Periostitis in Children

Differential diagnosis for periostitis in multiple bones:

• Physiologic periostitis: Symmetric, regular, seen at around 3 months and resolves by 6 months of age. Distal involvement in limbs (e.g., tibia) is preceded by proximal involvement (e.g., femur). Said in another way, if you see tibial involvement without femoral involvement, it's not physiologic periostitis. In the tibia, periostitis is invariably on the medial aspect. The new bone always involves the diaphysis and may extend partly into the metaphysis without extending to the end of the metaphysis.
• Child abuse: Asymmetric. Look for other signs of child abuse.
• Multifocal osteomyelitis: May be seen with congenital (TORCH, syphilis), TB, streptococcus.
• Hypervitaminosis A: Look for history of high doses of vitamin A.
• Polyostotic neoplasm: Metastases (e.g., Ewing sarcoma, medulloblastoma, neuroblastoma, osteosarcoma).
• Juvenile idiopathic arthritis: May first present with periostitis of fingers or toes with joint involvement later.
• Prostaglandin-induced neonatal periostitis: Prolonged prostaglandin therapy is associated with soft tissue swelling and reversible cortical hyperostosis in the long bones. Common side effects of short-term prostaglandin therapy include apnea, fever, convulsions, rash, skin flushing, vasodilatation with hypotension, diarrhea, and gastric outlet obstruction.
• Sickle-cell dactylitis: Initial manifestation of bone infarcts may be periostitis of fingers and toes.
• Caffey disease: Also known as infantile cortical hyperostosis. Self-limited, painful periostitis of long bones. Clavicular and mandibular involvement suggestive.
• Scurvy: Subperiosteal hemorrhage with corner fracture leads to periosteal elevation and reparative bone formation that mimics periosteal reaction.
• Primary Hypertrophic Osteoarthropathy: About 80% present before 18 years or age, and the disease stabilizes after about 5–20 years.

PERIOSTEAL SOCKS, an idiotic mnemonic that is too long to be of any practical use, includes many of the above entities: Physiologic/Prostaglandin, Eosinophilic granuloma (properly called Langerhans cell histiocytosis under the new classification of histiocytic disorders), Rickets, Infantile cortical hyperostosis, Osteomyelitis, Scurvy, Trauma, Ewing, A-hypervitaminosis, Leukemia & neuroblastoma, Syphilis, Osteosarcoma, Child abuse, Kinky hair syndrome, and Sickle cell disease.

See related post on periostitis in adults.

References

• StatDx
• de Almeida JF, Kimura H, Hercowitz LH, Korkes H, Troster EJ. Cortical hyperostosis secondary to prolonged use of prostaglandin E1. Clinics (Sao Paulo). 2007 Jun;62(3):363-6.
• de Silva P, Evans-Jones G, Wright A, Henderson R. Physiological periostitis; a potential pitfall. Arch Dis Child. 2003 Dec;88(12):1124-5.