Carneiro et al.

Insights Imaging (2021) 12:32

https://doi.org/10.1186/s13244-021-00978-8 Insights into Imaging

EDUCATIONAL REVIEW Open Access

Osteoid osteoma: the great mimicker

Bruno C. Carneiro, Isabela A. N. Da Cruz* , Alípio G. Ormond Filho, Igor P. Silva, Júlio B. Guimarães,
Flávio D. Silva, Marcelo A. C. Nico and Xavier M. G. R. G. Stump

Abstract
Osteoid osteoma is a painful, benign and common bone tumor that is prevalent in young adults. The typical clini-
cal presentation consists of pain that becomes worse at night and is relieved by nonsteroidal anti-inflammatory
drugs. The most common imaging finding is a lytic lesion, known as a nidus, with variable intralesional mineraliza-
tion, accompanied by bone sclerosis, cortical thickening and surrounding bone marrow edema, as well as marked
enhancement with intravenous contrast injection. When the lesion is located in typical locations (intracortical bone
and the diaphyses of long bones), both characteristic clinical and radiological features are diagnostic. However, oste-
oid osteoma is a multifaceted pathology that can have unusual presentations, such as intraarticular osteoid osteoma,
epiphyseal location, lesions at the extremities and multicentric nidi, and frequently present atypical clinical and radio-
logical manifestations. In addition, many conditions may mimic osteoid osteoma and vice versa, leading to misdiag-
nosis. Therefore, it is essential to understand these musculoskeletal diseases and their imaging findings to increase
diagnostic accuracy, enable early treatment and prevent poor prognosis.
Keywords: Bone neoplasms, Osteoma, Osteoid, Diagnosis, Differential, Magnetic resonance imaging, Tomography,
X-ray computed

Key points prevalent in Caucasian male adolescents and young

adults; moreover, 50% of these tumors occur during the
• Osteoid osteoma (OO) is a painful, benign and com- second decade of life, and they rarely occur before the
mon bone tumor. age of 5 and after the age of 35 [3–7].
• Characteristic clinical and radiological findings are OO consists of a core called the nidus (the tumor itself )
diagnostic, especially for lesions in typical locations. that is typically small, measuring as large as 1.0–2.0 cm
• Some OO cases present atypical location and unu- and is usually surrounded by corticoperiosteal thicken-
sual imaging findings that can lead to misdiagnosis. ing [1, 2]. Histologically, the nidus comprises an oste-
• Many musculoskeletal conditions may present clini- oid matrix with variable mineralization, osteoblasts and
cal and/or radiological features that mimic OO. some osteoclast-type multinucleated giant cells inter-
spersed by a loose fibrovascular stroma, with inflamma-
tory changes and reactional bone formation around the
Background lesion [8].
Osteoid osteoma (OO) was first reported by Jaffe in 1935 The typical clinical picture includes intermittent pain
[1] in a series of five cases; it is a painful, benign and that becomes worse at night and is relieved by salicy-
common tumor, accounting for 3% of all bone neoplasms lates [4, 5]. These tumors are highly vascularized and
and 10–12% of benign lesions [2–5]. It is particularly innervated [8], and the physiopathology of pain seems
to be related to high levels of prostaglandins (100–
1000 × higher than normal), especially prostaglandin E2,
*Correspondence: isabela.cruz@grupofleury.com.br
increasing the pressure in an innervated bone area within
Department of Musculoskeletal Radiology, Fleury Medicina e Saúde
Higienópolis, Rua Mato Grosso 306, 1st Floor, Higienópolis, São Paulo, SP the nidus, particularly in the reactive zone [4, 5, 9–12].
01239‑040, Brazil

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Carneiro et al. Insights Imaging (2021) 12:32 Page 2 of 17

