Axial Arthritis

In the appendicular skeleton, one is mostly

concerned with the diarthrodial synovial joints.
While this type of joint is also found in the axial
skeleton (the facet (a.k.a. aphophyseal) joints
and portions of the sacroiliac joints), there are
also many amphiarthrodial joints which are not
synovial (the intervertebral disc joints).
However, there are several structures in the
intervertebral disc joint which are analogous to with increasing age (arrow), progressive
structures found in a true synovial joint. The degeneration of the nucleus leads to decreasing
cartilaginous endplate, the annulus fibrosus, and disk space height
the nucleus pulposus are analogous to the Degenerative annular disease
articular cartilage, the joint capsule and the Yet another extremely common degenerative
synovial fluid of the synovial joint. disorder involves degeneration of the annulus
The different anatomy and physiology of these fibrosus. This leads to marginal osteophytosis at
joints means that we will see different disorders the endplates, especially in the thoracolumbar
affecting this part of the skeleton. However, the spine in many persons over 50 years of age. In
same basic logical principles mentioned in the the literature, this entity has been termed
last chapter also apply here. "spondylosis deformans" or "senile ankylosis".
Degenerative disorders However, both of these terms tend to make the
Osteoarthritis disease sound a lot worse than it really is. Using
This is, by far, the most common type of arthritis these terms in a film report can lead to calls
seen in humans. By definition, osteoarthritis from clinicians wondering just what horrible
occurs in a synovial joint. In the spine, disease their patients have. Therefore, I prefer
therefore, osteoarthritis occurs in the to state "marginal osteophytes are noted at
apophyseal (facet) joints, the uncovertebral multiple disc spaces in the spine" in my
joints (cervical spine), the costovertebral joints, dictations. The clinicians know what I'm
and the sacroiliac joints. Osteoarthritis may be describing and they and their patients are not
primary or secondary. unduly frightened by the unfamiliar terminology
used for this very familiar process.

with increasing age (arrow), progressive

degeneration of the annulus leads to increasing
osteophytosis at the disk space margins -- the
height of the disk space is largely preserved
In practice, one often sees evidence of
degeneration of both the annulus and the
nucleus. It usually doesn't make a lot of
marked osteophytosis and joint space narrowing difference to the referring clinician which
is noted in the facet joints in this patient with component of the disk has degenerated.
severe osteoarthritis of the lumbar spine -- the Therefore, I suggest using the term
osteophytosis is causing significant "degenerative disk disease" in one's dictations to
encroachment on the lateral recesses bilaterally refer to these entities.
Degenerative nuclear disease
Another very common disorder is degeneration
of the nucleus pulposus. With age, the nucleus
tends to become more and more dehydrated,
and gradually begins to degenerate. As this
happens, the intervertebral disc height begins to
decrease. When this happens, the altered
pattern of stresses may lead to marginal
osteophytosis adjacent to the affected
endplates. As the disc space decreases in height,
increased stress is also placed on the facet
joints, leading to the frequent association of
osteoarthritis of the facets at the same level.
 as idiopathic gout, encompassing the vast
majority of individuals, or gout associated with
known disorders or enzymatic defects.
Calcium pyrophosphate crystal deposition
disease
Calcium pyrophosphate crystal deposition
disease: a general term for a disorder
characterized by the deposition of calcium
pyrophosphate dihydrate (CPPD) crystals in or
around joints.
Pseudogout: a term applied to one of the
clinical patterns that may be associated with
CPPD crystal deposition disease. This pattern,
characterized by intermittent acute attacks of
arthritis, simulates the findings of gout.
Chondrocalcinosis: a term reserved for
marked marginal osteophytosis is noted at each pathologically or radiologically evident
disk space in this patient with predominantly calcification of hyaline articular cartilage or
annular degeneration fibrocartilage. In some cases, this calcification
may not indicate deposits of CPPD crystals but
rather accumulations of some other crystal.
Pyrophosphate arthropathy: a term used to
describe a peculiar pattern of structural joint
damage occurring in CPPD crystal deposition
disease simulating, in many ways, degenerative
joint disease but characterized by distinctive
features.
Hydroxyapatite deposition disease
This is a disorder characterized by recurrent
painful periarticular calcium hydroxyapatite
deposits in tendons and soft tissues.
Psoriatic arthritis
This is a relatively uncommon arthropathy which
occurs in about 2 to 6 % of patients with
psoriasis. Approximately 25 to 60 % of patients
with psoriatic arthritis are HLA-B27 positive.
disk space narrowing is noted at multiple levels Reiter's syndrome
in this patient with degenerative disk disease -- Reiter's syndrome is a relatively uncommon
a thin linear area of lucency in the L4-5 disk arthropathy of uncertain etiology with the classic
space represents gas in the degenerated disk triad of urethritis, arthritis, and conjunctivitis. Of
Diffuse Idiopathic Skeletal Hyperostosis (DISH) all of the rheumatic diseases, Reiter's syndrome
DISH is an extremely common entity of is most suspect for an infectious etiology. It
unknown etiology, which manifests itself by appears likely that the disease can be
ossification of the anterior longitudinal ligament, transmitted in association with either epidemic
which produces large flowing bony excrescences dysentery or sexual intercourse. The syndrome
along the spine, especially the anterior aspect. frequently follows an infection of the bowel or
Inflammatory spondyloarthropathies lower genitourinary tract, and it seems likely
Rheumatoid arthritis that these sites are the portals of entry for the
This is a disorder of unknown etiology causative agent. It has been suggested that the
characterized by synovial inflammation, pannus abnormalities of the vertebral column may be
formation, and then destruction of bone and related to organisms extending directly to the
cartilage. sacroiliac joints and spine via the prostatic
Ankylosing spondylitis venous plexus or via the venous plexus of
This chronic inflammatory disorder of unknown Batson. Implicated organisms include
etiology principally affects the axial skeleton. pleuropneumonia-like organisms (PPLO), the
Alterations occur in synovial and cartilaginous Bedsonia group of organisms, and viruses,
articulations and in sites of tendon and ligament although to date, no single agent has been
attachment to bone. Over 90 % of caucasian definitely incriminated in this disease.
patients with ankylosing spondylitis are HLA-B27 Approximately 75 to 96 % of patients with
positive. Reiter's syndrome are HLA-B27 positive.
Crystalline arthritis Enteropathic arthropathy
Gout This arthropathy occurs in about 1 - 26 % of
This is the prototypic crystalline arthropathy, patients with ulcerative colitis or Crohn's
characterized by the deposition of monosodium disease. The relationship between inflammatory
urate crystals in the skin, subcutaneous tissues, intestinal diseases and arthritis is not fully
and joints. This is most meaningfully classified understood. Infectious, immunologic, and
genetic etiologies have been advanced.
Approximately 90 % of patients with ulcerative
colitis or Crohn's disease who develop
spondylitis or sacroiliitis are HLA-B27 positive.
2. Radiographic Hallmarks
Osteophytes
In a diarthrodial joint, this is the sine qua non of
osteoarthritis. Osteophytes can be seen in both
primary and secondary osteoarthritis. They can
also be seen at various entheses, often due to
altered or increased stress at the entheses
(traction osteophytes). The traction osteophytes
of degenerative annular disease begin several
millimeters from the edge of the vertebral body,
and tend to be initially oriented horizontally at
their attachment to the vertebral bodies. They
then often curve slightly and may even form a
complete bony bridge across the disc space.
syndesmophytes (arrows) in the spine of a
patient with ankylosing spondylitis
Disc space narrowing
This almost always means degenerative nuclear
disease or infection. These can often be
distinguished by looking at the adjacent
endplates. In degenerative disc disease, the
endplates are often dense, sclerotic, and
associated with osteophytosis. In infection, the
subchondral line of the endplate often becomes
ill-defined and discontinuous.
Bony proliferation
This is a striking feature of the seronegative
spondyloarthropathies, particularly psoriatic
arthritis. This bony proliferation occurs about
erosions, and probably relates to an
exaggerated healing response of the injured
bone. This proliferation may take the form of
irregular excrescences, subperiosteal deposition
of bone, and intra-articular osseous fusion.
bridging osteophytes in the spine of a patient
Erosions
with degenerative disk disease
In general, the presence of erosions bespeaks
Syndesmophytes
some type of inflammatory disease, whether the
Syndesmophytes are generally seen only in the
erosions are due to synovial hypertrophy,
seronegative spondyloarthropathies. These are
crystalline deposits, or infection.
due to inflammation and ossification of the outer
Crystal deposition
fibers of the annulus fibrosus, known as the
In general, this is indicative of one of the
Sharpey's fibers. This is classically seen in
crystalline arthropathies -- either CPPD or
ankylosing spondylitis. In the other seronegative
hydroxyapatite.
spondyloarthropathies, one usually sees
Sclerosis
paravertebral ossification which forms in the
Not an especially specific finding in spinal
paravertebral connective tissue at some distance
arthropathy.
from the spine. In practice, it may be very
Ankylosis
difficult to distinguish osteophytes from
This may occur as a result of many degenerative
syndesmophytes or paravertebral ossification.
and inflammatory processes in their later stages.
Subluxation
Stability of the spine is maintained by the spinal
ligaments, articular capsules, and discs. Any
arthropathy which causes degeneration or
destruction of these structures may lead to
instability of the spine and subluxation in several
locations.
3. Pattern Approach
Osteoarthritis
Osteoarthritis of the spine looks much like
osteoarthritis elsewhere in the body. Any of the
spinal synovial joints can be affected, including
the facet and uncovertebral joints, the
costovertebral joints, and the SI joints. Findings with this entity are often much larger than those
include osteophytosis, joint space narrowing, seen with degenerative nuclear disease.
subchondral sclerosis, and subchondral cyst
formation. Besides causing local joint pain, facet
osteoarthritis may cause nerve root
impingement or compression if the osteophytes
are large enough to extend into the lateral
recess of the spinal canal, as shown below.

