Florid Reactive Periostitis Research Articles

Benign Bone Tumors of the Hand: Beyond Enchondromas.

Beyond enchondromas, the most common bone tumors of the hand, there are numerous less common benign bone tumors and mimickers with which orthopaedic and hand surgeons should be familiar. These include other benign cartilage tumors, cystic lesions, osteogenic tumors, giant cell tumor, and fibrous dysplasia. Particularly unique lesions include bizarre parosteal osteochondromatous proliferation (Nora lesion), florid reactive periostitis, turret exostosis (acquired osteochondroma), giant cell reparative granuloma (solid aneurysmal bone cyst), and epidermoid cyst. The purpose of this review was to present the epidemiology of this group of lesions as a whole and then focus on the unique radiographic and histological features, natural history, and appropriate management of each of the lesions. Unlike those of enchondromas, malignant bone tumors, and soft-tissue tumors of the hand, we are unaware of a previous comprehensive orthopaedic review focused on these less common benign hand processes.

Some Reactive Lesions of Bone Are Probably Neoplasms.

A number of fibro-osseous and osteocartilaginous lesions, especially common in the small bones of the hand and feet, pose a diagnostic challenge and have historically been thought to be reactive lesions. However, modern molecular techniques when supplementing clinical, radiographic, and histologic evaluation suggest they may, in fact, be neoplasms. To review the clinical presentation and histopathologic, molecular, and radiologic features of selective bone lesions, focusing most specifically on subungual exostosis, florid reactive periostitis, and bizarre periosteal osteochondromatous proliferation. Literature review and personal experience are the sources of this review. Some lesions previously thought to be reactive are locally aggressive and demonstrate reproducible molecular abnormalities, and thus may be neoplasms. Although most common in the bones of the fingers and toes, these lesions also occur in long and other bones. The clinical presentations, radiologic appearances, and histopathologic features often overlap, making the diagnosis challenging, and these lesions may require molecular evaluation to maximize accurate prognostication.

Retrospective study to find the prevalence of neoplasia in swellings of hand and foot bones

Lesions occurring in them are infrequently reported. In this retrospective study, we analyze all types of lesions affecting bones of the hands or feet, including infections and inflammatory conditions, benign and malignant tumors, and tumor like lesions, correlating clinical, pathologic and biopsy findings. Out of 50 lesions included in the study, infections/ inflammatory lesions constituted 46.0%, benign tumors 32.0%, malignant tumors 12.0%, and tumor like lesions 10.0%. Osteomyelitis was the most common lesion in this series, accounting for 44% of the cases. In other study also it is the commonest lesion. Walking barefoot and Diabetes mellitus constitutes a significant predisposing risk factor for osteomyelitis of the foot. Tuberculosis constitutes the major cause of osteomyelitis in India hence higher incidence of tuberculous osteomyelitis in the small bones of the hands or feet as compared to that in the West. Benign tumors were more common than malignant tumors in our series, GCT constituting 43.8% of benign tumors. Chondrosarcoma was the most common malignant tumor. Metastatic bone lesions and hematologic neoplasms were not seen in our study. Bones of the hands and feet are the most common extragnathic sites for GCR. Three such cases with typical histologic features were diagnosed in bones of the hand. It was difficult to differentiate them clinically and radiologically from GCT. This is important in view of the lower recurrence rate in the former compared to the latter. The only other 3 cases of GCR reported during the study period were located in the mandible. In view of overlapping ultrastructural and light microscopic features, as well as similar biologic behavior, aneurysmal bone cyst and giant-cell reparative lesions are thought to represent related responses to intraosseous hemorrhage. Florid reactive periostitis is a reactive process that predominantly involves the bones of the hands or feet, mostly in young women, and a history of minor trauma is seen in less than half of the cases. Similar clinical findings were noted in our patient as well. The importance of this entity lies in the possibility of it being misdiagnosed as a malignant lesion, especially osteosarcoma. Such a lesion was not seen in any other bone in our institution during the study period. Conclusion: Lesions of the bones of the hands or feet are uncommon. Infections/inflammatory lesions are more common in India. Benign tumors were more common than malignant tumors in our series. Giant cell tumor is the commonest neoplastic lesion. . Awareness and correlation of clinical, radiologic, and pathologic features help in making correct diagnoses Keywords: Hand Swelling, Foot swelling, Neoplasia in Hand, Neoplasia in foot

Florid Reactive Periostitis of the Proximal Phalanx-Case Report and Literature Review.