These prostaglandins are also responsible for vasodilata- usually smaller than 1.0 cm, with variable central nidus
tion and edema formation in the surrounding bone mar- mineralization associated with reactive surrounding
row and soft tissues [9]. sclerosis and fusiform cortical thickening; the two lat-
OO most often involves the diaphysis, followed by ter conditions are usually more marked in the pediatric
the metaphysis of the long bones (around 50% and 40%, population [4, 5, 14, 16]. OO is typically located at the
respectively) [13]. The femur and tibia are involved in diaphysis of long bones, and locoregional osteopenia,
more than 50% of cases, and the humerus can also be secondary to pain-related disuse, may occur [4, 16]. The
involved (around 8%) [8, 13]. The spine, hands and feet nidus can be distinguished in 85% of cases, and a cen-
are involved in approximately 30% of cases; OO more tral area of calcification is identified in 25–50% of cases
rarely occurs in the skull, scapula, pelvis, ribs, mandible [2, 4, 8].
and patella [14, 15]. The spine is involved in approxi- Some types of OO are harder to identify on X-rays,
mately 15% of cases [8], and the lumbar spine is the most such as intraarticular and medullary OO, due to there
affected segment of the spine, highlighting that posterior being less marked corticoperiosteal reactions and spi-
elements are involved in 90% of these cases [16]. nal OO manifestations because of the complex anatomy
Following the radiography-based classification system and overlapping structures at the spine [4, 14]. In addi-
proposed by Edeiken [17], OO cases can be classified tion, lesions that affect the extremities are even smaller
as cortical, cancellous (or medullary) or subperiosteal than usual, making the identification of the nidus chal-
according to the distribution of the tumor in the axial lenging. When conventional radiographs are not suffi-
plane [2]. Cortical OO accounts for the majority of cases cient, other imaging techniques should be used. Even
(75%), while the cancellous OO accounts for approxi- when there is high suspicion of OO on the basis of radi-
mately 20% of cases and usually occurs in atypical loca- ographic and clinical features, sectional imaging stud-
tions [4, 18]. Subperiosteal OO is the least common type, ies are performed to better visualize the lesion, confirm
accounting for as few as 5% of cases [14, 18]. Kayser [19] the diagnosis and eventually determine the treatment.
later proposed a classification system including four types CT is considered the modality of choice for OO, as
based on sectional studies, subperiosteal, intracortical, the nidus can be obscured on radiographs. The central
endosteal and medullary OO, and hypothesized that all calcification may be punctate, amorphous or ring-like,
OO cases arise in the subperiosteal area and eventually and it is usually regular and centrally located. On CT
migrate internally. scans, a “vascular groove” or “CT vessel” sign can be
OO is diagnosed by the combination of both typical identified, represented by low-density grooves enter-
clinical picture and imaging findings. Biopsy is recom- ing the nidus and corresponding to the enlarged vessels
mended at the time of the percutaneous treatment, espe- that arise from the periosteum to irrigate the hypervas-
cially for lesions with atypical presentation, even though cular nidus [9, 28].
it can be nondiagnostic in approximately one-third of The OO nidus shows variable signal intensities on MRI
cases [20–22]. OO has a natural history of spontane- scans with a target-like appearance since nonmineral-
ous regression within 6–15 years, but this period can be ized vascular stromata have an intermediate/high signal
reduced to 2–3 years with the use of nonsteroidal anti- intensity on T2WIs and usually presents intense gado-
inflammatory drugs [5]. Even though pharmacological linium enhancement, while the mineralized portion pre-
treatment is an option, due to the adverse effects of the sents a low signal intensity on all sequences and does not
prolonged use of these medications, such as bleeding enhance [29, 30]. Surrounding sclerosis and/or inflam-
complications and gastric and renal toxicity, it is reserved matory changes may be abundant and obscure the nidus,
for exceptional situations only [23, 24]. The more com- making diagnosis difficult [14, 16]. However, the presence
monly used treatment options include surgical resection, of bone marrow edema may help locate the nidus, serv-
which is associated with a high morbidity and long recov- ing as a red flag and suggesting a more thorough evalua-
ery period, and percutaneous imaging guided treatments, tion be conducted in the area of the tumor. Edema is also
especially radiofrequency and laser therapy, which have useful for distinguishing OO from other pathologies that
a clinical success rate greater than 90% [21, 22, 25–27] do not promote marked inflammatory changes [30].
(Fig. 1). Although many studies have suggested that the accu-
racy of conventional MRI in diagnosing OO is lower than
Diagnostic imaging: typical imaging findings that of CT [14, 31–33], the spatial resolution of modern
Conventional radiography (CR) is the usual first-line equipment has improved, volumetric isotropic sequences
imaging method used for osteoarticular pain, espe- are now used, and radiologists have become more knowl-
cially when OO is suspected. The typical radiographic edgeable, so OO can be easily suspected. Evaluations
features of OO consist of an intracortical lytic lesion, with a small field of view on the axial plane and proton
Carneiro et al. Insights Imaging (2021) 12:32 Page 3 of 17