extensive osteophytosis is noted in the thoracic

spine in this patient with predominantly
degenerative annular disease
marked osteophytosis is seen in the spine of a DISH
patient with osteoarthritis of the lumbar facet With DISH, the flowing ossification seen is
joints -- this osteophytosis is extending into the usually along the anterior longitudinal ligament.
lateral recesses bilaterally and causing nerve Although there has been recent speculation that
root compression DISH may be a disorder of vitamin A
Degenerative disc disease metabolism, DISH remains an idiopathic
Degeneration of either the nucleus pulposus, the disorder. As such, it lacks not only a known
annulus fibrosus, or both may be present. While specific cause but also a known specific disease
these processes can often be distinguished from marker (such as monosodium urate crystals in
each other, overlap in findings will be seen in gout). Therefore, DISH is necessarily a diagnosis
many patients who have both processes by exclusion. Since DISH is diagnosed on a
occurring in the same disc. morphologic basis alone, there will be of
The key distinguishing characteristic between necessity some overlap between certain cases of
these two processes is disc space narrowing. If DISH and other disorders with similar
present, this is strongly suggestive of radiographic features, such as ankylosing
degenerative nuclear disease. This is often spondylitis, and degenerative disc disease. To
accompanied by endplate sclerosis and mild to help minimize this overlap, certain arbitrary
moderate osteophytosis. morphologic criteria have been proposed.
Finding That Distinguishes
Similar Disorders
Them From DISH
Ankylosing SI and facet joints must be
spondylitis normal
Degenerative Disc spaces must be of
nuclear disease normal height
Ossification must be seen
Degenerative
along four contiguous
annular disease
vertebral bodies
Since we often don't have any specific therapy
for DISH, is there any reason to try to
distinguish it from all of these other disorders? I
feel that there is. If for no other reason,
knowing the name of a disease allows one to be
much more precise in giving a prognosis to a
intervertebral disc space narrowing, intradiscal patient. Knowledge of the presence of DISH may
gas, and osteophytosis are noted in this patient alter therapy for other disorders. For example,
with predominantly degenerative nuclear DISH patients are prone to heterotopic bone
disease formation in surgical sites. Because of this,
On the other hand, degenerative annular disease some orthopedic surgeons will prophylactically
is often not associated with significant disc space treat DISH patients with radiation or drug
narrowing, and the marginal osteophytes seen therapy prior to performing a total joint
arthroplasty, in an attempt to prevent or stages of the disease are almost invariably
diminish the development of heterotopic bone bilateral and symmetric in distribution. This
formation after surgery. symmetric pattern is an important diagnostic
clue in this disease and may permit it
differentiation from other disorders that affect
the sacroiliac articulation, such as RA, psoriasis,
Reiter's syndrome, and infection. Changes in the
SI joint occur in both the synovial and
ligamentous (superior) portions, and
predominate on the iliac side, for reasons that
are obscure.

