Periosteum: Periostitis Multiple Bones
B. J. Manaster, MD, PhD, FACR
DIFFERENTIAL DIAGNOSIS
Common
Physiologic Periostitis
Child Abuse
Multifocal Osteomyelitis
Juvenile Idiopathic Arthritis (JIA)
Hypervitaminosis A
Polyostotic Aggressive Bone Tumor
Less Common
Prostaglandin Periostitis
Sickle Cell Dactylitis
Rare but Important
Caffey Disease
Renal Osteodystrophy (Mimic)
Leukemia
Scurvy
Complications of Chemotherapeutic Drugs, Methotrexate
Hypertrophic Osteoarthropathy, Cystic Fibrosis
Complications of Retinoids
ESSENTIAL INFORMATION
Key Differential Diagnosis Issues
Periosteal reaction is common in a single bone, with a multitude of etiologies
Polyostotic periostitis is much less common; the polyostotic nature and patient age helps to limit the diagnosis
Hint: Some etiologies are limited by patient age
1st appearance BEFORE 6 months of age
Physiologic (should disappear by age 6 months)
Congenital osteomyelitis
Caffey disease
Prostaglandin periostitis
1st appearance AFTER 6 months of age
Juvenile idiopathic arthritis
Hypervitaminosis A
Sickle cell dactylitis
Renal osteodystrophy
Scurvy
Hint: Always consider the possibility of child abuse/nonaccidental trauma
Helpful Clues for Common Diagnoses
Physiologic Periostitis
Normal growth may be so rapid during first 6 months that new periosteal bone is produced
Symmetric, regular
Resolves by 6 months of age
Child Abuse
Always consider this diagnosis when periosteal reaction is seen in a child!
Often not symmetric
Often 2° to metaphyseal corner fracture
Fracture causes subperiosteal bleeding and lifting of periosteum
May occur without fracture 2° to normally loose periosteum and a twisting injury
Multifocal Osteomyelitis
Congenital infections
TORCH infections
Congenital syphilis (may have “celery stalking” at metaphyses as well)
Infections from newborn ICU: Generally Streptococcus
Multifocal osteomyelitis later in childhood
Hematogenous spread (metaphyseal)
Consider underlying disease: HIV/AIDS or sickle cell anemia
Tuberculosis (TB) involvement in hands: Dactylitis is termed spina ventosa
Juvenile Idiopathic Arthritis (JIA)
1st osseous manifestation may be periostitis of hand or foot phalanges
Later, joints will be involved
Differential is sickle cell and TB dactylitis
Hypervitaminosis A
Excessive intake of vitamin A results initially in periosteal reaction
Subtle at first but may become quite dense and thick
Painful
Continued use of excessive vitamin A may lead to coned epiphyses
Polyostotic Aggressive Bone Tumor
Bone metastases
Ewing sarcoma presents with osseous metastases as frequently as lung mets
Others to consider: Medulloblastoma, neuroblastoma, osteosarcoma
Leukemia: Common but usually presents with lucent metaphyseal bands or diffuse osteoporosis
Periostitis is a rare manifestation
Langerhans cell histiocytosis: Often polyostotic; may be aggressive enough to elicit periosteal reaction
Helpful Clues for Less Common Diagnoses
Prostaglandin Periostitis
Prostaglandins used for congenital heart disease in infancy to keep ductus open
Dense, nonspecific periosteal reaction on long bones
Sickle Cell Dactylitis
Generally young children (< 7 years of age)
Cold temperature → vasoconstriction of terminal vessels in phalanges → sludging of sickled red blood cells → bone infarct
Bone infarct may initially elicit periostitis; eventually has mixed lytic and sclerotic appearance
Helpful Clues for Rare Diagnoses
Caffey Disease
Rare disease manifests at birth
Painful periostitis of long bones
Involvement of clavicle and mandible is suggestive of diagnosis since not usually seen with other diagnoses
Self-limited; spontaneously resolves over 1st 2 years of life
Renal Osteodystrophy (Mimic)
Severe subperiosteal resorption, especially at proximal humeral, tibial, or femoral metaphysis or at radial aspect of middle phalanx, may mimic fluffy periostitis
Watch for underlying abnormal bone density, signs of rickets (widening at zone of provisional calcification)
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