Florid reactive periostitis is a benign and rare lesion that is a recurrent diagnostic problem. Its etiopathogenesis remains unknown. Florid reactive periostitis consists of a fibrotic, cartilage-producing tumor accompanied by an aggressive inflammatory periosteal and soft tissue reaction. It typically occurs in adolescents and young adults, mostly female; it often affects hand and foot bones, and it may occur in long bones. Its diagnosis remains a major challenge due to the vast possibility of differential diagnoses. Therefore, careful clinical, radiological, and pathological evaluation is required to establish a proper diagnosis. We report the case of a patient with florid reactive periostitis in the proximal phalanx of the right index finger, who underwent surgical excision with a wide margin, from the second ray to the proximal third of the second metacarpal bone, and evolved without complications, with satisfactory range of motion and strength.

Florid reactive periostitis of the long bone: A case series of seven patients

Florid reactive periostitis (FRP) is a rare benign periosteal lesion, which mostly involves the tubular bones of the extremities. FRP of the long bone is especially rare. We here report a case series of long bone FRP and also discuss the differential diagnosis and clinical outcome of our series. In total, four female and three male patients with long bone FRP and a mean age of 25.1 years were evaluated for this study, from which four upper extremity and three lower extremity FRP lesions were identified. Patients were classified according to the clinical, radiological and pathological manifestations of the lesion. Periosteal reaction and edema around the lesions were observed in all cases. Calcified mass, bone marrow edema and cortical erosion were observed in six out of seven patients. Moreover, two lesions with peripheral mineralization and zoning appearances were observed. Limb rest and anti-inflammatory therapy proved to be sufficient treatment in all cases. The lesions were spontaneously resolved in all cases, leaving a residual exostosis. Our report indicates that short bone and long bone FRP could reveal different characteristics in some aspects, including the choice of the therapeutic approach. In spite of the favorable clinical outcome of long bone FRP, its differentiation from more aggressive lesions, especially osteosarcoma and osteomyelitis, should still be taken into consideration. In addition, according to our evidence, the implication of the zonal pattern in differential diagnosis of FRP and myositis ossificans (MO) could be re-evaluated.

Paraosteal osteochondromatosis proliferation (Nora’s lesion) of the great toe

Parosteal osteochondromatous proliferation also called Nora’s lesion is a rare tumor which occurs on the proximal/distal phalanx, metacarpals, metatarsals of hand (more commonly) and feet. These lesions show 50% recurrence following excision. It has atypical histo-pathological features that must be differentiated from chondrosarcoma, low grade parosteal osteosarcoma and conventional osteosarcoma. Among benign lesions florid reactive periostitis, myositis ossificans, periosteal chondroma and osteochondroma should be considered.

The diagnostic conundrum of Florid Reactive Periostitis: A case report and review of the literature

We report on a case of digital benign fibroblastic proliferative lesion that aggressively recurred after multiple excisions and showed histologic progression from a Fibrosseous Pseudotumor (FOPT) to Florid Reactive Periostitis (FRP). We recommend caution on incisional biopsies that do not excise the lesion fully based on the clinical course, radiographic, and histologic findings. Our case demonstrates the protean nature of this entity and the difficulty in obtaining an accurate diagnosis based on the clinical course and radiographic and histologic findings.