prominent, flowing ossification is noted along

the anterior margin of the cervical spine in this
patient with DISH -- it is easy to see why such
patients often complain of dysphagia

bilateral erosions and sclerosis are noted in the

SI joints of this patient with ankylosing
spondylitis
The classic histologic descriptions of synovial
joint alterations in ankylosing spondylitis stress
that the synovitis is similar or identical to that in
rheumatoid arthritis. Indeed, ankylosing
spondylitis was once called rheumatoid
spondylitis, under the impression that
ankylosing spondylitis was just a variant of
rheumatoid arthritis. Further research into this
entity revealed enough clinical and
immunological differences between the two
flowing ossification is noted along the anterior
entities to warrant calling it a disease of its own.
margin of the thoracic and lumbar spine in these
In general, the inflammatory process in
patients with DISH -- note that the disk spaces
ankylosing spondylitis is more discrete and of
are preserved and that at least four contiguous
lower intensity that in rheumatoid arthritis.
bodies are involved
Ankylosing spondylitis
Ankylosing spondylitis affects synovial and
cartilaginous joints as well as sites of tendon
and ligament attachment to bone (entheses). An
overwhelming predilection exists for involvement
of the axial skeleton, especially the sacroiliac,
apophyseal, discovertebral, and costovertebral
articulations. Classically, changes are initially
noted in the sacroiliac joints and next appear at
the thoracolumbar and lumbosacral junctions.
With disease chronicity, the remainder of the
vertebrae may become involved. However, this
characteristic pattern of spinal ascent is by no erosions are noted in the lumbar facet joints of
means invariable; it may occur slowly or rapidly, this patient with ankylosing spondylitis
and is less frequent in spondylitis accompanying The characteristic radiographic features of
psoriasis and Reiter's disease. ankylosing spondylitis include erosions,
Sacroiliitis is the hallmark of ankylosing sclerosis, syndesmophytosis, and ankylosis.
spondylitis. It occurs early in the course of the Rheumatoid arthritis
disease. Although an asymmetric or unilateral As mentioned above, the histological changes
distribution can be evident on initial radiographic noted classically in rheumatoid arthritis are
examination, roentgenographic changes at later similar or identical to those of ankylosing
spondylitis. However, the general pattern of The incidence of gout in the sacroiliac joint has
distribution of these changes are usually quite been reported at 7 - 17 %, although many of
distinct from that of ankylosing spondylitis. For the changes ascribed to gout in the earlier
example, rheumatoid arthritis predominantly literature were probably mimicked in these
involves the cervical spine, with apophyseal joint reports by the changes of osteoarthritis.
erosion and malalignment, intervertebral disc Sacroiliac joint involvement is seen more
space narrowing with endplate sclerosis and frequently with early onset disease, and large
without osteophytes, and with multiple cystic areas of erosion in ilium and sacrum are
subluxations, especially at the atlanto-axial the most specific findings of gout in these joints.
junction. Abnormalities of the thoracolumbar Hydroxyapatite crystal deposition disease
spine and sacroiliac joints are infrequent and Hydroxyapatite crystal deposition disease is
less prominent than those of ankylosing most commonly seen about the shoulder.
spondylitis. However, it may also occur within the longus
colli muscle, which is the principal flexor of the
cervical spine. Tendinitis in this region may
result in acute neck and occipital pain, rigidity,
and dysphagia. Calcifications tend to occur
particularly in the superolateral group of the
longus colli. The typical radiographic findings of
this disorder consist of prevertebral soft tissue
swelling in upper cervical region, as well as
amorphous calcification, usually anterior to C-2,
and just below the anterior arch of C-1.
Resorption of this calcification and soft tissue
swelling is common, and it may disappear
completely in 1 to 2 weeks.
Psoriatic arthritis
About 30 to 50 % of patients with psoriatic
arthritis develop sacroiliac joint changes
the dens is eroded in this patient with radiographically. Bilateral sacroiliac joint
rheumatoid arthritis -- a mass of pannus is abnormalities are much more frequent than
noted behind the dens and impinging on the unilateral changes, and although asymmetric
thecal sac and cord in these T1- and T2- findings may be apparent, symmetric
weighted MR images abnormalities predominate. Radiographic
Other helpful differential findings are the sacroiliac joint changes include erosions and
absence of osteoporosis and the presence of sclerosis, predominantly on the iliac side, and
bony proliferation and intraarticular bony widening of the articular space. Although
ankylosis in the seronegative significant joint space diminution and bony
spondyloarthropathies. ankylosis can occur, the incidence of these
CPPD crystal deposition disease findings, particularly ankylosis, is less than that
The spine is frequently involved in CPPD crystal of classic ankylosing spondylitis or the
deposition disease. spondylitis associated with inflammatory bowel
Intervertebral discal calcifications are frequent in disease. Sacroiliitis may appear without
the outer annular fibers, and may mimic early spondylitis, just as spondylitis may appear
syndesmophytes of ankylosing spondylitis, without sacroiliitis.
because of their vertical orientation and slender As in Reiter's syndrome, paravertebral
appearance. These annular calcifications may be ossification about the lower thoracic and upper
associated with back pain. Disc space narrowing lumbar segments can occur in psoriatic arthritis,
is common in CPPD crystal deposition disease, and it may represent an early manifestation of
and may be extensive, widespread, and the disease. Such ossification appears as a thick
associated with considerable vertebral sclerosis. and fluffy or thin and curvilinear radiodense
However, the nucleus pulposus is not commonly region on one side of the spine, paralleling the
calcified. Calcification of ligamentum flavum may lateral surface of the vertebral bodies and the
also be noted. Occasionally, destructive intervertebral discs. Occasionally, slender,
abnormalities of cervical spine are present. centrally located, and symmetric spinal
Chondrocalcinosis is only infrequently seen in outgrowths in psoriasis are identical in
the sacroiliac joints, but is very common in the appearance to the syndesmophytes of
fibrocartilaginous joint of the pubic symphysis. ankylosing spondylitis. However, the greater
Gout size, the unilateral or asymmetric distribution,
Spinal manifestations of gout are extremely and the location farther away from the vertebral
uncommon, and documented urate deposition in column are features that distinguish
the spine is exceedingly rare. When seen, spinal paravertebral ossification from the typical
gout may manifest as erosions of the synovial syndesmophytosis of ankylosing spondylitis or
joints or endplates, and disc space narrowing the spondylitis of inflammatory bowel disease.
may be present. In addition to the pattern and distribution of
bony outgrowths, there are other features of
psoriatic spondylitis that differ from those in
classic ankylosing spondylitis. Osteitis and
squaring of the anterior surfaces of the vertebral
bodies are relatively infrequent in psoriasis.
Although apophyseal joint space narrowing,
sclerosis and bony ankylosis may be seen, the
prevalence of these findings is much less than
that in ankylosing spondylitis.
Cervical spine abnormalities may be striking in
psoriatic arthritis, including apophyseal joint
space narrowing and sclerosis, osseous
irregularity at the discovertebral joint, and
extensive proliferation along the anterior surface
of the spine. Atlanto-axial subluxation can also
be evident (in one series up to 45 % of patients
with psoriatic spondylitis). bony proliferation (arrows) is noted along the
Reiter's syndrome anterior margin of the lumbar spine in this
Reiter's syndrome is associated with an patient with Reiter's syndrome
asymmetric arthritis of the lower extremity, Enteropathic arthropathy
sacroiliitis, and, less commonly, spondylitis. The spondylitis and sacroiliitis of inflammatory
Although its general features resemble those of bowel disease are identical to those of classic
ankylosing spondylitis and psoriatic arthritis, ankylosing spondylitis. The history of
Reiter's syndrome possess a sufficiently inflammatory bowel disease can sometimes help
characteristic articular distribution to allow to distinguish these entities, although spondylitis
accurate diagnosis. in ulcerative colitis is poorly correlated with
Ankylosing spondylitis has a similar axial skeletal activity of the bowel disease. In ulcerative
distribution (although cervical changes are more colitis, spinal abnormalities may become
frequent in ankylosing spondylitis), but manifest prior to, at the same time as, or
significant peripheral articular changes are more following the onset of intestinal changes. In fact,
frequent. spondylitis most commonly precedes the onset
Psoriatic arthritis may lead to considerable of colitis and may progress relentlessly without
alterations in the articulations of both the relation to exacerbation, remission, or treatment
appendicular and the axial skeleton. However, in of the bowel disease. In Crohn's disease, the
psoriasis, widespread involvement of the upper joint abnormalities tend to occur simultaneously
extremity may be apparent, and distal with the bowel disease.
interphalangeal joint abnormalities in both upper Peripheral joint abnormalities tend to occur
and lower extremities are common. The much more frequently with enteropathic
sacroiliac and spinal changes of Reiter's arthropathy than with ankylosing spondylitis.
syndrome are virtually identical to those of When they do occur, they are usually self
psoriasis, although the incidence and severity of limited, and rarely cause lasting deformity of the
these abnormalities and the tendency to involve joint. However, in ankylosing spondylitis, the
the cervical spine are greater in psoriasis. peripheral joint findings typically include joint
space narrowing, osseous erosions, cysts, and
bony proliferation, which may help in
distinguishing these entities.
4. Demographics
All of the entities described in this section on
axial arthropathies can occur in the young or the
old, and in men or women. However, just as in
the appendicular arthropathies, there are certain
trends in the distribution of these disorders that
may sometimes be helpful in refining one's
differential diagnosis. The following tables show
some of these trends. As with the appendicular
arthropathies, other demographic features such
as home location, occupation, and ethnic
subtype may occasionally be of help.
sclerosis and ill-definition of both SI joints is
Age
noted in this patient with Reiter's syndrome
Age of Disorder
Age Group
Onset
Juvenile chronic
Young (< 20 arthritis
< 20 years
years) Septic arthritis
 Ankylosing disorders. Even though over 90 different
onset 15 - spondylitis rheumatic diseases are recognized by the
35 years Reiter's American College of Rheumatology, only three
entities are commonly seen in most clinical
radiology practices, even including those located
Enteropathic in large tertiary medical centers. Osteoarthritis
Middle (> 20 Young
arthropathies (a.k.a. degenerative joint disease) is the most
years) adults
commonly seen form of appendicular arthritis.
The other two commonly seen arthropathies are
Rheumatoid
rheumatoid arthritis and calcium pyrophosphate
25 - 55 arthritis
dihydrate (CPPD) deposition disease. Less
years Psoriatic arthritis
common arthropathies that may manifest
radiographic findings in the appendicular
Osteoarthritis skeleton include septic arthritis, and gout. Most
Older patients other appendicular arthropathies are seen only
> 55 years DISH
(> 55 years) rarely.
CPPD
2. Radiographic Hallmarks
Arthropathies with Male Predominance In George Orwell's Animal Farm, it is stated that
Disorder male:female ratio "All animals are equal. But some animals are
more equal than others." This principle is
Ankylosing spondylitis 4:1 to 10:1 manifested in the appendicular arthropathies,
where some radiographic findings are quite
2:1 to 3:1, but specific and can quickly lead one to the correct
Psoriatic
controversial diagnosis. Other findings are less specific and
Reiter's 5:1 to 50:1 are usually unhelpful in ordering one's
differential diagnosis.
Gout 20:1 In a diarthrodial joint, osteophytes are the sine
qua non of osteoarthritis. Osteophytes can be
DISH 3:2
seen in both primary and secondary
CPPD 1:1 osteoarthritis.