Fig. 1 Typical osteoid osteoma and percutaneous ablation. Male, 15 years old, presenting with medial hip pain for 2 months, which became worse
at night. Axial T1 (a) and T2 FS (b) MR images showing a small cortical nidus (arrows) within the femur shaft with a target-like appearance, edema
and sclerosis. CT (c) better detected the partially mineralized nidus (dotted arrow), cortical thickening and sclerosis than did MRI. CT percutaneous
biopsy and radiofrequency ablation (d) were performed (dashed arrow)

density sequences are preferable [31]. Thus, MRI might especially with MRI, since CT has lower contrast resolu-
be preferred to CT, especially in the pediatric population, tion between the enhancement and the background bone
to prevent exposure to ionizing radiation. and exposes the patient to radiation [33]. This method is
The use of intravenous contrast may be helpful since also useful for detecting residual or recurrent nidus after
the nidus presents strong enhancement due to its promi- percutaneous treatment, when the typical imaging fea-
nent vascularity [16]. However, OO enhances with a tures are no longer present, as a sensitivity and specificity
timing and degree of enhancement similar to those of greater than 90% have been reported [25].
perilesional arteries, with loss of conspicuity in delayed Bone scintigraphy with technetium-99 has been proven
phases of contrast-enhanced imaging due to progres- valuable for detecting OO, with a sensitivity of up to
sive perilesional enhancement and rapid washout within 100% [16, 34]. The lesion is usually represented by a cen-
the tumor [33]. Therefore, dynamic-contrast images are tral nidus with very high uptake surrounded by a larger
advantageous to better depict the nidus in early phases area with moderate activity, consisting on the double-
of enhancement, presenting a typical curve with rapid density sign, a classic and specific scintigraphic finding of
inflow followed by washout (curve type IV), typically OO [16, 34]. Single-photon emission computed tomog-
seen in hypervascular tumors, or less frequently, a peak raphy (SPECT) imaging presents higher spatial resolu-
enhancement followed by a plateau (curve type III) [25, tion, specificity and accuracy and allows the detection
29, 33] (Fig. 2). Dynamic-contrast studies are able to of smaller lesions when compared to planar scintigraphy
identify this pattern and may be used in doubtful cases, [34]. 18F-Labeled sodium fluoride (18F-NaF) PET/CT
Carneiro et al. Insights Imaging (2021) 12:32 Page 4 of 17

Fig. 2 Pattern of enhancement of osteoid osteoma. Male, 17 years old, presenting with metatarsalgia of the right foot for 2 months, which became
worse over the past week. He had no recollection of trauma and practiced sports regularly. CR (a) showed no significant findings, apart from mild
bone sclerosis in the middle phalanx of the second toe (arrowhead). Coronal T1 and T2WI (b, c) depicted marked edema of the bone marrow
and surrounding tissues (curved arrow) and a very small intracortical lesion (dashed arrow). Dynamic MR angiography (d–f) showed marked
enhancement of the intracortical nodule (arrow in d), presenting contrast kinetics similar to those of adjacent arteries, with a peak enhancement
followed by rapid washout, suggestive of OO (e, f). A CT scan (g, h) was later performed, and the findings confirmed the presence of a nidus
(arrows)

features, which may lead to incorrect diagnoses (Table 1).

