Florid reactive periostitis is a rare, benign process usually occurring in the small, tubular bones of the hands and feet. Typically the lesion occurs in an adolescent or young adult and presents as a small area of pain and erythema over the affected bone. Although the histologic features may suggest malignancy there is usually little radiographic evidence to support such a diagnosis. In the following report an unusual example of this entity is described whose large size and relentless local progression led to initial diagnostic uncertainty and eventual aggressive management. This case suggests that a wide spectrum of radiologic and morphologic changes may be seen in this entity and that a seemingly unrelated genetic disease may alter the typical clinical course. © 1990 Springer-Verlag.