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Lamellated, layered or onion skin
- Commonly associated with Ewing sarcoma, but may also be seen in osteosarcoma, langerhans cell histiocytosis or acute osteomyelitis.
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Codman triangle
- Commonly associated with osteosarcoma, but may also be seen in Ewing sarcoma, osteomyelitis, and a variety of other conditions less commonly.
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Solid
- Indicative of a slow, benign processes, a solid periosteal reaction is characteristically seen with osteoid osteoma (my favorite tumor) and stress fracture, but may be a feature of many other osseous pathologies.
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Spiculated, sunburst or hair on end
- This periosteal reaction indicates a rapidly progressive underlying pathology, and is characeristic of Ewing sarcoma (and PNET), osteosarcoma, and a variety of metastatic lesions.
General consideration
Although periosteal reactions may be seen in young and adult populations, the relatively loose attachment and active physiology of the periosteum in children leads to an earlier and more robust reaction to underlying pathology, and is a more sensitive indicator of disease. Lack of a periosteal reaction in adults, who have a tightly adhered and relatively inactive periosteum, is not unusual, even with highly aggressive underlying pathologies. (see the example of adult primary osteosarcoma at the bottom of this post)
Diagram
Primary osteosarcoma in an adult male. Note the absence of a periosteal reaction.
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