JULY, i966

NEW BONE PRODUCTION AND PERIOSTEAL

REACTI ON*
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By JACK EDEIKEN, M.D., PHILIP J. HODES, M.D.,

and LAWRENCE H. CAPLAN, M.D.
PHILADELPHIA, PENNSYLVANIA

N EW bone production, a frequent find mount importance to differentiate the one

ing in many bone conditions, may from the other.
originate from normal bone forming ele When new bone forms within a host bone,
ments (trabeculae and peniosteum) or from it may be difficult to differentiate tumor
tumor cells. Whereas osteogenic and chon new bone from reactive new bone. Reactive new
drogenic tumors alone are able to produce bone usually is represented by thickening
tumor new bone, many neoplasms, as well and increased density of pre-existing trabe
as infection, trauma and other disease, can culae. It is orderly and organized. Tumor
stimulate reactive new bone. It is of para new bone within a host bone may appear
as a nest or nests of ivory-like density (Fig.
i) or as multiple dense flecks of bone (Fig.
2). The former are produced by osteogenic
tissue (osteosarcoma and osteoblastoma);
the latter are produced by chondrogenic
tissue (chondrosarcoma, chondroblastoma,
and chondroma). As no tumors other than
chondrogenic or osteogenic produce tumor
new bone, once it is identified the differen
tial possibilities are considerably narrowed.
When new bone forms at the periphery of
a host bone, it may be due to tumor new
bone or peniosteal reaction. Peniostea!

FIG. 2. Tumor new bone formation due to chondro

FIG. i. Tumor new bone due to osteosarcoma. New sarcoma. The large mass extending from the ramus
bone formation is seen within the anterior portion of the pubis contains multiple flecks of calcifica
of the third rib due to osteosarcoma. The dense tion. This type of calcification is characteristic of
homogeneous density is characteristic of new bone cartilaginous calcification and indicates the pres
formation of osteogenic tumor. ence of a chondrogenic tumor.

*From the Department of Radiology, Jefferson Medical College Hospital, Philadelphia, Pennsylvania.

708
 VoL. @7,No. 3 New Bone Production and Peniosteal Reaction 709

TABLE I

Type
ExampleI.
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ReactionA.Thin Solid Periosteal

Eosinophilic
Granulomaand
OsteomaB.Dense Osteoicf
VascularC.Thin
Undulating
Undulating Pulmonary Osteoarthro
pathyD.I)ense
Osteoma@.
Elliptic Osteoid
WithDestructionLong-StandingMalignant
TumorsE.Cloaking
Storage
Diseases,Chronic
InfectionF.Codman's
andMalignancyII.
Triangle Hemorrhage

ReactionA.Lamellated
Interrupted Periosteal
Ewing's(Onion Osteosarcoma,
InfectionB.Perpendicular
Peel) Tumor and
Ewing's(Sunburst) Osteosarcoma,
InfectionC.Amorphous Tumor and
Malignant Tumor

FIG. 3. Dense undulating periosteal reaction second

ary to longstanding peripheral vascular disease.
There is periosteal new bone formation most no
ticeable on the lateral aspect of the fibula. The cx
ternal surface is undulated. The periosteal reac
tion is quite thick and almost homogeneous and
indicates a benignprocess.

tumor new bone has the same charactenis

tics as tumor new bone within the host
bone. It is produced by soft tissue exten
sions of primary bone tumors.
Periosteal reactions are common occur
nences in bone lesions. Despite their ease of
recognition roentgenographica!ly, there
exists considerable misapprehension re
garding their significance.
Peniosteal reactions may be described
roentgenographically as (@) solid or (2)
interrupted (Table i). FIG. @.Solid undulating periosteal reaction due to
longstanding varicosities. Periosteal reaction is
I. SOLID PERIOSTEAL REACTIONS most noticeable on the fibula in the anteroposterior
projection. The external surface is undulating and
The solid periosteal reactions may be de the reaction is solid. Notice the soft tissue changes
fined as a single layer of new bone greater due to longstanding varicosities.
 710 Jack Edeiken, Philip J. Hodes and Lawrence H. Caplan JULY, 1966

than i mm. in thickness. They are of uni Essential in the recognition of solid pen
form density; the entire sheet of peniosteal ostea! reactions is its persistence, relatively
new bone looks the same. Remarkable dif unchanged for weeks. Whereas it may in
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ferences may be seen from patient to pa
tient, but in the individual patient, the
newly formed bone, deposited as the result
of peniostea! reaction to an irritant, has an
even, uniform, solid appearance. When
seen, it is the hallmark of a benign process.
crease in size, the uniformity of its roentgen
density changes but little. In this regard the
importance of roentgen techniques cannot
be overemphasized. One should be able to
reproduce roentgenograms of uniform qual
ity in order that reliable roentgen compari

