#Traumatology

[jcmicr]

A 12 Day- Old Female Infant Diagnosed with Pelvic Osteomyelitis in the Pediatric Emergency Department by  Mehmet Ali Oktay in Journal of Clinical and Medical Images, Case Reports 

Abstract

Osteomyelitis (OM) is a bacterial disease that is very rare in newborns and has devastating consequences. Neonatal OM is seen in 1-3 in 1000 babies. We presented a 12-day-old female baby who was brought to the Pediatric Emergency Department (PED). Because she could not move her leg. She did not have fever and septic appearance and had a history of hospitalization in Neonatal Intensive Care Unit; acute phase reactants were high and radiological imaging performed gradually was consistent with OM. Our patient is the youngest patient who was diagnosed with pelvic OM upon admission to the PED. Earlydiagnosis and treatment prevent complications and sequels. Keywords: Osteomyelitis; newborn; pediatric emergency

Introduction

Osteomyelitis often occurs secondary to the hematogenous spread of microorganisms into the blood-rich metaphysis of the developing bone. When left untreated, it leads to complications such as joint destruction and decreased range of motion [1]. Osteomyelitis (OM) of the hip is rare in newborns. Signs and symptoms are quite different compared to older children. This may cause difficulties/delays in diagnosis and permanent disability [2]. Successful management of OM in the neonatal period has been associated with rapid correct diagnosis and adequate correct treatment [2, 3]. The incidence of OM in the pediatric age group is 1/5000 cases. About 50% of pediatric OM cases are under the age of five. The incidence of neonatal OM is 1-3/1000 cases [3]. Although there are studies on patients diagnosed with osteomyelitis while staying in neonatal intensive care unit (NICU) [1, 4, 5], cases diagnosed upon PED (Pediatric Emergency Department) admission are very rare [6]. In this article, the youngest case in literature who went to the PED and was diagnosed with pelvic and acetabulary OM is presented.

Case Report

A 12-day-old girl, born from the first pregnancy of a 28-year-old mother, was admitted to the PED with complaints of restlessness and inability to move her right leg. The day before the application, it was stated by her mother that she did not move her leg, that she was agitated when forced to move, and could not be consoled. The baby did not have a history of fever or trauma, her feeding was good, and her urine and defecation were normal. From her history, it was learned that she was born at 36 weeks and 3 days of gestation and had intrauterine growth retardation compatible with 31 weeks gestational age, and she was born by emergency cesarean section due to preeclampsia. The patient, who was hospitalized in the NICU due to temporary tachypnea of the newborn after birth, was discharged on the sixth postnatal day. During the follow-up in the NICU, umbilical catheterization was not applied to the patient. She had not received antibiotic treatment and no growth was detected in blood cultures taken before discharge.

At her evaluation in the Pediatric Emergency Department triage area, she was a restless baby with a good general appearance. Vital signs; body temperature was 37°C, heart rate was 140/min, respiratory rate was 42/min, pulse oximetry was 98%, and mean arterial pressure was 45 mmHg. There was no pathological finding in the physical examination, and it was observed that the patient's discomfort increased due to the position given to the hip and leg while changing the diaper. While abducting the right thigh from the hip in the supine position, there was limited range of motion compared to the left. No swelling or redness was detected on the joint surface.

Laboratory and radiological examinations were planned for the patient with a preliminary diagnosis of septic arthritis. In laboratory tests: hemoglobin (Hb) 14.6 g/dL, RBC (Erythrocyte) - 3.361 x10.e6/uL, hematocrit (Hct) 40.04%, white blood cell (WBC) 16.82 x10.e3/uL, neutrophil percentage 59.8%, C-reactive protein (CRP) 25.9 mg/L, erythrocyte sedimentation rate (ESR) 51 mm/hr, procalcitonin (PCT) 2.95 ng/mL, IL-6 145.6 pg /mL detected. On direct radiographs of the lower extremity and pelvis, the right femoro-acetabular distance was observed to be increased (Figure 1). Long bone radiographs were normal. In the superficial tissue ultrasound (US) performed for the right hip joint, bilateral hip joints were compared with each other, and no significant effusion was observed on the right side. The patient was consulted to the Orthopedics and Traumatology department with a preliminary diagnosis of septic arthritis. MRI was requested from the patient for the differential diagnosis of septic arthritis.

Figure 1: There is an increase in the right acetofemoral distance compared to the left.

Bilateral hip MR imaging showed “The right femoral head is small and irregular in appearance, and an area of pathological signal change in the right femur proximal metaphysis, medullary bone marrow, and solid periosteal reaction in the lateral proximal section is observed. Widespread edema was observed in the surrounding muscle planes, fascial surface and subcutaneous adipose tissue adjacent to the hip joint. In addition, medullary bone marrow edema was observed in the right acetabulum (osteomyelitis). Areas of pathological signal changes consistent with diffuse edema are observed in the right obturator externus, pectineus, quadriceps muscles, gluteal muscle planes and iliacus muscle (myositis). Minimal free fluid was observed in the right hip joint space. Findings were primarily evaluated as compatible with osteomyelitis and myositis.” (Figure 2).

