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In daily radiological practice, one often encounters problems in differentiating real bone tumors from tumoral bone lesions. Bone reacts in limited ways for any stimulus of developmental or acquired nature. These pathological reactions are reflected in radiology and imaging investigations. These include new or reactive bone which is dense, lysis of the bone are non-mineralized matrix which is lucent and periosteal reaction in several patterns. It may be a combination of these lesions.

Periosteum is a multipotential membrane giving rise to variety of reactions when mineralized. Any stimulus mechanical, physiological, biological and pathological stimulus can produce periosteal reaction and is best seen on conventional films. However, in order to detect early periosteal reaction, Ultrasonography is the mode of choice of investigation. There is a spectrum of imaging findings but no one really is specific. The number of etiological factors as well as the number of imaging features are listed and described. The message is that periosteal reaction is a radiological sign and not a disease, although is encountered in many focal, multifocal and systemic disorders.

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