Reactive Periostitis of the Hand

The patient is a 29-year-old woman, who complains of swelling and pain in the fifth finger of the left hand lasting for 3 months. She had no medical history and no previous trauma of the referred finger. On examination, she presented a tumor of 1.5 cm×0.5 cm on the tip of the finger and the subungual region, of indurated consistency which adhered to deep planes, with mild erythema and tenderness. Radiological studies showed awell-circumscribed, nodular ossified lesion with irregular borders, adhered to the l periosteum of the distal phalanx, without erosion of the cortex (Fig. 1). Laboratory studies, including biochemistry, hematology and acute phase reactants were all normal. Excision of the lesion was performed and the histopathological study revealed fibrous tissue and fibroblasts with prominent nuclei without atypia in its periphery, and immature osteoid deposits surrounded by an osteoblastic rim in the central area (Fig. 2). These findings were consistent with the diagnosis of florid reactive periostitis of the hand (FRPH). There was no recurrence of the lesion. FRPH is a rarebenignentity characterizedbya lushproductionof osteoblastic proliferative fibrous stroma in the periosteum of the fingers.1 Its pathogenesis is unknown but is considered to correspondmore to a reactive process than to a neoplasm,with a history of trauma being present in up to 50% of cases.2 Although it was described in 19333 there still is confusion in the literature caused by different denominations, including paraostal fasciitis, ossifying fasciitis, fibro-osseous pseudotumor, pseudomalignant bone tumor of the soft tissue of the fingers and nodular fasciitis, with FRPH being the accepted term.2,4 It is most frequently located in the proximal phalanx, followed by the middle phalanx, metacarpal joints and distal phalanx; it is rare in the first two fingers. It usually occurs in women during the second and third decades of life, and is clinically

99mTc-MDP– and 18F-FDG–Avid Florid Reactive Periostitis Ossificans Mimicking Recurrent Osteosarcoma

Florid reactive periostitis ossificans is a rare benign lesion usually affecting the tubular bones of the hands and feet, and its histological features may be confused with those of infection and osteosarcoma. We report a case with florid reactive periostitis ossificans of the femur showing increased tracer uptake on both Tc-MDP bone scan and F-FDG PET/CT mimicking a local recurrence in a 15-year-old patient with high-grade osteosarcoma.

Metacarpal solitary osteochondroma—case report of a rare condition

Histologically, osteochondromas are hamartomas developed from endochondral ossification which are coated with a thin cartilage layer [1]. Epidemiologically, these are the most frequent benign tumor, after nonossifying fibromas and metaphyseal lacunae, representing, in the Unni series [2], about 40 % of all benign tumors, and they are located preferentially at the metaphyseal level of long bones. Their location in the hand is extremely rare, except in cases of multiple hereditary exostoses. The following differential diagnoses should be considered: bizarre parosteal osteochondromatous proliferation (Nora's lesion) [3], florid reactive periostitis [4], and turret exostosis [5].

Florid reactive periostitis ossificans of long bones and digits associated with reaction in a patient with leprosy

Florid reactive periostitis ossificans is a rare bone lesion usually occurring in the small, tubular bones of the hands and feet. This entity is a benign and aggressive periosteal reaction associated with soft tissue swelling that appears similar to a bone lesion that radiographically and clinically mimics an infectious or neoplastic process. Typically the lesions occurs in an adolescent or young adult and presents as a small area of painful swelling and erythema over the affected bone. The cause of florid reactive periostitis ossificans is not exactly known though many authors have postulated varied etiopathogenesis for the same condition. In this report, is a very rare and unusual example of this entity that has been observed in association with erythema nodosum leprosum (ENL) a type 2 lepra reaction in a Leprosy patient.

Florid-reactive Periostitis of the Phalanges

Florid-reactive periostitis, also known as fibroosseous pseudotumor, is a benign bone lesion. It occurs rarely among pediatric patients. Usually, it affects the phalanges of the hands and feet, where most lesions concern the proximal phalanx. Girls are more commonly affected than boys. The lesion appears benign radiographically but on histologic examination could be mistaken for a variety of malignant lesions, especially osteosarcoma. Therefore, histologic evaluation is a must for distinguishing this benign lesion from malignant and infectious etiologies. We present 2 patients with florid periactive periostitis of the phalanges who were treated in our clinic. After physical and microscopy examination of the soft and bone tissues, we found no evidence of malignant process. Because of a definitive diagnosis and the benign nature of the histologic findings, a conservative treatment, that is, no surgical intervention, with a close supervision of our patients was used. During follow-up observations in both patients, we did not notice any limitations of finger movements or an enlargement of the tumor. These findings confirmed that for cases with no aggressive growth, a conservative treatment may be effective and beneficial for a patient.

