X-ray may be helpful in the diagnosis of Ewing’s sarcoma. Findings on x-ray diagnostic of Ewing’s sarcoma include permeative lytic lesion, periosteal reaction, and soft tissue calcification.

X-ray add valuable information in the initial evaluation of Ewing’s sarcoma.The appearance of these tumors is variable. Common x-ray findings are listed below:

• A permeative lytic lesion in the metaphysis and diaphysis of the bone with a prominent soft tissue mass extending from the bone.
• Periosteal reaction usually is present, and it often has an onionskin or sunburst pattern, which indicates an aggressive process.
• Codman triangle may be present at the margins of the lesion. These result from the elevation of the periosteum and central destruction of the periosteal reaction caused by the tumor.
• The wide zone of transition (e.g. permeative) is the most useful plain film characteristic in differentiation of benign versus aggressive or malignant lytic lesions.
• Soft tissue calcification is uncommon, seen in less than 10% of cases.

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  X-Ray of a child with Ewing’s sarcoma of the tibia.^[1]
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  Radiograph demonstrates classic sunburst pattern of periosteal reaction.^[2]