Table 1 OO’s typical and atypical imaging findings
One type of OO with atypical presentations is multicen-
Typical Atypical tric OO. It is a rare condition that is sometimes over-
Number Single nidus Multicentric or metachro-
looked and defined as the presence of more than one
nous nidus in the same bone (multicentric, as shown in Fig. 3)
Location within bone Cortical Medullary or subperiosteal or different bones (metachronous), which can cause diag-
Location along bone Diaphysis Metaphysis or epiphysis nostic and therapeutic difficulty since all nidi need to be
(including intra-articular) detected and treated. Most often, the nidi are close to
Distribution Long bones (espe- Extremities and axial each other [4, 35–37].
cially femur and skeleton Intraarticularly located OO is uncommon, with an inci-
tibia)
dence of up to 16% [10]. The most common location is
the hip (Fig. 4), and other joints, such as the ankle, elbow
is also useful for diagnosing OO due to the very intense (Fig. 5), knee and wrist, are more rarely affected [14, 38].
uptake of this radiotracer within the nidus and some- Intraarticular prostaglandins promote lymphoprolifera-
times at the perilesional area. Some OO nidi are also tive synovitis, which leads to atypical clinical symptoms,
FDG-avid and can be identified on FDG-PET/CT scans, such as arthritis, joint effusion, pain, stiffness and a high
with variable intensity [34]. local temperature [9, 11, 14]. There is most often no noc-
turnal worsening and little improvement after NSAID
Atypical imaging findings treatment, so the condition is easily mistaken for inflam-
The typical imaging and clinical findings are diagnos- matory or infectious arthritis. The nidus is identified in
tic. However, some OO cases may present with atypical only 28–50% of cases, and cortical thickening is reduced
Carneiro et al. Insights Imaging (2021) 12:32 Page 5 of 17

Fig. 3 Multicentric osteoid osteoma. A 26-year-old male handball player with lateral elbow and arm pain for 3 months. Orthopedists suspected
lateral epicondylitis or a stress reaction. MRI T1 (a) and T2 FS (b) showed cortical thickening on the lateral supracondylar crest with corticoperiosteal
edema (arrow) and small foci of intermediate signal intensity (dotted arrow), which raised the suspicion for OO. Scintigraphy (c) evidenced the
double density sign (black arrow), which cannot be used to distinguish between single and multicentric OO. CT (d) detected two nidi (dashed
arrows), confirming the diagnosis of multicentric OO

or absent in these cases since there is a small amount of joint contracture and muscle atrophy, resulting in growth
periosteal apposition at the joint due to the absence of disturbances [9]. Subchondral OO is even rarer and may
the cambium (internal) layer of the articular periosteum be confused with chondromalacia (Fig. 7) due to the
[4, 14]. The symptoms usually long precede the radio- reactional changes in the subchondral bone being similar.
graphic findings, and a delay in treatment may precipitate OO may also affect the distal extremities of the appen-
osteoarthritic changes in as many as 50% of cases [2, 6, dicular skeleton. Medullary OO is the most common
30, 39, 40]. type that occurs in carpal and tarsal bones, while all types
OO may be localized within the cancellous bone, usu- may occur in the metacarpal, metatarsal and phalangeal
ally in atypical sites such as the metaphysis of long bones bones. Medullary OO is usually accompanied by less cor-
(the femoral neck is the most common location) and tical thickening than is typical OO and may induce bone
carpal/tarsal bones. The periosteal reaction and cortical expansion [41]. Since the bones of the hands and feet are
thickening tend to be less marked in this type of OO than small and close to each other, it may be difficult to locate
in typical OO [5, 14], and bone marrow edema is usually the cause of inflammation, which may spread to adjacent
more intense, in which case MRI is more advantageous bones, joints and soft tissues. Additionally, there may be
than CT [30]. prominent soft-tissue swelling, resembling infection or
Epiphyseal OO cases are infrequent (less than 10%) and inflammatory arthritis [14, 41]. The nidus is very small
may be related to atypical features. Lesions close to the and may be difficult to identify. When OO is located in
growth plate may cause bone length discrepancy, espe- the distal phalanx, it may also cause nail deformities,
cially in very young children, and the affected limb is typ- which are also confounding factors [41]. In addition, the
ically longer [3, 6, 8, 41] (Fig. 6). This type of OO may also clinical presentation may be unusual, with atypical pain
cause premature fusion of the physis, angular deformity, or even the absence of pain, due to the absence of intral-
esional nerve fibers [39].
Carneiro et al. Insights Imaging (2021) 12:32 Page 6 of 17

Fig. 4 Osteoid osteoma mimicking synovitis of the hip. A 24-year-old man with right hip pain, swelling and tenderness for 2 weeks. Inflammatory
marker levels were also elevated. Orthopedists suspected inflammatory arthropathy, and ultrasound (not shown) depicted joint effusion and
synovitis. MRI T2 FS sagittal (a) and axial (b) shows joint effusion (arrowhead) with synovial thickening and a doubtful nidus (arrow), which was
better characterized on the CT scan (c). Arthroscopic aspect before (d) and after (e) nidus resection