Primary osteoarthritis
(< 45 years)
Enteropathic
arthropathy
Ulcerative colitis 4:1
Crohn's disease 1:1
Arthropathies with Female Predominance
Disorder female:male ratio
Rheumatoid Arthritis 2:1 to 3:1
marked osteophytosis (arrows) is seen in the
Primary osteoarthritis DIP and PIP joints in these fingers
(> 45 years)
CPPD 1:1
5. The law of parsimony
As in the appendicular arthropathies, a patient
may have more than one arthropathy going on
in a given joint. Again, this is most commonly
due to secondary osteoarthritis due to some
other arthropathy, although other unusual
combinations of arthropathies may be seen. This
principle can sometimes help to clarify what
otherwise might be a confusing radiographic
picture. osteophytosis (arrow) is noted at the articular
Appendicular Arthritis margin of the femoral head
1. Sutton's Law Osteophytes can also be seen at various
This law has been ascribed to Willie Sutton, a entheses (sites of tendinous or ligamentous
famous bank robber. When asked why he robbed attachment to bone), often due to altered or
banks, he reportedly said, "Because that's where increased stress there.
the money is." In the radiographic evaluation of In general, the presence of erosions bespeaks
appendicular arthropathies, the "money" is some type of inflammatory disease, whether the
generally in a relatively small handful of
erosions are due to synovial hypertrophy, erosions (arrows) are noted at the articular
crystalline deposits, or infection. margins of the tibia in this patient with juvenile
In rheumatoid arthritis, the erosions follow the chronic arthritis
development of an inflammatory proliferation of If the inflammation proceeds unchecked, the
the synovium, called pannus. As this pannus erosions of the bone and the cartilage may
increases in amount, it begins to cause erosions become profound, and the joint may finally
of the chondral surface. undergo fibrous ankylosis.
As the pannus increases further in amount, one The presence of crystal deposits
begins to see erosions at the periarticular "bare" (chondrocalcinosis or tophi) indicates one of the
areas. These "bare" areas refer to bone within crystalline arthropathies. In calcium
the synovial space which is not covered by pyrophosphate dyhidrate depostition (CPPD)
articular cartilage. The articular cartilage tends disease, the most common site of radiographic
to protect the bone that it covers. The marginal calcifications is in fibrocartilage and hyaline
"bare" areas are not covered by cartilage, and articular cartilage (chondrocalcinosis). However,
the earliest erosions of rheumatoid arthritis are calcifications may also be seen in the joint
seen here. capsule or synovial membrane.