Figure 2: Osteomyelitis in the proximal metaphysis of the femur

Due to the history of hospitalization in the intensive care unit, the patient was diagnosed with OM secondary to hematogenous spread and, according to the age, to include possible infectious agents, vancomycin (15mg/kg/dosex3), ceftazidime (30 mg/kg/dose x 3), fluconazole loading (12 mg/kg/dose)) and maintenance (6 mg/kg/dose) treatment was started. Blood culture was taken before antibiotic treatment. Our patient, who received antibiotic doses only one day before the operation, was operated on the postnatal 13th day.

The patient was operated by the Orthopedics and Traumatology department and the intra-articular pus was drained. From the material; joint fluid culture, fungal culture, tuberculosis PCR, ARB staining, fungus search was sent. There was no growth in the blood culture, but because of the growth of ceftazidime-resistant Klebsiella pneumoniae in the joint fluid culture, ceftazidime was discontinued and meropenem (20 mg/kg/dosex3) treatment was started. Fluconazole was discontinued on the 8th day because there was no growth in the fungal culture. The patient was discharged with oral trimethoprim-sulfamethoxazole treatment after 25 days of vancomycin and 27 days of meropenem treatment. Trimethoprim-sulfamethoxazole was discontinued 22 days after discharge. The regression of the inflammation was seen in the MRI taken under the control of the outpatient clinic. verbal consent was obtained from the patient's parents for the publication of the article.

Discussion

This case demonstrates the importance of detailed investigation of newborn infants admitted to PED. Although OM in newborns is rare, there are difficulties in diagnosing and treating it. High suspicion is required for early diagnosis and observation of clinical signs is very important.

Risk factors for osteomyelitis in newborns are stated as immature host-defense mechanisms, invasive intervention such as umbilical catheterization. It has been shown that half of the cases diagnosed with neonatal OM have a history of umbilical catheterization. It has been observed that the pregnancy and delivery history of the mother is also important in the development of OM, and maternal complications such as maternal hypertension, preeclampsia, ablatio placentae, infection are present in approximately half of the infants who develop OM [7]. Particular attention should be paid to the evaluation of newborn cases, especially in PEDs where is crowded and the number of patient admissions is high. Newborns are among the patients at risk for PED and require special care. Application complaints and prenatal, natal and postnatal history should be questioned in detail. It was observed that the mother of our case had preeclampsia during pregnancy, but umbilical catheterization was not applied to the baby.

In studies conducted in newborns with neonatal osteomyelitis, the most common sites of involvement were reported as femur, humerus, and tibia, respectively [1, 4, 8]. The pelvis is a rare site of hematogenous disseminated OM for neonates. Pelvic OM constitutes 2.3% of all childhood osteomyelitis cases [3]. Our case also had pelvic (acetabular) OM, which is a rare site of OM involvement. Involvement was also demonstrated in the proximal region of the right femur.

Pelvic OM was defined in three cases at 5, 15, and 18 days in the neonatal period [3, 9, 10]. In the literature, it has been observed that mostly cases hospitalized in the NICU were diagnosed with osteomyelitis [1, 3, 4, 8-10]. As far as we can find in the literature, a 4-week-old case with a diagnosis of distal tibial OM and culture of GBS has been reported, just like our case [6]. Our case is the youngest OM case diagnosed in the emergency department, except for the case in the literature. The clinical features, presentation symptoms, cultures and risk factors of cases diagnosed with neonatal osteomyelitis in the literature are shown in (Table 1)

Table 1: Comparison of cases with neonatal osteomyelitis in the literature.

Clinical symptoms are related to the bone or joint area involved in newborns. Swelling and local inflammation findings are common findings in the neonatal osteomyelitis group. Systemic findings such as fever are seen in fewer of these cases. A highly variable rate of fever was found in 9.1-76.5% of patients with extensive neonatal osteomyelitis. In addition, it has been shown that the WBC count, CRP and ESR levels are high in the cases [1, 4, 8, 11]. In our case, there was no fever, but there were complaints of inability to move her right leg and restlessness. Laboratory parameters were high and consistent with the literature. In cases with osteomyelitis, direct radiographs can guide the correct diagnosis, exclude other diagnostic possibilities, or provide clues for underlying pathological conditions [12]. Soft tissue swelling on plain radiographs can be seen within days of the onset of infection. It can also show periosteal reaction, lytic lesions, joint effusions and destructive bone changes 7-10 days after the onset of infection [13]. US findings begin with nonspecific swelling in the soft tissues adjacent to the bone. US can show thickening and elevation of periosteal and subperiosteal fluid collections as early as 3 days [14]. In a study comparing osteomyelitis groups, it was shown that the diagnostic value of US was statistically higher in the newborn group compared to the other groups, regarding the capacity of detecting subperiosteal abscesses [11]. In our case, however, an increased femoro-acetabular distance was observed on direct X-ray, but no finding was found on US. This supports the view that the primary step in the pediatric emergency department in patients with suspected osteomyelitis should be started with direct X-ray as recommended in the literature.

