Periosteal reaction

Last revised by Henry Knipe on 07 Jun 2022

Periosteal reaction is a nonspecific radiographic finding that indicates new bone formation in reaction to the abnormal stimulants. Periosteal reactions may be broadly characterized as benign or aggressive, or more specifically categorized by pattern.

Periosteal reaction is the recommended term over periostitis/periosteitis and periosteal new bone formation, although all three are used synonymously 6

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

Low-grade chronic irritation allows time for the formation of normal or near-normal cortex. The cortex will be thick and dense and have a wavy or uniform appearance.

Benign periosteal reactions can be seen in callus formation in a fracture or with slowly growing tumors.

Rapid irritative processes do not allow the periosteum time to lay down and consolidate new bone to form normal cortex. The cortex may appear lamellated, amorphous, or sunburst-like.

Aggressive periosteal reactions can not only be seen with malignant tumors, but also with more benign processes like infection, eosinophilic granuloma (Langerhans cell histiocytosis), aneurysmal bone cyst, osteoid osteoma, hemophilia 4, and trauma.

More specific classification of periosteal reactions can be made to narrow the differential diagnosis:

Unilateral periosteal reaction is non-specific and can be due to localized 7:

  • trauma
  • tumor
  • infection

Symmetrical periosteal reaction carries a separate differential diagnosis. 

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Cases and figures

  • Figure 1: schematic overview
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  • Figure 2: types of periosteal reaction (diagram)
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  • Case 1: Codman triangle
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  • Case 2: layered periosteal reaction with LCH
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  • Case 3: Codman triangle
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  • Case 4: from chronic venous stasis
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  • Case 5: from osteosarcoma of knee
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  • Case 6: from conventional osteosarcoma
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  • Case 7: osteosarcoma with sunburst periosteal reaction
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  • Case 8: solid periosteal reaction
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  • Case 9: periosteal osteosarcoma
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  • Case 10: chronic venous insufficiency
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