FIG. 5. Dense undulating periosteal reaction due to pulmonary osteoarthropathy. The periosteal reaction is
quite thick. Initially, a small dense periosteal reaction may be noted but as the condition progresses it
becomes much thicker and irregularly calcified. (A) Standard roentgenogram. (B) Magnified roentgeno
gram.
 FIG. 6. Solid thin periosteal reaction due to pul
monary osteoarthropathy. Most of the meta
carpals and phalanges reveal periosteal prolifera
tion. This occurs relatively early and the appear
ance is solid.
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FIG. 8. Solid periosteal reaction secondary to osteo

myelitis. This lesion was asymptomatic and dis
covered on a routine chest roentgenogram. The
solid periosteal reaction on the medial aspect of
the humerus at the site of the osteolytic destruc
tion indicated the benign nature.

FIG. 7. Dense elliptic periosteal reaction due to long

standing osteoid osteoma. The solid nature of the
reaction indicates benignancy.
 712 Jack Edeiken, Philip J. Hodes and Lawrence H. Caplan JULY, 1966

lating superficial surface. Thickness and

density seem related to the aggressiveness
of the irritant. Duration, too, may play a
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part. Thus, low level irritants acting for

longer periods of time on more aggressive
irritants acting for shorten periods of time
may eventuate similar roentgen changes.
Regardless of time and intensity, the pen
osteal response in benign conditions usually
will be even and uniform.
Among the lesions that commonly pro
duce solid periosteal new bone may be in
cluded eosinophilic granuloma, fractures,
osteomyelitis, hemorrhage, hypertrophic
pulmonary osteoarthropathy, osteoid oste
oma, vascular diseases, and the storage
diseases.
Noteworthy is the fact that, whereas

FIG. 9. Solid periosteal reaction due to osteoid

osteoma. The solid nature of the periosteal reac
tion suggests benignancy.

sons may be made in successive follow-up

roentgenograms.
Solid peniosteal reactions vary from pa
tient to patient depending upon the nature
and course of the patient's illness. As an
example, in one individual eosinophilic
granuloma may produce minor peniosteal
reaction with but a thin layer of peniosteal
new bone. In a second, the reaction may be
more aggressive with a thicker peniostea!
response. Yet, in both patients the penios
teal new bone appears solid and uniform.
They may differ remarkably in density as
well as thickness. It is their uniformity and
solidarity that are important, not their
thickness or density. The latter only signify FIG. 10. Solid periosteal reaction due to eosinophilic
the progress and age of peniosteal response. granuloma. The large destructive area in the
humerus associated with periosteal reaction was
Morphologically, solid uniform peniosteal considered Ewing's sarcoma. The solid nature of
new bone may be thick or thin, of any de the periosteal reaction should suggest a benign
gree of density, and have an even or undu condition.
 VOL. @7,No. 3 New Bone Production and Peniosteal Reaction 713

solid uniform peniosteal reactions bespeak benign or malignant tumors of the thoracic
benignancy, it must be remembered that cavity (Fig. 6). The mechanism of growth
benign lesions may not always express them is unknown, but after thonacotomy (with
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selves in this classic manner. They may
cause periosteal responses highly suggestive
of malignant disease.
Dense undulating periosteal reactions often
occur with longstanding varicosities or ar
terial disease. The peniosteal reaction often
is i cm. or more in thickness, and its free
edge is rough and undulating (Fig. 3; @; and
5, A and B). The mechanism
is unknown.
Thin undulating periosteal reactions are
located primarily on the concave aspect of
long bones. Pulmonary osteoarthnopathy is
the best example. These reactions are not
densely ossified and are associated with
or without removal of tumor) the reaction
subsides within 6 months.
Dense, elliptic periosteal reactions vary
from 2 mm. to I cm. in thickness. The
elliptic peniosteal reactions are thickest
near the center; they taper towards both
ends (Fig. 7, 8, 9 and io). They are present
in longstanding cortical osteoid osteomas.
of production Occasionally, round cell tumors (Ewing's
tumor or reticulum cell sarcoma) treated by
irradiation may cause elliptic reactions. In
the latter, however, the elliptic reaction is
permeated by osteolytic areas which are
characteristic of malignant growth.
Periosteal cloaking is found in longstand

o4 0
FIG. I I. Periosteal cloaking due to Gaucher's disease. Notice the rather straight borders and the elevation
of the periosteum from the host bone. (A) Standard roentgenogram. (B) Magnified roentgenogram.
 714 Jack Edeiken, Philip J. Hodes and Lawrence H. Caplan JULY, 1966