MR imaging is the most useful imaging technique for evaluating suspected OM, allowing early detection of osteomyelitis and assessment of the extent of involvement and disease activity. MRI is very sensitive in detecting OM 3-5 days after the onset of infection [12]. As seen in our case, it still remains the gold standard. However, we recommend hospitalization in order not to miss the newborn cases because MRI is difficult in emergency conditions.

In infants, osteomyelitis and septic arthritis often coexist. While Staphylococcus aureus is the most common organism causing osteomyelitis at all ages, GBS and Escherichia Coli are important pathogens to be considered in newborns [6]. Culture is found to be negative in 22-50% of the cases [15]. Antibiotics to be used in neonatal OM should be effective against these pathogens [16]. In our case, treatment with antibiotics covering these pathogens was applied and Klebsiella pneumoniae growth was observed in the pus culture.

We think that even with rapid diagnosis and aggressive treatment, there are orthopedic sequelae and inadequate treatment increases the risk of chronic osteoma [16], therefore, in cases who apply to the pediatric emergency department with these complaints, early diagnosis and treatment of neonatal OM should be planned in a timely manner to minimize long-term sequelae.

In conclusion, a detailed anamnesis should be taken and a careful physical examination should be performed in newborns who present to the PED with limited range of motion at joints. Neonatal OM cases mostly consist of cases diagnosed while staying in the NICU. Pelvic involvement is rare and our case is the youngest pelvic OM case diagnosed in the PED.

For more details : https://jcmimagescasereports.org/author-guidelines/ 

[spooksicl-e]

personal little reference i mocked up for sherlock and john :p

[adr1025]

the er is so full someone please save me

[ley-med]

And it paints the hospital floor a nice and children friendly shade

blood is so cool

[literaturepublishersjournal]

Journal of orthopedic case reports publishes Images in Orthopaedics Case Reports Journal, Orthopaedics Journal, Case Reports in Orthopaedics etc. Journal of Orthopaedics and Traumatology Case Reports provides an equal platform to orthopaedic based medicine as well as personal experience and every case report should reflect these important concepts.

[ghostscrown]

Fuck it I'm gonna say it, Dragons Rising 2 coming out literally a few days after I went to therapy and got signed up for traumatology because of textbook symptoms of PTSD and/or CPTSD, with Lloyd now having panic attacks and implied PTSD too, Bonzle being another trans allegory after Sora, AND Arin being even more autistic coded, really made me feel seen. I love this show so much

[barksenji]

I posted this on reddit, but I've seen some gnarly posts about Venezuela here, so I'll post it here too.

"I'll try to answer all of them. I don't know if I can explain like you're 5 because I'm autistic af and English is not my first language, but I hope I can make myself understood.

I condemn practically everything about the government. In Venezuela, on average, only four out of 10 operating rooms in the country's main hospitals are operative, and the shortage of supplies in emergency rooms is around 37%, while in operating rooms it reaches 74%. As for my own experience, I have Classical Ehlers-Danlos Syndrome, I had a shoulder subluxation and I still do, and I went to the Victorino Santaella hospital in my country, there's little personnel, to the point that in the area for traumatology you could see dry blood on the floor because there just wasn't enough people to clean it up. Not a little bit of blood, but a lot. If you want decent medical attention, you will have to pay a bunch of money.

I had a strangulated umbilical hernia, which again, is something that commonly happens with the EDS. My dad had to spend 4000$ dollars on the operation, which for us, is a unachievable amount of money. He had to sell his car, and beg his job for the rest of the money, because the car was old asf and only covered about 200$.

Many people say the government is progressive, it is not. In Venezuela the LGBTQ community has absolutely no rights, it's incredibly difficult for trans people to change their documents or access hormonal treatment. Abortion is not legal here, not even in rape cases, gay marriage isn't legal either, and domestic violence largely goes unpunished.

The minimum wage is around 3 dollars, my dad works in transit so he earns minimum wage, because I have so many medical emergencies he has to make illegal driving licenses in order for me to get treatment. It is incredibly hard for my mom to find a job.

If you want an overview of the whole political situation, this thread can explain it better than I can:

This also explains many of the faults with the government, really, there are too many, I can't count them all.

There’s also no freedom of speech in Venezuela due to Nicolas Maduro’s oppression. All the news channels that are available are on his side. CNNE was removed from Venezuela after doing a documentary on Maduro and also was DW. Our only way to inform ourselves are socials, and most venezuelans are speaking through there.

