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

5. thick irregularthin solid

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

7. Codman trianglesunburst disorganized

8. 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

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

11. 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

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

13. 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

14. 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

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

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

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

19. 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.

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

21. 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.

22. 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).

23. 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).

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

26. 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).

27. 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.

28. 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.

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

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

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

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

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

34. 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).

35. Periosteal reactions – bilaterally asymmetrical