Fig. 5 Osteoid osteoma mimicking synovitis on the elbow. Female, 20 years old, with elbow pain and edema for 4 months. Ultrasound in anterior
sagittal view (a) at the coronoid fossa level shows joint effusion (arrow). MRI T1 (b) and T2FS (c, d) show bone marrow edema (dotted arrows) and
synovitis (dashed arrows). Further investigation with a CT scan (e, f) revealed a mineralized nidus (curved arrow) in the cancellous bone of the
medial humeral condyle
Carneiro et al. Insights Imaging (2021) 12:32 Page 7 of 17

Fig. 6 Osteoid osteoma near a growth plate. An 11–year-old male with a history of surgical removal of an OO on the distal metadiaphysis of the
left femur. His symptoms persisted, and follow-up MRI (a, b) and CT (c) showed a residual nidus at the medial femoral margin represented by the
intracortical nodule (arrows) and surrounding bone marrow edema (asterisk in b). In a, note that the affected side of the distal femur is longer than
the lateral side, resulting in a femoral deformity and length discrepancy of the left lower limb

Pitfalls, differential diagnoses and OO‑mimicking lesions is usually larger than 1.0–2.0 cm and does not enhance
Some pathologies may mimic OO due to there being sim- in its central portion (since it consists of bone necrosis
ilar imaging findings, such as cortical thickening, reactive and pus), while OO lesions show strong enhancement
sclerosis, small lytic lesions and bone marrow edema. In of the nidus, except for the mineralized portion [14, 30].
general, the presence of a large lesion, a medullary lesion, Dynamic MR images may also be helpful since the nidus
a small surrounding region of osteosclerosis, a periosteal presents early arterial enhancement [16]. The penumbra
reaction and bone marrow edema may help distinguish sign (Fig. 7), characterized by a high signal intensity halo
OO from mimicking lesions [20]. The main differen- on T1WIs around the lesion, is nonspecific but indicates
tial diagnoses are described below and summarized in the possibility of infectious diseases [42].
Table 2. Fracture/stress reaction (Figs. 9, 10, 11): In young
Osteomyelitis/intraosseous abscess (Fig. 8): A small patients who practice physical activities, this differential
osseous abscess with internal bone sequestrum may diagnosis may be problematic since both fractures and
resemble the mineralized nidus of OO and vice versa, OO frequently occur in the femoral neck region (Fig. 9)
especially on plain radiographs. However, some fea- and tibia diaphysis (Fig. 10). In stress fracture cases,
tures allow the nidus to be differentiated from osseous periosteal reactions, the fracture line and bone marrow
abscesses in sectional studies. The inner margin of an edema can be visualized. In OO cases, although there
abscess is usually uneven, and the sequestrum is irregu- may be edema and periosteal reactions, the unequivo-
larly shaped and eccentrically positioned; in contrast, in cal nidus characterization and absence of a cortical frac-
OO cases, the margins are smooth, and nidus mineraliza- ture confirm the presence of OO [14, 43]. However, if
tion is regular and central [9, 14]. Moreover, an abscess the diagnosis remains uncertain, a CT scan should be
Carneiro et al. Insights Imaging (2021) 12:32 Page 8 of 17

Fig. 7 Subchondral osteoid osteoma mimicking trochlear chondromalacia. A 35-year-old male with anterior knee pain for 4 months. Axial T2 FS MR
images (a) showed deep chondral erosion (arrow), subchondral edema (asterisk) and a small, low signal intensity foci that could be a nidus (dashed
arrow). Sagittal T1 MRI (b) and CT (c) confirmed the diagnosis of the OO nidus (dashed arrow). Surgical images before (d) and after (e) resection

performed to detect either cortical discontinuity or the cases regress over time [14]. Depending on the location
nidus. Follow-up imaging is also helpful since fractures/ of OO, subchondral fractures might also have a similar
stress reactions consolidate and bone marrow edema presentation (Fig. 11).