.,
peniosteal elevation caused by an expanding
mass.
The significance of the triangular Cod
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man's cuff merits particular mention. Long

considered a manifestation of malignant
bone disease, it is now appreciated that it
may result by anything lifting the penios
teum, be it benign or malignant (Fig. 12
and 13). Microscopically, tumor cells are
not present within the cuff. Indeed, when
invaded by tumor, Codman's triangle dis
appears. In contrast, collections of pus and
blood notoriously elevate peniosteum, pro
ducing these peniosteal triangles.

2. INTERRUPTED PERIOSTEAL REACTIONS

The interrupted periosteal reactions are
not uniform. They are pleomorphic with

FIG. 12. Codman's triangle due to hemorrhage.

Note the erosion of the distal end of the radius
and the presence of a Codman's triangle on the
medial aspect of the radius. This was considered a
malignant tumor but eventually proved to be
hematoma. Codman's triangle occurs with benign
and malignant lesions.

ing benign conditions such as storage

disease and chronic osteomyelitis. It is
usually several millimeters thick and irreg
ularly dense. The free margin is straight FIG. 13. Codman's triangle secondary to osteo

(Fig. ii, A and B). It does not occur with
malignancy.
Codman's triangle was first described by
Ribbert in 1914, who believed it was due to
sarcoma. A Codman's triangle is noted at the
proximal end of an osteolytic lesion in the distal
end of the femur. Codman's triangle is frequently
present with malignant tumors but may be present
with benign conditions.
 VOL. 97, No. 3 New Bone Production and Peniosteal Reaction 715

varying roentgen patterns. Lamellated to Sisson,3 single !amellations may form

(onion skin) or perpendicular (sunburst) within i week. Brunschwig and Harmon2
peniosteal reactions are classic examples. believe that the lamellations are the result
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Caused by peniosteal elevation in active of alternating periods of rapid and slow

conditions (malignant tumor, infection, re growth. During the slow growth, the pen
peated hemorrhage), the interrupted pat osteum has time to form a layer of bone
tern indicates an active rapidly progressive analogous to the involucrum of infection.
process. During rapid growth no new bone is
Characteristic of interrupted peniosteal formed. Bleeding into the periosteum, too,
reactions is their lack of stability; roent influences these roentgen appearances (Fig.
genographically, they change constantly. 14, A and B).
The more aggressive the irritant, the Perpendicular (sunburst) reactions are the
greaten the degree of peniosteal change from result of new bone growing at night angles
week to week. Sometimes, even days suffice to the shaft of host bone (Fig. ‘¿5,
A and B;
for these changes to become apparent. i6; and 17). Usually, they are caused by a
Lamellated periosteal reactions occur in malignant tumor which elevates the pen
active conditions such as acute osteomyeli osteum. In Brunschwig and Harmon's2
tis and malignant tumors. The lamellations opinion the new bone formation lies along
are due to intermittent growth. According fibrous bands (Sharpey's fibers) which ex

FIG. 14. Lamellated periosteal reaction secondary to osteosarcoma. There is a large destructive area within
the distal end of the femur. The periosteal reaction on the anterior surface is layered. (A) Standard roent
genogram.(B) Magnifiedroentgenogram.
 716 Jack Edeiken, Philip J. Hodes and Lawrence H. Caplan JULY, 1966
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0
FIG. :@ç.
Perpendicular (sunburst) periosteal reaction due to osteosarcoma. There is marked destruction in the
distal end of the femur with considerable soft tissue extension. Notice that in the inferior portion of the
soft tissue extension, posteriorly, there are perpendicular densities radiating from the bone. (A) Standard
roen tgenogram. (B) Magnified roen tgenogram.

