintain the patency of the ductus arteriosus in infants with congenital heart disease and ductal-dependent physiology. They are believed to decrease osteoclast bone resorption, which can result in periosteal reaction associated with limb pain and considerable swelling of the extremities, all of which improve after cessation of the drug. 46

27. Infection Osteomyelitis can cause localized periosteal reaction anywhere but primarily causes this appearance in the long bones. Subperiosteal spread of inflammation elevates the periosteum and stimulates the laying down of layers of new bone parallel to the shaft. Eventually, a large amount of new bone surrounds the cortex in a thick irregular bony sleeve (involucrum). Disruption of the cortical blood supply leads to bone necrosis with dense segments of avascular dead bone ( sequestra ) remaining. 47 Lateral radiograph of distal femur shows dense thick periosteal reaction (involucrum) surrounding dead bone (sequestrum)

28. 48 CT- Chronic osteomyelitis -Thick irregular periosteal reaction enveloping a sequestrum

29. Among the many subtypes of periosteal reaction that can occur with infection are disorganized, thin, lamellated, or spiculated forms. A Codman triangle can also develop, often with lytic destruction of bone in the acute phase. 49

30. Thyroid acropachy It is a rare complication of autoimmune thyroid disease that is characterized by progressive exophthalmus , relatively symmetric swelling of the hands and feet, clubbing of the digits, and pretibial myxedema . It can develop after thyroidectomy or radioactive iodine treatment of primary hyperthyroidism, with most patients being euthyroid or hypothyroid when symptoms develop. Thyroid acropachy produces generalized and symmetric thick irregular periosteal reaction that primarily involves the midportions of the diaphyses of tubular bones of the hands and feet. 50

31. 51

32. Stress Fracture Stress fractures can show subtle solid periosteal reaction in the region of pain or trauma. Abnormalities are seen earlier on MR images than on radiographs, with bone marrow edema and increased signal in the muscles and periosteum on T2-weighted images. Common sites of stress fracture include the tibias, metatarsals, long bones, pelvis, and calcaneus. 52

33. 53 A- Lamellar periosteal reaction on the medial aspect of the tibial diaphysis in case of stress fracture. B- Lamellar periosteal reaction on axial MRI, T2W. Additionally, increased fluid signal can be observed at the adjacent soft tissues.

34. Fracture Periosteal reaction related to fractures can show a solid, nonaggressive appearance or a more disorganized, aggressive appearance . A fracture occurring at a site involved in a greater degree of motion may produce a more disorganized pattern of periosteal reaction. Periosteal reaction from traumatic and pathologic fractures can have a similar appearance. In addition, there may be a related soft-tissue mass on radiographs, which should be followed up to confirm resolving hematoma. 54

35. 55 A - Frontal radiograph obtained 7 days after injury shows disorganized aggressive periosteal reaction at site of fracture involving neck of third metatarsal. B - Repeat radiograph obtained 4 weeks after injury shows smooth, thin, nonaggressive periosteal reaction at same site, consistent with healing.

36. 56 Axial T2W with fat saturation demonstrating increased intraosseous fluid signal and increased fluid signal at the adjascent soft tissues. The arrow indicates fracture related periostitis.

37. Osteosarcoma Conventional osteosarcomas are common high-grade intramedullary neoplasms that produce an osteoid matrix. The majority of lesions occur in patients under 25 years old , with the femur, tibia, and fibula the most common sites. The sunburst, hair-on-end, or Codman triangle subtypes of periosteal reaction are most frequently seen. However, laminated, solid, thin, or disorganized forms of periosteal reaction can also be present. A wide zone of transition, cortical breakthrough, and soft-tissue mass are all concerning features that warrant further evaluation. 57 Lateral radiograph of mid femur shows sunburst periosteal reaction with bone formation in divergent pattern

38. 58 MRI- Laminated periosteal reaction – Osteosarcoma of femur Axial CT- spiculate periosteal reaction in iliac osteosarcoma

39. Ewing’s sarcoma It is derived from undifferentiated mesenchymal cells of bone marrow or primitive neuroectodermal cells and accounts for 6–8% of primary malignant bone tumors . Although characteristically intramedullary in location, on radiographs, only the cortical changes may be apparent with a permeative or moth-eaten osteolytic component. A large soft- tissue mass can be seen. The periosteal reaction ONION PEEL (MUTIPLE LAMELLETED )pattern is typically aggressive, with the hair- on-end subtype highly characteristic for Ewing’s sarcoma. 59

40. 60 Hair-on-end periosteal reaction (Ewing’s sarcoma). Lateral radiograph of lower leg shows bony spicules emanating perpendicular to cortex .

