The early metaphyseal changes of osteoporosis and destruction are usually patchy but involve the whole width of the shaft (Fig. 40.4).

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Fig. 40.4A-F. The progress of the osteomyelitis of smallpox in the legs. (A) Bilateral periosteal reaction along the shafts, with minimal changes in the metaphyses. (B) Thickening of the periosteum, destruction of the diaphysis. Note the asymmetry in the extent of the disease between the two legs. The left leg has more extensive disease than the right. (C) In this patient each fibula is more affected than the tibia. There is a florid periostitis, smooth in outline but varying in thickness and irregularity. The cortex remains well defined beneath. (D) In this patient the tibiae are affected more than the fibulae, and the left fibula more than the right. In addition to the typical periosteal reaction along the length of the shafts of the bones, there is marked metaphyseal and diaphyseal destruction. (E) Very florid periostitis involving the bones of the lower limbs. The cortex of each appears to be sequestrating. The periosteal thickening has not extended beyond the capsular ligaments in either the knees or the ankles. (F) The stage of healing: the periosteum is consolidating; the shaft of the fibula is grossly thickened and distorted. The ghost of the cortex remains interred but will not sequestrate. The tibia has remained remarkably unaffected in this patient.