calcification may be seen at several sites about a

joint in CPPD
erosions (arrows) are noted in the periarticular
areas of the toes in this patient with rheumatoid
arthritis

chondrocalcinosis is seen in the triangular

fibrocartilage of this wrist

multiple erosions and marked joint space

narrowing are noted in a pancarpal distribution
in this patient with rheumatoid arthritis

chondrocalcinosis is seen in both the

fibrocartilage of the menisci and in the hyaline
articular cartilage of this knee
In gout, erosions are caused by tophi. These
tophi may be either intra- or extra-articular in
location. Calcifications are occasionally seen in
tophi. The erosions of gout may appear very
similar to those seen in rheumatoid arthritis.
However, in gout, there tends to be early
sparing of the articular cartilage between the
erosions, while the cartilage is thinned much
earlier in the course of rheumatoid arthritis.
 joint compartments of the wrist -- CMC (first
carpometacarpal), CCMC (common
carpometacarpal), ST (scaphotrapezial), MC
(midcarpal), RC (radiocarpal), and DRUJ (distal
radioulnar joint)
a gouty erosion (arrow) is noted along the
medial margin of the first metatarsal head in
this patient with gout -- relative sparing of the
articular cartilage is also noted
Other findings, such as joint space narrowing,
subchondral cyst formation, sclerosis, ankylosis,
or subluxation are not especially specific and
may occur in a wide variety of degenerative or
inflammatory disorders in the appendicular
skeleton. It is important to describe these
findings, as they tell us a lot about the severity typical distribution of arthritis in the wrists
of the patient's disease -- it's just that they
don't tell us a whole lot about what specific
disease is causing them.
3. Pattern Approach
It would be nice if one could start with a few
basic pathophysiological axioms, and from these
first principles go on to deduce the characteristic
sites of joint involvement of the various
appendicular arthropathies. Unfortunately, such
principles remain obscure, forcing one to
memorize empirical patterns. However, once
learned, these patterns can be helpful in typical distribution of arthritis in the knees
ordering the differential diagnosis. Although
such patterns have been described for most of
the appendicular joints (Resnick, 1995), the
most specific of these patterns of joint
involvement are seen in the hands and wrists.
Less specific patterns are seen in the hips and
knees.

