Periosteum: sometimes unseen and forgotten
Poster No.:
C-2312
Congress:
ECR 2017
Type:
Educational Exhibit
Authors:
A. M. Alvarado , S. Arango , M. Estrada , S. Osorio ; Medellín/
1
1
2
1 1
2
CO, Medellin, Antioquia/CO
Keywords:
Trauma, Infection, Cancer, Education, Digital radiography,
Musculoskeletal bone
DOI:
10.1594/ecr2017/C-2312
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Page 1 of 15
Learning objectives
- To ilustrate the normal appearance of the periosteum and the different types of
periosteal reaction on plain films.
- To propose a diagnostic algorithm with emphasis on the differential diagnoses.
Background
The periosteum is a membrane of connective tissue that covers nearly every bone
surface except for tendon insertions, the intraarticular surfaces, and sesamoid bones. Is
composed chiefly of two distinct layers, an outer fibrous layer that contains fibroblasts
and broad collagen fibers and an inner layer that is characterized by abundant blood
vessels and a high cell density with mesenchymal stem cells that have osteogenic,
chondrogenic and significant osteoblastic potential. The periosteal cambium layer is
the deepest surface of the periosteum, and is responsible for bone growth in width by
depositing layers of new bone on the bone surface.
In children, the periosteum is thick and elastic, with few attachments to the underlying
bone. The cambium is thick and has osteoblastic potential.
96 Normal 0 21 false false false ES-TRAD X-NONE X-NONE
In adults is thinner with less elasticity and firmness. It is more attached to the cortex and
has less osteoblastic potential.
Findings and procedure details
A periosteal reaction is the response of cortical bone to an insult affecting the underlying
bone, surrounding tissues or to a generalized process. The appearance of periosteal
reaction is determined by the aggressiveness, duration and intensity of the underlying
insult. Several patterns of periosteal reaction exist and they may appear in combination.
It Is important to note that in children periosteum is more active and less adherent to the
cortex, for that reason periosteal reaction can appear more aggressive.
A periosteal reaction is visible on radiograph after it is mineralized, generally 1 to 3 weeks
after the insult.
Page 2 of 15
Diagnostic approach:
1. The main goal is to recognize its presence. To identify whether there is a periosteal
reaction is a key step in the diagnosis approach.
2. There are two major forms of periosteal reaction: aggressive and nonaggressive. Note
that aggressiveness is not equal to malignancy and in many cases it is not possible to
determine whether the underlying process is benign or malignant.
Nonaggressive:
Processes that are less intense and progress more slowly, with enough time to form a
nearly normal cortex.
May be seen with healing fracture, osteoid osteoma, and osteomyelitis.
Includes:
-Solid periosteal reaction: known also as compact periosteal reaction, cortical thickening,
or hyperostosis. Results of successive and slow additions of compact layers of bone with
gradual incorporation or fusion of the layers. It can appear as either thin (Fig. 1 on page
5) or thick sheets (Fig. 2 on page 6). It is caused by response to a chronic benign
process such as osteoid osteoma and osteomyelitis.
-Single lamellar: caused by the response of the periosteum to passive hyperemia that
accompanies active, usually a benign process that is characteristic of stress fractures,
but may be present in cute osteomyelitis, pulmonary osteoarthropathy, Langerhans cell
histiocytosis, and osteosarcoma. It appears as a single layer of new bone (Fig. 3 on page
6).
Aggressive:
Processes that cause rapid deposition of bone over a short time. It is not exclusive
of malignant tumors, and may be seen with osteomyelitis, eosinophilic granuloma and
aneurysmal bone cyst
Includes:
-Laminated or onionskin: Multilamellar periosteal reaction occurs when multiple layers
of bone are deposited beyond the cortex. It suggests a pathology of intermediate
aggressiveness, frequently malignant. It can be present in benign conditions like acute
osteomyelitis, Langerhans cell histiocytosis and Caffey's disease (Fig. 4 on page 7).
Page 3 of 15
-Spiculated: occurs when periosteum is elevated by a pathologic process, usually
secondary to malignant and aggressive processes, creating a new space where
osteogenesis occurs perpendicular to the cortex. 2 different patterns are identified: in hairon-end subtype has a parallel periosteal reaction pattern. Spicules of new bone formation
along Sharpey's fibers and they reflect the direction of tumor growth (Fig. 5 on page
7) . Sunburst pattern combines a periosteal reaction and the production of new bone
by a malignant process. It has a divergent spiculated pattern (Fig. 6 on page 8) .