Maduro's government is not a socialist government anymore, it paints itself that way to outsiders, but it is not. Money that should be going to public institutions is not going to those institutions, hence why the hospitals are in such dire state and you have to pay for private clinics in order to get appropriate care. I don't know if you're familiar with the CLAP bags, The Local Supply and Production Committees (CLAP) is a distribution program of some basic imported foodstuffs promoted by the Venezuelan government since 2016 in which the communities themselves organized in committees supply and distribute priority foods through a modality of delivery of products, house by house at first, later distributed in a local of the community. The problem with these is that they're frequently infected with weevils, maggots, and even if they look "good" on the outside, they can be infected with bacteria and give you food poisoning. Worse is, some people are entirely reliant on these.

They're supposed to protect our indigenous people, but a Venezuelan indigenous leader who opposed the incursion of armed groups and illegal mining was shot twice while in a neighborhood in the capital of Amazonas state. Maduro is also the richest man in Venezuela.

In the protests that occurred in 2017, around 150 people died thanks to the armed forces and colectivos (paramilitaries on the side of the government), police came out with tanks (idk the name exactly in English) and ran over people who were peacefully protesting. Right now, I believe there has been 11 people confirmed injured, though there's probably more, since hospitals are asking for resources to treat the injured.

I think most of these payment methods are only available in Venezuela, but I saw a Paypal here and there, if you can help I'd thank you so much:

As for the self-sufficiency, I don't know. As I said, I'm 17 and heavily reliant on my parents. This country's also really not accessible for disabled people, I cannot go down stairs and have to walk with a cane, there's rarely a place where elevators are functioning properly: ironically, especially in hospitals. In the hospital Victorino Santaella, my dad has to carry me through a bunch of stairs, he has a bunch of hernias in his back so that's obviously no good for him. I'm also at heavy risk of fainting, so yeah.

Also: I don't know how the housing situation is in Venezuela statistic-wise, but for the young adults, is impossible to get a house. Houses can cost up to 100.000$ and more, the average job will pay enough for you to eat, buy toilet paper, basic needs and that's about it.

My friends, who were studying university, couldn't finish cause they had to get a job in a supermarket or bakery in order to be able to support their parent economically. It's horrible.

We also have no running water, when we do it's brown, our power goes off all the time and I have no health insurance"

Do I support María Corina? Or the opposition? I'm skeptical about them, they're still politicians, and Machado is a Zionist. I'm worried about idolizing these figures, deeply. But there's no alternative guys.

For gringos saying that we are supporting fascists, and whatnot. We have literally no other option. This didn't start with US sanctions, it just got WORSE with them. But these sanctions are a symptom, not the root of our problem.

Please, listen to venezuelan voices. If you're really a leftist, just a bit of research will be enough to convince you that this is NOT even a socialist government anymore.

[ley-med]

Long live the pathology book, reading that caused me to self-diagnose, suffer through, and then miraculously survive 5 different types of cancer and at least 2 deadly infections all within a week.

Since then, I accepted that one day, I'm going to drop dead and there's nothing I can do about it. But all the other days? I'm going to live.

being in medical school is turning me into a hypochondriac dhjshdksh whaddya mean you can drop dead from infective endocarditis without any prior symptoms or only innocuous mild symptoms ehjsdjksjsls whaddya mean autopsies show that in 10% of deaths in younger populations theres evidence of infective endocarditis dhskdjskks im gonna scream

[zvhiux34]

Simon Riley realizes how much touch starved he is due to his physical therapy.

Pairing: OC (Female, Dr Eavanson) x Simon "Ghost" Riley

w.c: 2.5k

Warning: Fluff, a little twisted Simon I guess, a small sexual inuendo. English it's not my first language.

••••••••••••••••••••••••••••••••••••

Due to his work, Simon Riley is a man accustomed to looking death in the eye, but his skill has helped him dodge it, avoid it, and even mock it to the face a few times.

But what he could not escape, no matter how hard he tried, was the pain.

Although adrenaline and satisfaction also accompanied him, sometimes, when he and his team completed a mission.

But those pleasant sensations went away when the pain knocked on the door. It was always there, like the shadow of a bad thought.

At least it reminded him that he was still alive, and not just another «Ghost» wandering through the valleys of violence.

A few months ago, while he was deploying a mission to capture one of many criminal gangs in Afghanistan, Simon and his team were cornering the leaders when suddenly one of those damned people managed to hit a bullet in his right shoulder, almost hitting his shoulder blade.

It was incredible how such a small object could transmit such a heartbreaking sensation that reached half of his body.

Fortunately, that did not prevent the capture of those scum, but the price of pain was quite expensive to pay.