Fig. 8 Osteoid osteoma versus osteomyelitis. (a–d) Male, 15 years old, presenting with knee pain for 2 months. MRI T2 FS (a), T1 (b), T1 FSGD (c)
and CT (d) showed a nidus with smooth margins (arrows), a central mineralized portion (dashed arrows), homogeneous gadolinium enhancement
(dotted arrows) and hazy T1 bone marrow edema around the lesion (asterisk). (e–h) Male, 13 years old, presenting with knee pain for 6 weeks. MRI
T2 FS (e), T1 (f), T1 FS GD (g) and CT (h) showed a bone abscess with irregular margins and peripheral enhancement (arrows). Note there was mild
bone marrow edema (asterisk), a positive penumbra sign (dashed arrow in f) and a small peripheral bone sequestrum (curved arrow in h)
Carneiro et al. Insights Imaging (2021) 12:32 Page 9 of 17

Table 2 Painful OO’s differential diagnoses main imaging findings

Differential diagnoses Key points

Osteomyelitis/intraosseous abscess Uneven inner margin; irregularly shaped and eccentrically located sequestrum; usually intramedullary located and
larger than 2.0 cm; does not enhance in its central portion; penumbra sign may be present
Fracture/stress reaction Fracture line may be present; lack of a nidus; Follow-up imaging can be helpful in doubtful cases because the
bone marrow edema regress over time and the fracture consolidates
Osteoblastoma Larger than 2.0 cm; less painful; fewer inflammatory changes and reactive sclerosis; smaller response to salicylates;
grow progressively; malignant potential and may be associated with other tumors
Glomus tumor Well-defined nodule in the nail bed; no thickening of the rest of the nail bed or matrix; may exhibit well-defined
remodeling of the dorsal cortical of the distal phalanx
Chondroblastoma Epiphyseal intramedullary location; lobulated contours; larger dimensions; chondral calcifications and signal
intensity

Fig. 9 Osteoid osteoma versus calcar femorale stress fracture. (a–d) Male, 35 years old, presenting with hip pain for 3 months. MRI T1 (a) and T2
FS (b) showed bone marrow edema on the femoral neck (arrowhead), T1 FS GD (c) and CT (d) showed a small nonmineralized nidus (arrows) with
gadolinium enhancement (c) and mild cortical thickening (dotted arrow in d). (e–h) Male, 33-year-old runner, presenting with hip pain for 2 weeks,
which worsened during running workouts. MRI T1 (e) and T2 FS (f, g) showed bone marrow edema on the lower femoral neck (arrowhead) and a
cortical fracture line (arrows), which was also seen on the CT scan (h)

Osteoblastoma: Although some authors consider OO Crystal deposition disease (Figs. 12, 13): Crystal
and osteoblastoma as spectra of the same pathology, deposition disease can occur at any site, such as the
most papers and the WHO classify these tumors as sepa- tendons, ligaments, fibrocartilage or joint capsule,
rate entities [44]. The two lesions, although very similar, and may complicate the differential diagnosis for OO
present important clinical and radiological differences: when there is intraosseous migration leading to cor-
osteoblastomas are larger, typically measuring more than tical remodeling and bone marrow edema (Figs. 12,
2.0 cm; are less painful; have a smaller response to salicy- 13). Age should be considered for the differentiation
lates; grow progressively; have the potential to be malig- between these entities since OO affects mainly younger
nant; may be associated with other tumors; lead to fewer patients, and the microcrystal deposition usually affects
inflammatory changes; and less often lead to reactive an older age group [47]; however, there is considerable
sclerosis [14, 45, 46]. overlap around the 4th decade of life, especially regard-
ing hydroxyapatite deposition. Ultrasound and CT are
Carneiro et al. Insights Imaging (2021) 12:32 Page 10 of 17

Fig. 10 Osteoid osteoma versus tibial stress syndrome. A 15-year-old male soccer player with posteromedial tibial pain for 3 months that worsened
while training and upon palpation of the upper posteromedial tibia. MRI axial T1 (a), axial (b) and coronal (c) T2 FS showed cortical thickening,
periosteal reaction, pes anserinus tendon edema (arrows) and bone marrow edema (asterisk), mimicking a stress syndrome. Further investigation
with a CT scan (d, e, f) demonstrated a nidus (dashed arrow), causing this corticoperiosteal reaction (arrowhead) and confirming OO