typical distribution of arthritis in the hips

Any joint in the body can be affected by
secondary osteoarthritis due to trauma, infection
or another arthropathy. However, the findings of
primary (idiopathic) osteoarthritis are usually
seen in the distal interphalangeal (DIP) joints of
the hand, and the first carpometacarpal joint
and scaphotrapezial joint of the wrist. The
proximal interphalangeal (PIP) joints may
typical distribution of arthritis in the hands
occasionally be affected. Rheumatoid
arthritis(RA)tends to involve the PIP and
metacarpophalangeal (MCP) joints of the hand
and all of the major joint compartments of the
wrist (pancarpal involvement). CPPD deposition
disease usually initially affects the radiocarpal
(RC) joint in the wrist, but may also involve the
MCP joints of the hand.
4. Demographics
Age and gender may occasionally be useful in form an effective framework for the diagnosis of
narrowing the differential diagnosis of the most of the cases of appendicular arthropathy
appendicular arthropathies. For example, the which one actually sees in a clinical radiology
most common arthropathies in children are practice, and can be very helpful in elucidating
juvenile chronic arthritis and septic arthritis, the cause of even radiographically complex
while entities such as rheumatoid arthritis, arthropathies.
osteoarthritis and CPPD arthropathy are Lucent Bone Lesions
generally seen in older adults. CPPD arthropathy Mnemonic = FOGMACHINES
affects both genders equally. Rheumatoid Differential Diagnosis of Solitary Lucent
arthritis has a moderate female predominance, Bone Lesions
as does osteoarthritis in the older age group. • Fibrous Dysplasia
Gout, on the other hand, has a moderate to
strong male predominance.
• Osteoblastoma
Other demographic factors, such as home • Giant Cell Tumor
location, occupation and even ethnic subtype • Metastasis / Myeloma
can occasionally be helpful in steering the
differential toward or away from certain disease
• Aneurysmal Bone Cyst
entities. • Chondroblastoma / Chondromyxoid
5. The Law of Parsimony Fibroma
In the first two years of medical school, one is • Hyperparathyroidism (brown tumors) /
taught to take historical points and physical Hemangioma
findings and to put them together into one
diagnosis which explains everything (the law of
• Infection
parsimony). However, once one reaches the • Non-ossifying Fibroma
ward rotations and opens a patient's chart to the • Eosinophilic Granuloma / Enchondroma
problem list, one sees that most real patients
have several disorders going on simultaneously. • Solitary Bone Cyst
By the time one gets out of medical school, into This is a fairly long differential diagnosis.
radiology, and begins to interpret joint films, this However, it is one that you must learn. I still run
lesson often seems to have been lost. In real through it every time I see one of these lesions,
life, patients often have more than one just to make sure that I consider all of the
arthropathy. This is most commonly seen in important possibilities.
patients with secondary osteoarthritis The discussion that follows will dwell almost
superimposed upon some other arthropathy. totally on the plain radiographic findings of these
Virtually any arthropathy which causes cartilage lesions. CT and MRI are wonderful tools for
loss can lead to secondary osteoarthritis, with all tumor workups, but they are fairly non-specific.
of the classic signs of osteoarthritis, including Their place in the workup is to tell us where the
osteophytosis. In fact, in certain patients, the lesion is: what its extent is; whether there are
changes from the primary arthropathy may be any metastases (either in the same bone or
significantly obscured by the secondary elsewhere); and whether an adjacent joint,
osteoarthritic changes. A clue that this is nerve or blood vessel is involved. However, to
happening is that the most distinctive sign of tell us what a lesion is, the plain radiograph is
osteoarthritis, osteophytosis, is often fairly still supreme. We've been looking at the darned
minimal compared to other findings such as joint things for almost a century now, and the plain
space narrowing or subchondral sclerosis. In film findings of most bone tumors are fairly well
fact, this is a very common presentation of known. Plain films are not terribly sensitive, but
rheumatoid arthritis of the knee: marked joint they do have a decent specificity. Therefore, any
space narrowing and subchondral sclerosis, but workup of a bone tumor should start with a good
no evident erosions, and only minimal set of plain films.
osteophytosis. In primary osteoarthritis, on the Age
other hand, marked joint space narrowing is Patient age is a very important bit of knowledge
usually accompanied by moderate or marked to have in the workup of a tumor. According to
osteophytosis. Edeiken, about 80% of malignant tumors can be
Other combinations of arthropathies are correctly diagnosed on the basis of age alone.
possible, such as gout and CPPD, gout and RA, From a study of the age prevalence of 4,000
RA and DISH (RADISH), etc. Therefore, when malignant bone tumors, he gives the following
apparently contradictory findings are noted, table:
remember that the law of parsimony is often Age vs. Malignant Tumor Type
broken. AGE
TUMOR
Conclusion (years)
The five simple principles listed above are
neither absolute nor comprehensive, and they 1 neuroblastoma
should not be followed dogmatically. Relying 1 - 10 Ewing's of tubular bones
solely on them for the diagnosis of arthritis
would be like using only the rule "buy low, sell 10 - 30 osteosarcoma, Ewing's of flat bones
high" to seek wealth. However, these principles
 reticulum cell sarcoma (Primary producing a sclerotic and usually distinct margin
histiocytic lymphoma), fibrosarcoma, around the lesion. If process grows more rapidly,
30 - 40 the bone may only have time to retreat before
parosteal osteosarcoma, malignant
giant cell tumor, lymphoma the lesion, and not have time to lay down this
sclerotic rim. Solitary lucent lesions in bone with
metastatic carcinoma, multiple a distinct margin are generally called
40 +
myeloma, chondrosarcoma "geographic" lesions, whether or not they have a
Size sclerotic rim.
What does the size of a lesion tell us?
Unfortunately, not a whole lot about the
histological type of lesion that we are dealing
with. However, describing the size of a lesion is
part of another important aspect of tumor
management: pretreatment staging of the
extent of the lesion.
Surgery is the preferred treatment for many
lesions in this category. The surgeon wants to
know where to cut so as to remove all of the
lesion, along with an area of normal tissue on all
margins of the tumor. Lesion size as measured
on plain films will not tell us this accurately -- if geographic lesion with geographic lesion with
anything, it tends to greatly underestimate the ill-defined rim well-defined rim
extent of the lesion. However, it provides a If the lesion grows more rapidly still, there may
convenient first-order approximation of the not be time for the bone to retreat in an orderly
extent (a lower bound on its size) while the manner, and the margin may become ill-defined.
early workup is being arranged. Definitive Rather than a single discrete lesion, we may see
assessment of the pretreatment extent of a several ill-defined foci of lucency. This has been
lesion will require MR or CT. termed a "moth-eaten" pattern.
Margins
This is one of the most important things that
you can determine about a solitary, lucent,
expansile lesion of bone. Why is this? Because,
this is the finding that will give you your best
shot at determining the biological activity of the
lesion (how fast is it growing?). This is
important, because in general, the faster a
process grows, the more likely it is to be
malignant.
So, how can we determine biological activity
from the margin of the lesion? The answer is
bone response. Bone is sensitive to a variety of a "moth-eaten" lesion
stimuli, and generally responds to one of the If, alas, the process grows more rapidly still,
processes in FOGMACHINES by either removing then the bone's retreat may become disorderly
bone or creating bone. That's right! The bone indeed. Continuing this battlefield analogy, the
itself does the removing or creating of bone - boundary between normal and abnormal bone
not the disorder involving the bone. At the AFIP, may be lost altogether, with only a very ill-
they are fond of saying that the only things that defined pattern of lucency seen, caused by
can remove bone are osteoclasts and orthopedic many small, irregular holes in the bone, left
surgeons. I agree with this rule, but would also behind by osteoclasts. This is an extremely
add talented amateurs to the list (lawnmower aggressive pattern, sometimes called a
and saw accidents, auto crashes, blast injuries, "permeative" pattern.
and animal bites are favored mechanisms of
bone removal by amateurs -- professionals
prefer saws, drills, and osteotomes and confine
their efforts to operating rooms). For this
reason, the term "expansile lesion" is a bit of a
misnomer, since the lesion itself is not
expanding the bone. The bone is remodeling
itself in response to the stimulus of the lesion.
The other thing to know about bone response is
that while it is certain, it is rather slow. If a
lesion is growing slowly, then the bone will have
plenty of time to retreat from the lesion,
removing some bone around the lesion, but also permeative pattern normal bone
laying down new bone around the margins of
the lesion. This generally has the effect of
The presence of a permeative pattern usually
means that the patient either has an aggressive
infection or a malignant tumor. The most
common malignancies that give this pattern are
metastases, myeloma, primary histiocytic
lymphoma, and Ewing's sarcoma. These lesions
are sometimes referred to as "round cell lesions"
due to the small, dark, round cells that they
display to the pathologist.
Matrix
What is matrix, anyway? It is stuff produced by
osteoblasts and chondroblasts that eventually
becomes, respectively, normal bone and
cartilage. Bone tumors form matrix just as a
normal bone does, but sometimes in greater
quantity. Also, matrix produced by tumors is
usually quite abnormal, and does not ossify figure after Madewell, et al 1981
properly. Why do we look for tumor matrix? Epiphysis
Because, it helps us to give a bone tumor a Very few lesions tend to arise in the epiphysis.
rough histological classification into one of three Chondroblastoma is one of the very few tumors
categories: cartilage-producing, bone-producing that arise here before the physis closes.
or other. Cartilaginous tumors (enchondroma, Osteomyelitis can also arise in the epiphysis.
chondrosarcoma, chondromyxoid fibroma, etc.) Several entities can spread across the physis.
will tend to produce cartilaginous matrix, while Osteomyelitis is a classic example of this.
tumors from the osteoid series (osteoma, Although the dogma for years has been that
osteoblastoma, osteosarcoma, etc.) will tend to malignancies such as osteosarcoma and Ewing's
produce osseous matrix. In order to see matrix tumor rarely cross the physis, more recent
on plain radiographs, it has to calcify. Chondroid experience with MRI has shown this to be
matrix, for example tends to produce small untrue. With very sensitive pulse sequences
punctate or swirled areas of calcification. such as STIR (short-tau inversion recovery),
Adjectives applied to this cartilaginous matrix subtle extension across the physeal plate may
include "popcorn-like", "curvilinear", or be seen not uncommonly.
"speckled". Osseous matrix tends to be dense After the plate closes, the physis ceases to be an
and confluent, and invokes descriptive terms like anatomic barrier to disease, and a variety of
"cloud-like" or "mashed potatoes". Other lesions lesions can be seen involving the epiphyseal
tend to produce little or no calcification in their area, such as giant cell tumor, enchondroma or
matrix (fibrous dysplasia, fibrosarcoma, aneurysmal bone cyst. Helpful tips in steering
malignant fibrous histiocytoma, solitary bone the differential diagnosis among these entities
cyst, etc.). Although the term "ground-glass" include the facts that most enchondromas will
has been applied to this appearance of matrix, I exhibit chondroid matrix, most giant cell tumors
think that it is a bit confusing, since a fogged will abut an articular margin, and most
film with no diagnostic information on it has a aneurysmal bone cysts appear, well,
ground-glass appearance also. If I don't see any "aneurysmal" or expansile. It was once thought
definite calcified matrix in a lesion, I prefer to that aggressive tumors, such as Ewing's tumor
just say that instead. and osteosarcoma tended to "respect" the
Location physeal plate and only rarely cross it. However,
Most expansile, lucent lesions are located in the more recent studies (Panuel, Norton) of the
medullary space of the bone. However, we can behavior of such tumors with sensitive MR pulse
further define the location of the lesion by noting sequences show that osteosarcomas may cross
its relationship to the physis. Many lesions tend the plate into the epiphysis in 70 - 80 % of
to occur in a "favorite" part of the bone. The cases and Ewing's tumor in about 20 %.
favored locations are listed in the figure below. Metaphysis
This is the fastest growing area of a bone, and
also the most likely area for a primary neoplasm
to arise. This is especially true in the distal
femur and proximal tibia, which are the fastest
growing metaphyseal areas in the skeleton. The
metaphysis also has the best blood supply of the
bone, so entities such as infection or metastasis
will commonly be seen in this area as well. In
general, most of the entities in FOGMACHINES
(with the exception of chondroblastoma) will be
most commonly seen in the metaphyseal area of
a given bone.
Diaphysis
Most of the entities in FOGMACHINES can also think of one of these three entities, also
appear in the diaphysis, although with less think of the other two.
frequency. Notable exceptions are: 3. Giant cell tumors nearly always occur
chondroblastoma, which almost always occurs in near a joint surface.
an epiphysis or epiphyseal equivalent (most 4. Certain bones in the body can be
apophyses, the patella and the calcaneus); giant considered "epiphyseal equivalents" for
cell tumor, which almost always occurs in an purposes of differential diagnosis.
apophysis or in the bone adjacent to a join These include the patella, the
space; osteoblastoma, which usually occurs in calcaneus, and most apophyses.
the posterior elements of the spine; and Therefore, for lucent lesions in these
aneurysmal bone cyst, which is usually areas, one should include the classic
metaphyseal in location. epiphyseal entities such as
Periosteal Reaction chondroblastoma, giant cell tumors and
Periosteal reaction is an important finding to aneurysmal bone cysts.
note in the workup of bone tumors. However, it 5. Lucent lesions of the sternum should be
also occurs due to several other processes considered malignant until proven
besides tumors. Therefore, I have given otherwise (Helms CA, personal
periosteal reaction a chapter all to itself. Please communication, 1983).
refer to this chapter on periosteal reaction for a 6. Keep in mind that the classic
discussion of how it relates to bone tumors.
descriptions of bone tumors that you
Multiplicity spend so much time studying are for
So, what do you do if the patient has multiple
untreated lesions. What kind of lesions
lucent lesions? Well, you go through pretty much do radiologists spend most of their time
the same thought processes that you went
looking at? Treated lesions -- treated
through for a solitary lesion. The main thing that with surgery, chemotherapy,
is different is the differential diagnosis that you
cryotherapy and radiation therapy. In
use. A lot of the entities in FOGMACHINES don't surgically treated lesions, besides
really make sense as a cause of multiple lucent
simple resection of the lesion, one may
lesions. However, some of them do. It turns out also see replacement by a metal
that one can simply trim out the entities that
prosthesis, an allograft, or other forms
don't make sense and what's left works just fine of bone grafting. In short, you won't
for multiple lesions. Thus, our differential
see the "classic" appearance of a lesion
reduces like this: for very long in a given patient. When
Differential Diagnosis of Multiple Lucent
the patient first presents to you, you
Bone Lesions may not even have any history of these
Mnemonic = FOGMACHINES --> FEMHI
prior interventions, so you will just
• Fibrous Dysplasia have to remember this phenomenon.
• Metastasis / Myeloma Also, any given film that you see of a
patient is just one frame out of a long
• Hyperparathyroidism (brown tumors) /
documentary movie about that patient
Hemangioma -- movies change. Remember this
• Infection Sclerotic Lesions of Bone
• Eosinophilic Granuloma / Enchondroma What does it mean that a lesion is sclerotic?
This leaves the letters FMHIE as our differential Well, generally, it means that it is due to a fairly
for multiple lucent lesions. Try as I might, I still slow-growing process. Bone reacts to its
haven't been able to come up with any kind of environment in two ways -- either by removing
decent word out of these letters. Clyde Helms some of itself or by creating more of itself. If the
orders them as FEMHI, and you can make up disorder it is reacting to is rapidly progressive,
your own order if you like. If you do come up there may only be time for retreat (defense). If
with a real word in English or some other the process is slower growing, then the bone
language out of these five letters, tell me what it may have time to mount an offense and try to
is and I will buy you a taco. form a sclerotic area around the offender.
Wise Sayings About Solitary Lucent Lesions How should one approach sclerotic bone
Sometimes, all the logical principles that you disease? I think that the best way is to start
have at your disposal don't seem to help very with a good differential diagnosis for sclerotic
much, and one must fall back on some of the bones. One can then apply various features of
empirical maxims that musculoskeletal the lesions to this differential, and exclude some
radiologists have accumulated over the years. things, elevate some things, and downgrade
Here are a few of the ones I have used over the others in the differential.
years. Let's apply the good old universal differential
1. With a long lesion in a long bone, think diagnosis to sclerotic bone lesions.
of fibrous dysplasia. Mnemonic = VINDICATE
2. Simple cyst, enchondroma, and fibrous Generic Differential Diagnosis of Sclerotic
dysplasia can mimic each other and can Bone Lesions
be hard to distinguish. Thus, when you • Vascular
 o hemangiomas o fracture (stress)
o infarct • Endocrine/Metabolic
• Infection o Paget's disease
o chronic osteomyelitis As you can see, by just dropping the items that
• Neoplasm tend to cause generalized sclerosis, we have
generated a fairly good differential for focal
o primary lesions. The differential for multifocal lesions
 osteoma happens to be identical to that for focal lesions.
 osteosarcoma Differential Diagnosis of Diffuse Sclerotic
o metastatic Bone Lesions
 prostate • Vascular
 breast
o infarct (e.g. sickle cell)
 other • Neoplasm