The pain is what brought him here, in a seat in the waiting room of your medical office. Although the doctor successfully removed the bullet, the impact affected several muscles in his shoulder which prevented him from handling his weapons with the mastery that characterizes him. Therefore, they gave him a medical leave to recover, away from the battlefield.

Simon snorted in annoyance at the memory of his superiors demanding him to take the leave. They also recommended a doctor specialized in traumatology in his homeland, in England, who could carry out his therapy.

As hard as it was to accept it, he knew he needed therapy, so his body would be in optimal condition, just like before.

-Mr. Riley? -The receptionist, a middle-aged woman behind her desk, caught his attention- You can now go into the office, Dr. Eavanson is waiting for you.

Simon stood up from his seat and walked to where the woman indicated. He carried his hands in his pockets as she knocked lightly on the door and then opened it.

Simon didn't know what to expect, he thought you were a gray-haired man who was in charge of this office.

But there you were, a mirage of a delicate figure behind your desk visualizing something on the computer. Seeing you again, Simon felt something tense inside him, the receptionist closed the door behind her, leaving the two of you alone.

You raised your gaze to where he was and smiled kindly at him, Simon didn't know what to do, he was frozen, for a second he thought you had caught him and knew all the paralyzing sensation you caused him in just a few moments. "What's happening to me?" he thought to himself.

-Mr. Riley, right? -Finally, your welcoming voice broke the walls of silence. Simon was able to escape from his trance to nod slightly.

-It's nice to meet you, I'll take care of you today. I was reviewing the X-ray plates of your shoulder along with the medical file, I see that you have an injury in the supraspinatus muscle. Is that correct? -You got up from your seat and took a few steps to approach your new patient, Simon, but he, the lituanent who led a group of soldiers with the same strength and violence as he possesses, and who had experience in fighting against equal or worse subjects...

He took a step back at your approach, as if it were by instinct.

You realized that gesture, and then looked at him a little strangely.

Simon cursed himself inwardly. He was acting like a stupid teenager, or worse, like an antisocial who doesn't know how to deal with people, he had to do something.

-Yes. -He answered, finally while composing himself- That's right. The doctor who treated me in the camp made the same diagnosis... And therefore assigned me a series of therapies.

He almost let out a sigh of relief when he saw your face lose the signs of strangeness that you had shown a few seconds ago.

It was strange, normally he didn't pay attention to what others thought of him.

His mind began to search for an answer to the question that formed inside him. Why was it different with you?

-That's right. -You affirmed with the same smile.-Fortunately, in cases like his, recovery is guaranteed if you undergoes a series of therapies.

Simon nodded as he listened... while he used an effort to contain the desire of his eyes to travel something further below the borders of your face, he didn't want you to notice him doing that, while you looked at him straight in the eye.

-But first, I have to examine you. Could you undress and sit down on the stretcher, please? -Suddenly all of Simon's thoughts fell silent, as you pointed with your head to the stretcher that was on the right side of the room. And a coat rack to hang clothes.

«Shit» when he saw you he had totally forgotten that he had to undress in front of the doctor who was going to treat him.

He just didn't take into account that it was going to be someone like you.

In those microseconds where he tried to dilute his little panic, he glanced at you while you were checking something on your iPod.

You didn't seem to give the matter any big importance, anyway, for you it was just another body to check.

But for him, it was a body formed by years of work, but it was also full of tattoos and scars, in which each trace of them contained hundreds of stories. Some he still knew by heart, others... Not only were they too obvious, but the memory was also very present.

But the problem wasn't him, he wasn't embarrassed at all by his appearance, the problem was you... He didn't know how you were going to react to seeing a body like his, nor... Nor if you were going to like it.

He couldn't just stand there either.

Simon started by removing his black jacket, feeling the bother sensation by his right shoulder, then finishing with his long-sleeved shirt of the same color. He hung them on the clothes rack, and proceeded to sit on the strecher, feeling it soft at the same time he heard the squeal beneath him.

He assumed that was what announced to you he was ready for the evaluation. You put your iPod on your desk and went straight to where he was.

There, Simon's eyes escaped from their prison to be able to quickly and discreetly explore a little more of what he had already been able to capture.

You were smaller than him, without a doubt, even when he saw you sitting at the desk he realized. You barely reached the height of his chest.

His honey-colored eyes lowered a little more, until they met your neck. It was firm, not willing to allow your head to look down at any eventuality, and the skin that protected it looked so soft and delicate.

Simon wondered how many times you had covered it, not only from the cold weather, but to protect it from the curious glances the love marks made by some lucky indiscreet lover to whom you allowed such audacity.

Although you were not carrying any by now, he made sure of that.

His eyes lowered further, and found the protective layer that was your white coat and the blue uniform, those in your profession usually wear.

He did not deny he was only a little disappointed, since his imagination would have to cooperate to draw the shapes hidden beneath the layers of fabric.

But it did not matter, the best part was in front of him, totally accesible to his sight.