Fig. 11 Osteoid osteoma versus subchondral fracture. (a–c) Female, 32 years old, presenting with metatarsalgia for 2 months. T1 coronal (a) and T2
FS coronal (b) and sagittal (c) MRI showed a mineralized nidus (arrows) with reactional bone marrow and adjacent edema (asterisk). (d–f) Female,
33 years old, presenting with metatarsalgia for 3 weeks. T1 sagittal (a) and T2 FS coronal (b) and sagittal (c) MRI showed a subchondral fracture
(dotted arrows) with bone marrow edema (asterisk)
Carneiro et al. Insights Imaging (2021) 12:32 Page 11 of 17

Fig. 12 Osteoid osteoma versus crystal deposition disease. (a–d) Male, 19 years old, presenting with groin pain for one year. Axial (a) and coronal
(b) T2 FS MRI and CT (c) showed a small mineralized nidus (arrows) and reactional bone marrow edema (black asterisk). Percutaneous CT-guided
drill excision was performed (d). (e–h) Female, 36 years old, presenting with hip pain for 5 months. Coronal (e) and axial (f) T2 FS and coronal T1
(g) MRI showed calcifications (arrows) close to the indirect head of rectus femoris (arrowheads), which were better characterized on the plain
radiograph (h), with reactional bone marrow edema (asterisk)

Fig. 13 Osteoid osteoma versus crystal deposition disease [2]. (a–c) Male, 30 years old, presenting with posterior thigh pain for 3 months. Axial T1
(a) and axial (b) and sagittal (c) T2 FS MRI demonstrated a cortical nidus (arrows) and reactional bone marrow edema close to the gluteus tuberosity.
Note that the gluteus maximus tendon (dotted arrow) insertion is below the nidus. (d–f) Female, 38 years old, presenting with very intense
posterior thigh pain for 2 days. T2 FS axial and coronal MRI (d, e) and plain radiograph (f) showed corticoperiosteal and bone marrow edema in the
right gluteus maximus tendon (arrows) insertion and some calcifications (dotted arrows)
Carneiro et al. Insights Imaging (2021) 12:32 Page 12 of 17

Fig. 14 Osteoid osteoma versus glomus tumor. (a–f) Male, 19 years old, presenting with second toe clubbing and night pain (a). Sagittal T1 (b) and
sagittal (c) and axial (d) T2FS MR images showed diffuse nail bed thickening (dotted arrows), with no defined nodule, as well as a low signal cortical/
juxtacortical nodule at the distal phalanx (arrows), accompanied by bone marrow edema (arrowhead). A CT scan (e, f) was performed, and the
findings revealed a sclerotic nodule corresponding to an OO nidus (arrows), with minimal reactional surrounding sclerosis. (g–k) Female, 53 years
old, presenting with pain on the 4th finger that radiated to the forearm. Sagittal, coronal, axial T2 FS, axial T1 and T1 FS GD MR images depicted a
subungual nodular well-defined lesion (arrow) with remodeling of the subjacent phalanx cortex (dotted arrow) and homogeneous enhancement
after gadolinium injection (k). Note that diffuse thickening of the nail bed or phalanx sclerosis was absent.

useful for visualizing the extension and location of the and may exhibit remodeling of the dorsal cortical of the
calcifications, allowing the identification of extraosse- distal phalanx [51] (Fig. 14). Moreover, single-digit club-
ous calcific foci associated with crystal deposition. bing is relatively rare, and the possibility of primary bone
Glomus tumor (Fig. 14): OO of the distal phalanx is neoplasm should always be investigated, with enchon-
often associated with an atypical clinical picture, with lit- droma and OO representing the most common types of
tle to no pain, single-digit clubbing and diffuse thicken- neoplasm with this manifestation [48–50].
ing of the nail bed, with a high T2WI signal intensity and Aggressive bone lesions: Most aggressive bone lesions
gadolinium enhancement, which can lead to the erro- have very different imaging patterns than does OO, as
neous diagnosis of a glomus tumor, especially if MRI is they are characterized by the replacement of bone mar-
the only available imaging modality [48–50]. However, row with a markedly low T1 signal intensity, leading to
glomus tumors are well-defined nodules in the nail bed, a generally well-demarcated transition with preserved
with no thickening of the rest of the nail bed or matrix bone marrow, and they may also exhibit cortical rupture
Carneiro et al. Insights Imaging (2021) 12:32 Page 13 of 17

