cause of microthrombotic events further predisposing bone to infection This is supported by an association of trauma with the occurrence of osteomyelitis and the preponderance of infections occurring within the long bones, especially those of the lower extremities In sickle cell patients, microinfarcts within the more tenuously supplied area of the diaphysis may explain the increased occurrence in this region of the bone As infection progresses, pressure increases and organisms penetrate up through the cortex to the subperiosteal space Differences in the underlying bony structure in the neonate and young infant predispose them to a higher incidence of multifocal osteomyelitis and concomitant septic arthritis The thin cortex allows easier penetration to the subperiosteal space The periosteum is less adherent in these ages and less effective in limiting the spread of infection Transphyseal vessels, which are present through the first 18 months of life, allow bacteria to gain access to the adjoining epiphysis and joint space A less common source of osteomyelitis in children is penetration of the periosteum by adjacent infections such as a cellulitis or abscess Inoculation of the bone from stepping on a nail, surgical instrumentation, or intraosseous line placement provides a third means for infection to gain entrance to the bone Goals of Treatment Early recognition and treatment of osteomyelitis prevents the spread of infection and minimizes the risk of poor outcomes such as growth disturbance, abscess formation, sepsis, chronic osteomyelitis, or even death The time to initiation of antibiotic administration from onset of symptoms or arrival to medical care is a key objective of care Empiric antibiotic treatment is based on the patient’s age, Gram stain of an aspirate if performed, the likely means of contracting the infection, and underlying comorbidity The ultimate choice of antibiotic and the length of treatment are dictated by the offending organism which is identified through appropriate cultures Although acute operative intervention is rarely necessary, timely consultation of orthopedic surgery facilitates bone aspiration when indicated and the initiation of treatment Clinical Considerations Clinical Recognition The infant or child with osteomyelitis typically presents with fever, localized musculoskeletal pain, or pain with movement Trauma is not an obvious explanation for the symptoms The absence of fever does not rule out the presence of osteomyelitis