Your face.

-Well, I am going to examine the state of your shoulder with a series of movements to evaluate its condition - You announced, while you positioned yourself in front of him.- It is important that you let me know if you feel any pain, since that way I will know what type of therapy will be the most appropriate for you, okay? -You looked into his eyes to get his approval, Simon looked back at you and nodded.

-Okay.

-Perfect, let's get started.

You took the wrist of his right arm, and raised it slightly while your other hand gently rested on Simon's affected shoulder.

-I'm going to move your arm in a circular motion.-You announced again to begin to make the movements, gently.- From one to ten on a pain scale, how do you feel it?-She ask him.

Nothing could prepare him when he felt the touch of your soft fingers on his rough skin. He had to use an effort to contain the small exaltation that his body emitted.

Until you began to move his arm in a circular motion.

The sensation that the movements caused on his affected shoulder reminded him of the reasons why he was right now here, the pain was not as intense as the days after his operation. But it was still very annoying, he tried not to let the pain be reflected in his gestures.

-Seven. -He confessed.

-Perfect. -You snapped. You left his arm in the original position.- I'm going to repeat the procedure with another exercise, the conditions are the same. -You assured him with your voice that he felt as velvety in his ears.

You took his right arm wrist again, except this time you gently bent his arm until you were directing his hand towards his left shoulder, where your other hand was resting.

To do this, you had to put your arm around Simon's back, who was a significantly larger person than you.

But the one who was aware of all this was him, who felt his breathing stop for a moment, as he felt your delicate arm surround the skin of his back, which he felt was getting warmer and warmer.

While your chest was only centimeters away from coming into contact with his skin.

After months and months of combat, where many times he faced each other in hand-to-hand combat, using the power of his strength to weaken the enemy or using his perfect technique in the execution of weapons, where many times his opponents responded with scratches, bruises, blows, or even bullets, like the last time.

This was the first time he felt how physical contact with another person... did not imply some kind of harm to him.

And suddenly he realized, he realized after all these events how much he needed at least some small kind touch after the sea of violence he subjected himself to day after day.

He felt his heart ache a little below his chest.

Simon looked back at you, and imagined how he took advantage of the position to take you in his arms and place you on his lap, while you allowed his mouth to finally capture yours in an almost suffocating way, but you responded in the same expectant way as he did.

-From one to ten on a pain scale, how do you feel? -Your voice takes him out of the perfect imagination in which he was submerged, he answered quickly to pretend he never imagined such scenes with you just a few seconds ago.

-Six.

-Perfect. -You answered with your warm smile.

And so the first therapy session with you passed, where Simon had to honor his good sense of self-control, and for the first time in his life he realized he was almost on the verge of losing it.

-Very well Mr. Riley, you can put your clothes back on now. -You kindly indicated while looking into his eyes, Simon did as you asked, surprised that time had passed so quickly- As I suspected, the injury from your wound does not present a depth that supposes a serious magnitude, fortunately -You went to your desk to record with your computer the physical examination that you performed in detail- Therefore, you have been prescribed two sessions of physical therapy including interferential therapy for five weeks starting next Thursday.

Next, you removed two copies of the prescription from the printer. You gave a copy to Simon, who was already dressed and in front of the desk, which he took very willingly.

-On the prescription, write down two painkillers that will help you a lot with the pain and the necessary doses.-You indicated.- That's all for today, we'll see each other next Thursday, Mr. Riley, take care, and if you have any questions, you have my phone number that you can call- You assured, then getting up from your chair and offering him your hand as a momentary farewell, which Simón gladly took.

Since it was the last trace of contact with the one he would have to survive until his next meeting.

-Thank you very much for everything, Dr. Eavanson. See you next Thursday.- He said in farewell, then opening the door that separated him from the outside world... From you.

Darkness had already fallen over the city, and Simon was inside his apartment with the light off, on his bed, ready to finally rest. He had already taken the medicine you recommended, and for the first time in months, his shoulder was no longer bothering him so much in this position.

With his head on his pillow, he began to think on today's events.

After thinking for a while, he discovered that what happened a few hours ago had never happened to him before, until he was under your touch.

And he didn't understand why, certainly the last mission was one of the longest he had had in his career, where the only people he saw daily were his teammates.

It is true that he couldn't remember the last time someone had touched him in such a delicate and kind way.

And well, he had already gone on long missions before... And he had also touched other women in the past, and they had touched him too.

But none of them caused him the slightest bit of what you did. Even though they had only known each other for less than half an hour.

And after thinking, and thinking without coming up with any logical answer, he simply stopped looking for an answer, and dedicated the last moments of his day to enjoying the beautiful moments he spent with you in the walls of your doctor's office.

And with that he posed a question that perhaps would never have a clear answer: How would you react... if Simon lost the self-control he had left?

What would you think of all the things he had done with you inside his mind without you knowing?

