Your ultimate resource for Musculoskeletal teaching files and Musculoskeletal imaging & case of the day. Improve your diagnostic imaging skills online.

8 years old Painful Leg, low grade fever
Thumbnail imageThumbnail image
Detail View

Findings, DDX, next step?
Thumbnail imageThumbnail image
MRI Correlation
DDX, #1 Choice?
Thumbnail imageThumbnail image
Same Disease, Different Patient.
Thumbnail image

What is the name for this appearance in bone, and does it favor a benign or malignant process?
Does it alter your DDx?


  • Initial radiographs showed a highly-aggressive, permeative lesion in the proximal tibia, with a wide zone of transition and abdunant overlaying periosteal reaction
  • Permeative lesion in a child, DDx: Ewing’s, infection, EG
  • MRI (actually from another patient) confirmed an overlaying soft tissue mass and invasion of the marrow cavity
  • Final image shows a “laminated” periosteal reaction, which is malignant and often seen in Ewing’s Sarcoma

Ewing’s Information

  • Ewing’s is the most common malignant bone tumor in children, 4th most common bone tumor overall
  • Peak age 15 year old, 95% occur between 4-25 years old (96% occur in Caucasians)
  • ”Small round cell” tumor histologically, very similar to PNET
  • Clinical: severe localized pain; soft-tissue mass; fever, leukocytosis, anemia simulating infection
  • Location – classically in long bones (60%) and flat bones (40%): femur > pelvis/ilium >tibia > humerus > fibula > ribs
  • Mottled “moth-eaten” destructive permeative lesion (72%)
  • Early fusiform lamellated “onionskin” periosteal reaction (53%); alt.spiculated “sunburst” periosteal reaction (23%)
  • Broad DDx includes: Multiple Myeloma (should be older); Osteomyelitis; eosinophilic granuloma; osteosarcoma (bone forming, no ;lamellated periosteal reaction); reticulum cell sarcoma (30 to 50 year old); neuroblastoma (< age 5); anaplastic metastatic carcinoma


These signals are relayed buying clomid online safe which then is by a number of such as medial preoptic and paraventricular nulcei.