Fig. 15 Osteoid osteoma versus chondroblastoma. (a–d) Male, 29 years old, presenting with knee pain for 3 months. MRI sagittal T1 (a), axial and
coronal T2 FS (b, c) and CT (d) showed a round and central mineralized nidus (arrows) with reactional bone marrow edema (asterisk) and cortical
thickening (dashed arrow in d). (e–h) Male, 24 years old, presenting with ankle pain for 9 months. MRI axial T1 (e), sagittal T2 (f), axial T1 FS GD (g)
and CT (h) showed a large and lobulated bone lesion (arrows) with peripheral arciform calcifications (dotted arrows), internal enhancement (c) and
reactional bone marrow edema (asterisk)

and extracortical involvement. In contrast, the pattern of signal intensity and gadolinium enhancement. Cen-
edema that occurs in OO cases is characterized by a gray, tral chondroid-pattern calcifications may be present in
hazy and ill-defined T1 intermediate signal intensity, approximately 30–40% of cases. This condition is asso-
with no substitution of bone marrow. ciated with inflammatory changes and is sometimes
Chondroblastoma (Fig. 15): Chondroblastomas are accompanied by synovitis and surrounding soft-tissue
rare and painful benign bone neoplasms that are gen- edema [14]. Epiphyseal and medullary localization,
erally smaller than 4.0 cm. They predominantly occur lobulated contours, chondral-like calcifications and
in epiphyses or apophyses of immature bones; they are larger dimensions may aid in the differentiation of
most prevalent in the femur, followed by the humerus chondroblastoma from OO, which is usually smaller
and tibia; and they are predominant in males. The and located on cortical bone and on the diaphysis;
lesion is lytic, central or eccentric intramedullary, with however, small and mineralized chondroblastoma may
well-defined limits, a thin sclerotic halo, a high T2 be indistinguishable from OO [14].
Carneiro et al. Insights Imaging (2021) 12:32 Page 14 of 17

Fig. 16 Osteoid osteoma mimicking bone marrow contusion. Male, 16 years old, presenting with right elbow and arm pain for 2 days after falling
during physical activity at school. First, the MRI T1 (a) and T2 FS (b, c) findings were interpreted to indicate contusion bone marrow edema (asterisks)
without a fracture. However, the pain persisted for more than 3 months. Follow-up CT (d, e) and MRI (f, g) scans revealed small subchondral OO
with a lytic nonmineralized nidus (arrows) and enhancement (dotted arrows) on the T1 FS GD MRI scan (f, g)

Miscellaneous (Figs. 16, 17, 18): OO can resem- compensatory hypertrophy of the pedicle, intracorti-
ble pathologies other than those previously men- cal hemangioma, osteochondroses, cortical desmoid,
tioned, such as contusional bone marrow edema fibrous dysplasia and eosinophilic granuloma [4, 6, 14].
(Fig. 16), impingements (Fig. 17), enthesitis (Fig. 18),
Carneiro et al. Insights Imaging (2021) 12:32 Page 15 of 17

Fig. 17 Osteoid osteoma mimicking anterior impingement. A 29-year-old male presenting with anterior ankle pain for 4 months. CR (a) showed
mild sclerosis on the dorsal talar neck (arrow). T1 (b), T2 (c, d, e) and CT (f) showed a mineralized nidus (dotted arrows) with reactional synovitis
(arrowhead), bone marrow edema (asterisk) and sclerosis

Fig. 18 Osteoid osteoma mimicking enthesitis. Male, 20 years old, presenting with back pain for six weeks. CR (a) showed left scoliosis with no
identifiable bone lesions. Sagittal T2 FS MRI (b) revealed bone marrow edema on the posterosuperior corner of the vertebral body (asterisk), which
raised the suspicion for enthesitis. The CT scan (c, d, e) showed a small and mineralized nidus on the concave side of the region of scoliosis (arrow)
with reactional bone sclerosis (dashed arrow)
Carneiro et al. Insights Imaging (2021) 12:32 Page 16 of 17

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similar to that of other pathologies. The atypical forms NA (2012) Osteoid osteomas: a pain in the night diagnosis. Pediatr
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