Florid reactive periostitis of the forearm bones in a child

Florid reactive periostitis is a pronounced periosteal reaction, usually affecting the hands and feet, for which there is no obvious cause. It is rare in children and in long bones. We report an unusual case of florid reactive periostitis in a ten-year-old girl that involved both bones of the forearm. The lesion resolved over a period of one year, leaving a residual exostosis. She developed a physeal bar in the distal ulna in the region of the lesion at one-year follow-up. This was thought to be a complication of the biopsy procedure and was treated by resection and proximal ulnar lengthening.

Immunohistochemical analysis of MDM2 and CDK4 distinguishes low-grade osteosarcoma from benign mimics

Parosteal osteosarcoma and low-grade central osteosarcoma are two types of low-grade osteosarcoma that show similar clinical behaviors, histological features, and genetic background (ie, amplified sequences of 12q13–15, including MDM2 and CDK4). Low-grade osteosarcoma is often confused with benign lesions, and ancillary techniques to enhance diagnostic accuracy have been awaited. This study explores the use of MDM2 and CDK4 immunohistochemistry for the histological diagnosis of low-grade osteosarcoma. We studied 23 cases of low-grade osteosarcoma from 21 patients (parosteal osteosarcoma (n=14), low-grade central osteosarcoma (n=9)) and 40 cases of benign histological mimics (myositis ossificans (n=11), fibrous dysplasia (n=14), osteochondroma (n=6), desmoplastic fibroma (n=1), florid reactive periostitis (n=4), Nora's lesion (n=3), and turret exostosis (n=1)). Low-grade osteosarcoma labeled for MDM2 in 16 cases (70%) and for CDK4 in 20 cases (87%). All low-grade osteosarcomas expressed one or both markers (100%), with 13 cases (57%) expressing both. Staining pattern was diffuse in most cases, and the majority expressed moderate or strong intensity for either antibody. MDM2/CDK4 immunostaining was shown irrespective of low-grade osteosarcoma histological subtype. In contrast, only 1 Nora's lesion out of the 40 miscellaneous benign processes showed immunoreactivity for MDM2 or CDK4. The combination of these two markers thus shows 100% sensitivity and 97.5% specificity for the diagnosis of low-grade osteosarcoma. MDM2 and CDK4 immunostains therefore reliably distinguish low-grade osteosarcoma from benign histological mimics, and their combination may serve as a useful adjunct in this difficult differential diagnosis.

Periostitis reactiva florida: caso clínico y actualización del tema

Florid reactive periostitis is a benign lesion which can be confused with other more serious lesions such as infections and malignant bone tumours because of...

Long bone florid reactive periostitis ossificans: a case in the distal femur mimicking osteosarcoma

Florid reactive periostitis ossificans is a well-known benign lesion classically described in hands and feet which histopathological features can lead to a misdiagnosis of osteosarcoma. To the best of our knowledge, there is only one previous report of this lesion in a long bone. In this study we report a case of florid reactive periostitis ossificans located in the distal metaphysis of the left femur that histologically mimicked an osteosarcoma and discuss the differential diagnosis between these two entities to warn about a diagnostic pitfall.

Florid Reactive Periostitis Ossificans of the Distal Ulna

Florid reactive periostitis is the term used to describe a benign disease characterized by aggressive periosteal reaction and benign soft-tissue inflammation. Although it is considered rare, there are numerous reports in the literature that refer to this disease with different names such as parosteal fasciitis, fasciitis ossificans, benign fibro-osseous pseudotumor, pseudomalignant osseous tumor of soft tissue, and bizarre parosteal osteochondromatous proliferation. As a result, the nomenclature is confusing, and some authors have placed florid reactive periostitis ossificans into the heterogeneous group of pseudomalignant osseous tumors of soft tissue or proliferative periosteal processes, whereas other authors place this entity in the myositis ossificans group. In the same manner, florid reactive periostitis has been considered to be a previous stage of bizarre parosteal osteochondromatous proliferations. This article presents a case of florid reactive periostitis ossificans of the distal ulna in a 13-year-old boy. The patient presented with a painful lesion in the distal ulna, and plain radiographs suggested the presence of a quickly growing periosteal lesion with associated calcification and soft tissue mass. Histologically, the appearance was that of reactive periostitis. The clinical, radiological, and histologic features of florid reactive periostitis are described.