-Disorganized: is a complex periosteal reaction with spicules of random orientation and
appearance (Fig. 6 on page 8).
- Codman triangle: is a solid wedge of reactive bone at the lateral margin of an aggressive
bone lesion (Fig. 7 on page 9) .
3. Unilateral versus bilateral periosteal reaction: Bilateral periosteal reaction is usually
due to systemic processes and unilateral periosteal reaction is caused by a localized
process (tumors, trauma or infection)
4. In case of bilateral periosteal reaction, the age of the patient can help narrow the
diagnosis:
< 6 months:
- Physiologic periostitis of the newborn.
- Caffey disease.
- Periostitis related to prostaglandin use.
> 6 months:
- Hypertrophic osteoarthropathy.
- Juvenile idiopathic arthritis.
- Hypervitaminosis A.
- Venous stasis.
Page 4 of 15
Fig. 8
References: Department of Radiology, Hospital universitario San Vicente fundación,
Medellin/CO
96 Normal 0 21 false false false ES-TRAD X-NONE X-NONE
Images for this section:
Page 5 of 15
Fig. 1: Solid periosteal reaction. Frontal leg radiograph shows a solid periosteal reaction
due to hypertrophic pulmonary osteoarthropathy. The solid nature of the periosteal
reaction suggests a nonaggressive process.
© Department of Radiology, Hospital universitario San Vicente fundación, Medellin/CO
Fig. 2: Frontal radiograph of lower leg shows thick irregular periosteal reaction caused
by venous insufficiency.
© Department of Radiology, Hospital universitario San Vicente fundación, Medellin/CO
Page 6 of 15
Fig. 3: Single lamellar periosteal reaction. Frontal radiograph of the knee reveals a single
layer of smooth periosteal reaction poterior to removal of osteosynthesis material.
© Department of Radiology, Hospital universitario San Vicente fundación, Medellin/CO
Fig. 4: Onionskin periosteal reaction. Lateral femur adiograph shows periosteal reaction
with linear layers that form a laminated skin and central disorganized pattern.
© Department of Radiology, Hospital universitario San Vicente fundación, Medellin/CO
Page 7 of 15
Fig. 5: Spiculated hair-on-end periosteal reaction. Frontal radiograph of lower leg shows
bony spicules perpendicular to cortex.
© Department of Radiology, Hospital universitario San Vicente fundación, Medellin/CO
Fig. 6: Lateral radiograph of forearm shows sunburst and disorganized agressive
periosteal reaction in pacient with Ewing sarcoma
Page 8 of 15
© Department of Radiology, Hospital universitario San Vicente fundación, Medellin/CO
Fig. 7: Codman triangle. Lateral radiograph of distal femur shows edge of periosteum
lifted off cortex at site of osteosarcoma.
© Department of Radiology, Hospital universitario San Vicente fundación, Medellin/CO
Page 9 of 15
Fig. 9: Lateral radiograph of distal femur shows the edge of periosteum lifted off the
posterior cortex at sites of chronic osteomyelitis, (sequestrum and anterior periostic
reaction).
© Department of Radiology, Hospital universitario San Vicente fundación, Medellin/CO
Page 10 of 15
Fig. 10: Anteroposterior radiograph with bilateral femur periosteal reaction. Patient with
Hypervitaminosis A diagnosis.
© Department of Radiology, Hospital universitario San Vicente fundación, Medellin/CO
Page 11 of 15
Fig. 11: X Ray of the hand with IFP shows soft tissue edema and periosteal reaction in
the distal portion of the proximal phalange of the third finger.
© Department of Radiology, Hospital universitario San Vicente fundación, Medellin/CO
Page 12 of 15
Fig. 12: 3-year-old patient with Caffey Disease diagnosis. - X Ray of the clavicles and
mandible with enlargement of these structures secondary to the periosteal reaction. Same patient, X Ray of the humerus with anterior and posterior periosteal reaction.
© Department of Radiology, Hospital universitario San Vicente fundación, Medellin/CO
Page 13 of 15
Fig. 13: Comparative X Ray of forearm and femur in a patient with periostitis related to
prostaglandin use.
© Department of Radiology, Hospital universitario San Vicente fundación, Medellin/CO
Page 14 of 15
Conclusion
There are many causes of periosteal reaction, and recognize it is the first step. Having a
systematic approach helps to identify specific processes, however one must must keep
in mind that there are multiple causes of periosteal reaction and many of this entities can
overlap between each other.
Personal information
Ana M. Alvarado
Third year radiology resident.
Universidad CES, Medellin Colombia.
[email protected]
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