Without a doubt, he was going to attend all his therapies.

•••••••••••••••••••••••••••••••••••••••••

I'll be glad for any sugestion 💘.

M A S T E R L I S T

[f1-giuki]

97 and 8 for the mashups!!!

HI DARLING CAROOOOO💖💖💖💖 i love you so much mwah💖💖💖💖 97: Time Travel and 8: Hospital AU, hope you like this!!!!

mash up prompt list!

-

I was thinking about a choscar thingy! Maybe Charles works in a time travelling agency, where he has to fix the fuck-ups of people that go on a time-travelling holiday. Time Ensurance or things like that!

And Charles thinks it's a scam of a job, because why is he convincing Michelangelo not to sculpt huge ass dicks on his statues? He's not paid enough for it.

That gets worse when he gets punched in the face after trying to arrest a temporal criminal, and he is sent to the Hospital bc he may have a broken nose. Charles want to quit bc if he loses his preciously straight nose it's going to be the end of him, loser at a loser job with no skills.

Until...

He sees doctor Piastri, a young guy getting his specialisation in traumatology, and the doctor is all cute and slightly buff and tall, and with a nice accent, and all worried about Charles' nose.

Charles is obviously mad in love after Oscar tells him the thing is not broken, just very swollen. And Charles is nearly sorry for it, because it means he won't see sexy doctor Piastri a next time.

The next time obv comes, after Charles accepted a job trying to fix a mess made during the reign of Richard Lionheart and John Lackland. He goes to the hospital and he got stabbed this time.

Doctor Piastri runs to him and fixed his arm, and Charles flirts saying he was hurt in combat. And Oscar is all concerned as Charles badly attempts to flirt.

And the thing goes on and on and on, because Charles can't simply ask doctor Piastri out, that's embarrassing. Fighting against the Vikings and fistfighting hisbway through the hospital isn't.

Until Charles, after doctor Piastri patched him up again, goes to work and finds the agency closed and his boss arrested because he didn't protect the workers enough. And Charles is desperate because what is he meant to do now? How can he get to see Mr Sexy Doctor if he doesn't throw a few punches around?

Turns out in the little crowd that gathered in front of the agency there's doctor Piastri. And Charles is like fml I have to say goodbye to this complete package of a man!

But that doesn't happen, because Oscar confesses he was the one calling the police, because he was so afraid for Charles and the way they allowed him to getting beaten up badly every single time.

And Charles is like "BUT I DID IT FOR YOU! SO I COULD SEE YOU! but yeah the boss sucked ass" and Oscar is so confused and worried but so fucking smitten and he has that soft smile bc Charles likes him back!

So obv they date later, and Charles gets a cooler job at an Time Travelling Architecural Studies place and he's happy and he has a lot of kinky sex with doctor Oscar and he's not getting his bones smashed anymore!! That's a win!

[swiftsdelucaa]

So I hear you're taking Grey's anatomy x reader request? 😗

Any particular characters and rules?

Like say how would you feel about April x Jacksons sister! reader or the other way around? Maybe with fluff and teasing older siblings?

❛ 𝑻𝒉𝒂𝒕'𝒔 𝒎𝒚 𝒈𝒊𝒓𝒍! ❜

𝙋𝙖𝙧𝙞𝙣𝙜: April Kepner x Avery!f!reader ♡

𝘼/𝙣: Hi! I hope this was what you had in your mind, enjoyy :)

When Jackson finished his internship you just had to start yours. There had been a plane crash, and everyone seemed so strange.

Jackson was very sad about Mark and Lexie's death, he loved them both so much, this destroyed him. Well, you hadn't met them, but he almost always told you about them and you would have liked to meet them.

In fact, they weren't the only people he often told you about. April Kepner.

Those two were the closest friends you've ever seen in your life. He talked so much about her, insisted you should meet her, you almost couldn't stand her anymore even though you'd never seen her. But God, he was right. Even you would have talked about it constantly if you had known her before her.

It had been a short time since you had started dating and you were already crazy about her. Now she was an attending in traumatology and seeing her in action got you so excited. You loved every single detail about her, it seemed mutual, but she was also able to be quite strict with you at work. Oh she was so hot when she got angry.

Every night you loved to invite her over to your house, watch movies, or just hang out with each other all the time.

Your hands were in her hair as you lay on top of her and she kept kissing you softly.

"You are disgusting" Jackson sat down on the couch next to you with a packet of chips in hand.

"Excuse me?" you looked at him to wave him up and leave.

"This is my home too" he said. April threw a pillow at him causing the chips to fall out.

"Oh come on!" he complained.

"Did I already tell you how much I adore you?" you asked turning to April smiling at her.

"Well maybe not enough..." she replied placing your hands on her hips. Jackson turned on the television and turned up the volume so that it became annoying.