tend between peniosteum and cortex. Blood
vessels, too, nun between peniosteum and
cortex; very likely perpendicular bone
growth also takes place along these vascu
lar channels.' Micronoentgenography as
well as serial histopathologic sections sup
port this concept.
Osteosarcomas and Ewing's tumor tend
to stimulate “¿sunburst― reactions. Chon
drosarcomas and fibrosarcomas show much
less peniosteum activity. At times, Ewing's
tumor and osteosarcoma will elevate the
peniosteum without provoking reaction.
Amorphous reactions. Malignant tumors,
in addition to causing lamellations and per
pendicular stniations (with or without inter
spersed deossified areas), often reveal amor
phous calcific densities ‘¿(Fig.i8). Lying
mainly between peniosteum new bone and
its parent bone cortex, these amorphous
deposits may present extension of tumor
bone rather than peniosteal response to the
tumor. Often oval or spherical in shape,
they vary in size from millimeters to centi
meters in cross sections. These amorphous
deposits usually denote bone malignancy.
 VOL. 97, No. 3 New Bone Production and Peniosteal Reaction 717

Rarely do they accompany benign bone

tumors. Usually, they help differentiate
primary from metastatic bone tumors, the
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latter being far less likely to cause peniosteal

reactions or extraosseous amorphous de
posits unless an associated pathologic frac
ture is present.
Some malignant bone tumors tend to pro
voke more peniosteal reaction than others, a
difference not related to the degree of pen
osteal elevation. Fibnosarcomas notoriously
peel the peniosteum a considerable height
from parent bone, yet they produce little
peniosteal new bone formation. The micro
scopic evidence suggests that a peniosteal
response does occur which is destroyed a!-

FIG. 17. Perpendicular (sunburst) reaction of the

fourth metacarpal due to Ewing's sarcoma. Exten
sive destruction is noted in the fourth metacarpal.
Perpendicular periosteal reaction extends on both
sides of the metacarpal.

most as soon as it forms. This is true also

of chondrosarcomas. In contrast, osteosar
coma and Ewing's tumor seem to stimulate
new bone formation. It is but fain to recall
that sometimes osteosancoma and Ewing's
tumor, though they elevate the peniosteum,
may not provoke demonstrable peniosteal
new bone response. Perhaps rate of tumor
FIG. I 6. Perpendicular (sunburst) periosteal reac
growth explains the difference.
tion due to osteosarcoma. There is a large tumor
in the distal end of the femur with a Codman's In general, the following train of thought
triangle on the posterior aspect and lamellated may reasonably be applied to bone lesions
periosteal reaction anteriorly. with particular reference to the peniosteum.
 718 Jack Edeiken, Philip J. Hodes and Lawrence H. Caplan JULY, :966

than metastatic (unless the primary lesion

is of bone origin). Solid peniosteal new bone
usually proves to be due to a benign process.
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SUMMARY

i. Peniosteal reactions occur in a variety

of bone diseases and may be useful in dif
ferentiating among these conditions.
2. Solid reactions are seen in benign
conditions and are useful in differentiating
eosinophilic granuloma and osteoid osteoma
from malignant bone tumors (Ewing's
“¿ii tumor).
3. Interrupted peniosteal reactions are
common in active, progressive disease
which may be either neoplastic or inflam
matory. The lamellated type is associated
with both neoplasm and infection, while the
perpendicular type is more common in
neoplastic conditions and rare with infec
tion.
@.
Codman'striangleis due to elevation
FIG. I8. Amorphous deposits of tumor new bone of the peniosteum and not necessarily to
and extensive destruction of the neck of the femur
due to osteosarcoma. The small deposit of amor
malignancy.
phous calcification is often present with malignant Jack Edeiken, M.D.
bone tumors. It probably represents a deposit of Jefferson Medical College Hospital
tumor new bone rather than periosteal reaction. Philadelphia 7, Pennsylvania

REFERENCES
Osteoblastic lesions confined to the host i. AEGERTER, E. E. Personal communication.
bone, unattended by changes beyond the 2. BRUNSCHWIG, A., and HARMON, P. H. Studies in
bone, may be benign or malignant. If inter bone sarcoma: III. An experimental and patho
rupted periostea! new bone is manifest logical study of role of periosteum in formation
of bone in various primary bone tumors. Surg.,
beyond the parent bone, in the absence of Gynec. & Obstet., 1935, 6o, 30—40.
infection on trauma, the lesion is far more 3. SIssoN,H. A. Intermittentperiosteal activity.
likely to be a primary bone malignancy Nature,1949,163,1001—1002.