• Drugs
o metastatic
o Vitamin D  prostate
o fluoride  breast
• Inflammatory/Idiopathic  other
• Congenital • Drugs
o bone islands o Vitamin D
o osteopoikilosis o fluoride
o osteopetrosis • Congenital
o pyknodysostosis o osteopetrosis
• Autoimmune o pyknodysostosis
• Trauma • Endocrine/Metabolic
o fracture (stress) o hyperparathyroidism
You may have been surprised to see metastatic
• Endocrine/Metabolic
disease listed as a leading cause for diffuse
o hyperparathyroidism sclerotic bones. It is true that the usual
o Paget's disease appearance of skeletal metastases is that of
One of the first things you should notice about focal lesions -- diffuse sclerosis occurs in only a
sclerotic bone lesions is whether they are single small fraction of cases of skeletal metastases.
and focal, multifocal, or diffuse. You can then However, cancers that metastasize to bone are
customize the above differential for whichever very common. The lesson here is that when we
pattern of sclerosis that you see. Generally, this are dealing with a very common disorder, even
just follows common sense -- some lesions its less common presentations will be seen
should logically be expected to be focal, others commonly.
multifocal, and yet others diffuse or systemic.
For example:
Differential Diagnosis of Focal or Multifocal
Sclerotic Bone Lesions
• Vascular
o hemangiomas
o infarct
• Infection
o chronic osteomyelitis
• Neoplasm
o primary diffuse sclerotic metastases to the pelvis,
 osteoma sacrum and femurs
Wise Sayings About Sclerotic Lesions
 osteosarcoma There are a number of other helpful findings you
o metastatic can look for that can help you to cone in on or
 prostate away from specific entities in one of these
 breast differential lists.
1. Most cases of chronic osteomyelitis look
 other
pretty nonspecific. However, if one sees
• Congenital sinus tracts associated with a sclerotic
o bone islands area, one should strongly consider
o osteopoikilosis osteomyelitis.
2. Diffuse skeletal infarcts can be a
• Trauma
common cause of diffuse skeletal
 sclerosis. In fact, in areas where sickle histological diagnosis. Alas, this is not that kind
cell disease is common, this may be the of world. We can't give a precise histological
leading cause of diffuse sclerotic bones. diagnosis. But wait -- it gets worse! We can't
When you are considering even tell for sure if the underlying process is
osteonecrosis in your differential benign or malignant! As it turns out, about all
diagnosis, look at the joints carefully. If we can do is say with some confidence whether
you can find evidence of subchondral the process is a benign or an aggressive one.
collapse or the typical lucent/sclerotic Why is this? Well, the periosteum is a fairly
appearance of the necrotic bone in the promiscuous tissue, and puts on a similar
weight-bearing bone, then response to all comers. The main determinant of
osteonecrosis becomes a much more how the new bone formation looks is how fast
likely diagnosis. the abnormal process grows, and has little to do
3. Patients with sclerotic lesions due to with any intrinsic properties of the periosteum.
metastasis often have a history of prior Therefore, any differences in the pattern of
malignant disease. Ask the patient or periosteal reaction must arise in the disease
the clinician about this. process itself -- not in the periosteum. Again,
4. Likewise patients with sclerotic lesions evidence of the speed at which these processes
due to various drugs or minerals will are growing is the main thing we look for when
tell you what they are taking if you ask assessing periosteal reaction. Knowledge of this
them. speed will help us to differentiate these
5. When considering congenital causes of processes into two broad categories.
sclerotic lesions, benign causes such as With slow-growing processes, the periosteum
bone islands or osteopoikilosis usually has plenty of time to respond to the process.
have a fairly typical appearance and are That is, it can produce new bone just as fast as
hard to mistake. Osteopetrosis and the lesion is growing. Therefore, one would
pyknodysostosis are likewise hard to expect to see solid, uninterrupted periosteal new
mistake for other entities since the bone along the margin of the affected bone.
bones are denser than in any other
disorder, and the long bones tend to
have very tiny medullary canals.
6. When considering trauma as a cause
for sclerotic lesions, remember to check
and see if the areas involved are areas
in the typical distribution for stress
fractures.
7. When considering hyperparathyroidism,
look for evidence of subperiosteal bone
resorption.
8. When considering Paget's disease, it is
extremely helpful to note whether there
is associated bony enlargement. This is solid periosteal reaction along the cortex of a
extremely common in Paget's disease bone
but extremely uncommon with a blastic figure after Ragsdale, et al 1981
metastasis. Another finding classic for However, with rapidly growing processes, the
Paget's disease is that it almost always periosteum cannot produce new bone as fast as
starts at one end of a bone and then the lesion is growing. Therefore, rather than a
spreads toward the other end of the solid pattern of new bone formation, we see an
bone interrupted pattern. This interrupted pattern can
Periosteal Reaction manifest itself in several ways, depending on
The periosteum is a membrane several cell just how steadily the lesion grows. If the lesion
layers thick that covers almost all of every bone. grows unevenly in fits and starts, then the
About the only parts not covered by this periosteum may have time to lay down a thin
membrane are the parts covered by cartilage. shell of calcified new bone before the lesion
Besides covering the bone and sharing some of takes off again on its next growth spurt. This
its blood supply with the bone, it also produces may result in a pattern of one or more
bone when it is stimulated appropriately. What concentric shells of new bone over the lesion.
does it take to make this happen? Practically This pattern is sometimes called lamellated or
anything that breaks, tears, stretches, inflames, "onion-skin" periosteal reaction.
or even touches the periosteum. So, when some
anonymous process stimulates this reactive
bone formation, eventually we see evidence of it
on some imaging study.
Once we spot this reactive new bone, how do we
deal with it? In the best of all possible worlds,
one would be able to look at the pattern of
periosteal reaction and then give a precise
 thin shells of new bone, sometimes only the
edges of the raised periosteum will ossify. When
this little bit of ossification is seen tangentially
on a radiograph, it forms a small angle with the
surface of the bone, but not a complete triangle.
So, when a process is growing too fast for even
the Sharpey's fibers to ossify, one may only see
a soft tissue mass arising from the bone,
perhaps with small Codman's triangles at its
margins.