41. 61 C- Axial C T image : arrow indicates one of the spicules of the periosteal reaction D- axial MRI T1W image aacquired following intravenous contrast agent injection. The arrow indicates one of the periosteal spicules.

42. Chondroblastoma Chondroblastomas are benign cartilage-producing lesions that typically occur in the epiphyses of skeletally immature patients. The lesions are typically lytic and may have a sclerotic margin. Periosteal reaction due to chondroblastoma most commonly occurs in large lesions in flat or small tubular bones. The periosteal reaction can be thick, solid, or laminated. 62 Radiograph shows laminated and disorganized periosteal reaction along proximal humerus .

43. Eosinophilic Granuloma It is the benign form of the three clinical variants of Langerhans cell histiocytosis (the others are Letterer- Siwe and Hand-Schüller-Christian diseases). Neoplastic proliferation of Langerhans cells present predominantly as lytic lesions. However, there may be sclerotic areas with a thick or laminated pattern of periosteal reaction, especially during the healing phase. This appearance can be mistaken for osteomyelitis. 63

44. Osteoid osteoma It is a benign bone-forming tumor affecting children and adolescents, most commonly occurring in the femur, tibia, fibula, or humerus . A thick and dense periosteal reaction develops as a response to the tumor . The central lucent nidus may be difficult to visualize on radiographs, and CT can be helpful in these instances . Subperiosteal osteoid osteomas can produce extensive aggressive periosteal reaction, whereas intraarticular lesions typically cause relatively little periosteal new bone formation. 64 Frontal radiograph of proximal tibia shows smooth, thick periosteal reaction along medial tibia cortex

45. 65 Coronal reformatted and axial CT images show lucent central nidus surrounded by reactive periosteal reaction.

46. Leukemia and Lymphoma Both can be associated with an aggressive-appearing periosteal reaction. In children, leukemia is more likely to affect long bones, whereas in adults, the axial skeleton is more commonly affected. A thin or laminated pattern of periosteal reaction is common, with a hair-on-end appearance less frequent. Lymphoma may produce an aggressive and disorganized periosteal reaction, and there may be an associated soft-tissue mass that is larger than the area of bone destruction. 66 Leukemia - Frontal radiograph of femurs shows dense thick periosteal reaction along femoral shafts bilaterally

47. Venous Stasis Venous stasis, especially in the lower extremities, can result in generalized solid undulating periosteal reaction that initially can be separate from the cortex . The increase in mean interstitial fluid pressure in venous stasis may exert pressure on the periosteum, leading to periosteal new bone formation. Although not always present, clues to this diagnosis include widespread subcutaneous edema and phleboliths in varicose veins. 67 Periosteal new bone formation cloaks tibia and fibula

48. 68 Axial CT shows and axial MRI T1W image with fat saturation showing the circumferential involvement of solid periosteal reaction

49. Unilateral Versus Bilateral Periosteal Reaction Unilateral periosteal reaction is caused by a localized process, such as trauma, tumor , or infection. Bilateral periosteal reaction is typically due to systemic processes, and the differential diagnosis can often be narrowed by patient age and clinical presentation. Before 6 months, the most common causes are physiologic periostitis of the new born, Caffey disease, and periostitis related to prostaglandin use. Bilateral periosteal reaction that appears after 6 months should suggest hypertrophic osteoarthropathy, juvenile idiopathic arthritis, hypervitaminosis A, and venous stasis. In the appropriate clinical situation, it is essential to consider nonaccidental trauma resulting in multiple healing fractures as the underlying cause. 69

50. Bilaterally symmetrical periosteal reactions in Adults Hypertrophic Osteoarthropathy (HOA)  Pachydermoperiostitis Vascular insufficiency Thyroid Acropachy

51. Bilaterally symmetrical periosteal reactions in children Physiologic periosteal reaction in infancy Caffey’s disease Congenital syphilis Prostaglandins E1 therapy Acute leukaemia Scurvy Hypervitaminosis A

52. Bilaterally asymmetrical periosteal reactions: Metastases Psoriatic Arthritis Reactive Arthritis Flurosis

53. CONCLUSION

54. THANK YOU.