Cortico-medullary continuity in bizarre parosteal osteochondromatous proliferation mimicking osteochondroma on imaging

Bizarre parosteal osteochondromatous proliferation (BPOP), or Nora's lesion, is an unusual surface-based lesion of bone found most commonly in the hands and feet. In the original description of the lesion and in all publications that followed, one of the key imaging characteristics used to define this entity was the lack of cortico-medullary continuity with the underlying bone. The authors present 4 unique cases of pathologically proven BPOP in which cortico-medullary continuity with the underlying bone was demonstrated on imaging. It is believed that florid reactive periostitis, BPOP and turret osteochondroma may reflect points along the same continuum with trauma the likely inciting event. The authors suggest that, given this continuum, it may be possible to have BPOP lesions demonstrating overlapping imaging features with osteochondroma. If this is the case, strict adherence to the standard imaging criterion of lack of continuity between the lesion and the underlying bone may lead to misdiagnosis of these unusual cases of BPOP as osteochondromas.

High-grade surface osteosarcoma of the hand

A 32-year-old woman presented with a 1-year history of mild pain in the right ring finger. Radiographs and CT revealed a calcified lesion with cortical erosion on the surface of the proximal aspect of the right ring finger proximal phalanx. On magnetic resonance imaging (MRI), the lesion showed low signal intensity on T1- and T2-weighted images and slight enhancement with gadolinium. Clinically, it was diagnosed as a benign bone-forming lesion such as florid reactive periostitis, and excision was accordingly performed. However, histological examination revealed proliferation of atypical osteoblastic cells among irregularly arranged osteoid seams. Taking the imaging findings into account, a pathological diagnosis of high-grade surface osteosarcoma was established. In general, bone- and cartilage-forming lesions of the hands and feet are benign. Osteosarcoma of short tubular bones in the hands and feet is extremely rare; moreover, high-grade surface osteosarcoma is one of the rarest subtypes of osteosarcoma. Nonetheless, high-grade surface osteosarcoma should be included in the differential diagnosis, particularly if the radiological findings or clinical course are not entirely typical of a more common benign process, to avoid incorrect clinicoradiological and pathological diagnosis.

Nora’s lesion, a distinct radiological entity?

To describe the radiological findings of "Bizarre parosteal osteochondromatous proliferation"(BPOP)-otherwise known as Nora's lesion, to describe the natural evolution of BPOP and to assess radiologically if BPOP is indeed part of a spectrum of reactive lesions including florid reactive periostitis and turret exostosis. Four experienced musculoskeletal radiologists studied plain radiographs and other imaging documents of histologically-proven Nora's lesions, looking for soft-tissue changes, periosteal reaction/calcification and calcified/ossified pseudotumours, and compared those findings with findings on pathology reviewed by a peer group of pathologists. Twenty-four Nora's lesions originating from a series of 200 consecutive, histologically-verified bone (pseudo)tumours of the hand, seen by the "Netherlands Committee on Bone Tumours" for review and second opinion. Nora's lesions have a recognised presentation on radiographs without specific MR characteristics. Natural evolution could be assessed retrospectively in four cases. Recurrent lesions were seen in seven cases and are difficult to differentiate from primary lesions. Nora's lesion, defined as a "well-marginated mass of heterotopic mineralization arising from the periosteal aspect of an intact cortex, without medullary changes" has a distinct radiological presentation and is part of a spectrum of reactive lesions which includes florid reactive periostitis and turret exostosis. As it has a distinct radiological appearance, differential diagnosis of malignant lesions such as osteosarcoma and chondrosarcoma should be clear. It does not require immediate biopsy unless the natural evolution is unspecific.