lamellated periosteal reaction

figure after Ragsdale, et al 1981
If the lesion grows rapidly but steadily, the
periosteum will not have enough time to lay
down even a thin shell of bone, and the pattern
may appear quite different. In such cases, the
tiny fibers that connect the periosteum to the
bone (Sharpey's fibers) become stretched out
perpendicular to the bone. When these fibers
ossify, they produce a pattern sometimes called
"sunburst" or "hair-on-end" periosteal reaction, a Codman's triangle
depending of how much of the bone is involved figure after Ragsdale, et al 1981
by the process. Soooooo...... what is the significance of all of
these patterns? Well, we can usually
differentiate lesions into one of two categories:
benign vs. aggressive processes. If we see a
solid pattern of periosteal reaction, we can be
fairly confident that we are dealing with a
benign process. How confident? In normal
everyday practice, my estimate is that you can
be about 90 - 95 % confident in this rule(9), but
your mileage may vary. As with many rules in
medicine, there are some caveats associated
with the use of this rule. The main caveat with
this rule is that benign processes and malignant
processes may coexist. The usual way that this
"sunburst" and "hair-on-end" periosteal reaction may manifest is when there is a fracture or
figure after Ragsdale, et al 1981 infection in the same area as a tumor. In this
case, you may see a fairly complex pattern of
periosteal reaction that demonstrates some
elements that look benign and some that look
very aggressive.

Osteosarcoma of the distal femur, demonstating

dense tumor bone formation and a sunburst
pattern of periosteal reaction.
Another pattern seen in rapidly growing
processes is called the Codman's triangle. This is
a bit of a misnomer, since there really is not a a complex pattern of periosteal reaction
complete triangle. When a process is growing figure after Ragsdale, et al 1981
too fast for the periosteum to respond with even
The take home point here is that complex • hypertrophic pulmonary
patterns like this may be very misleading, and osteoarthropathy
should be interpreted with caution. In general,
though, the more aggressive the pattern of
• deep venous thrombosis (lower
periosteal reaction, the greater the chance that extremity)
you are dealing with a malignancy. Causes of Aggressive Periosteal Reaction
Here are partial lists of causes of both solid and • osteomyelitis
aggressive periosteal reaction: • malignant neoplasms
Causes of Solid Periosteal Reaction o osteosarcoma
• infection o chondrosarcoma
• benign neoplasms o fibrosarcoma
o osteoid osteoma o lymphoma
• eosinophilic granuloma o leukemia
o metastasis

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