Refusal to move a limb or pseudoparalysis may be a sign of osteomyelitis Up to 40% of children with osteomyelitis will be afebrile Radiographs are helpful in evaluating for alternate diagnoses but not rule out osteomyelitis when obtained early in the course of the illness Osteomyelitis is frequently associated with septic arthritis in neonates Pathogens or etiology of musculoskeletal infection vary by age of the patient Staphylococcus aureus is the most common organism in all ages Magnetic resonance imaging (MRI) is the imaging study of choice Patients with sickle cell disease are at risk for Salmonella osteomyelitis Inflammatory markers are elevated in up to 90% of cases of osteomyelitis CRP is the most effective inflammatory marker in monitoring the response to therapy The lower extremity accounts for up to 70% of cases of osteomyelitis in children Current Evidence Osteomyelitis is an inflammation of the bone and bone marrow that is most commonly of infectious origin Infection is confirmed by the presence of two of the following: pus on an aspirate of the bone, clinical findings consistent with the diagnosis, positive blood or bone aspirate cultures, and consistent findings on medical imaging Osteomyelitis is more common in boys, with the highest incidence found among infants and preschool age children Younger age and underlying disorders are associated with an increased risk for contracting osteomyelitis, as well as for the particular pathogens involved Bacteria gain entrance to the bone through one of three routes: hematogenous, direct spread from adjacent infection, or inoculation through a penetrating wound Hematogenous spread is the most common route of infection in children A transient bacteremia is believed to be the initiating event in the infection Bacteria enter the bone at the level of the metaphysis where the predominant vascular supply is located The sluggish blood flow within the microvasculature of the marrow predisposes to infection Local trauma has been suggested as a possible