"Fuck you Jackson!" you exclaimed getting up in frustration and taking April by the hand going upstairs.

The next day you happened upon Jackson, who gave you an annoying smile as soon as he saw you.

"Goodmorning" he said trying to be normal.

"No please"

"What?"

"Don't say anything, just- shut up" you begged.

"It's not fair, you keep me from sleeping and I can't say anything?" he said teasing you more. It seemed like it was his favorite hobby teasing you.

"Can we just- work?" you protested rolling your eyes.

"Okay..." he said again having printed that horrible little smile.

"Plastic surgery wasn't even my first choice" you complained, changing the subject.

"And what are you passionate about?"

"I was thinking about general surgery... Or traumatology too..."

"Oh and I'm asking why..." he added with an ironic tone. You nudged his arm.

"Stop that!" hoping that this time he would really stop it, you entered the patient's room to analyze the case.

All you wanted all day was to see April again and feel her presence.

When this long day was finally over you went looking for her, and she seemed to have the same idea. You saw her in front of the nurses station.

"Hi!" you came up behind her and she whirled towards you placing a hand on her chest.

"God, you scared me" she gave you a little push.

"I'm sorry, well, how is going?" you asked giving her a little kiss.

"Good, you?"

"Besides Jackson, I would say good too, but I missed you" she gave you another kiss. You didn't mind being in public, in short, relationships of this type now are more than normal in this hospital, you didn't pay much attention to the fact that she was your boss. Why keeping it a secret?

Unfortunately for April the day wasn't over, but as usual you would have seen each other tonight.

She came back quite late, she looked very tired. She threw herself on the bed.

"I can't move any muscles anymore" she said with her head buried in the pillow. You approached her putting your arm around her waist hugging her. You kissed her cheek. "Goodnight baby"

"I love you" she said as she turned towards you meeting your eyes.

"Mee to" you smiled at her.

Yes, once she was your brother's best friend, his girl, but now she she is yours. She is your girl.

[acelizystudying]

LAST DAY OF 2023 DUMP & CHECK:

• it was literally the hardest years in my life. started with visiting bestie every 2nd days at traumatology ward and praying for her coma’s end, and ending the year with celebrating NYE with the same bestie! the hardest thing was in this whole procedure (expect my suffering with irritable intestine syndrome and insomnia, also the disgust which i started to feel about my place at the healthcare system, i wanted to instantly quit) when my friends was gone because we hoped in bestie’s improvement when she was in vigil coma, and yes, i was selfish because for me some love life shit wasn’t enough problem to think about when my best friend was in a coma and was in between death and living. continous reading articles and researches about comas and traumatic brain injuries, looking through her medical stuff, cry above them… it was truly hard. but she woke up and she’s in the path to full recovery. i lost literally my old friend group’s 90 percent, but i’m not mad about it. they literally left me in the best possible time, also my bestest best friend is with me still. our medical miracle🤍

• after 3 years suffering with applications into medical school, i gave up and ended up in engineering. medicine was a forced destiny for me, after 21 years of my life i realized, it’s not for me. i knew that it’s totally okay to quit a path which isn’t for you, bit i was scared, because the other way was too new. but! to be honest, i’m the happiest alive studying in that major! i have a lot of interesting classes, yes i have difficult times to understand calculus 1 and programming, but even with the little disappointments i’m so sure about my place there. i found my best mates in molecular bionics class, we are a big family together! i can’t be more grateful for them to appearing in my life after all of this 2023’s shit!🌞🦾

• also, i had an opportunity to start working as a pre-thesis work at a lab that works with microglias and investigate about brain and neuroimflamattory, overall i have a huge chance to be a part of some amazing experiments and researches about the mice/human brain!!🐁🧫

• i’m not very sure about what i wanna do or not to do in 2024 (get well in school, being there to every best friend, find a job, studying a lot at lab, etc basic things) but i hope that i will have some kind of like 2023 was, but please, without the hospital visiting part!:D i’m so glad that i’m here, nothing is perfect, but i have everything what i want, so just don’t mess up this circle, 2024!✨🌻

[bigwishes]

hi! I just found your blog recently. he's amazing! I love the topic of desires and what they can turn into :) Can I ask for one wish too? I am a 24-year-old Slavic guy with an ordinary build who has just graduated from a medical university. I've always dreamed of working in traumatology, but unfortunately, I'm not strong enough to move injured patients or perform operations that require strength and endurance. Could you make me more suitable for such a profession?

that is definitely a noble wish indeed. Wishing for strength and muscle not for vanity or but to help others, truly inspiring. I like to think I help others myself, giving them what they both ask for and need, even if it isn't exactly what they want. So I think I'll help you out too.

You said you had an ordinary build? well I think its time we push that to more of an extraordinary build. That means packing some meat on your bones bro. Don't worry nothing too ridiculous (unfortunately) but you'll find yourself headed into the gym after each shift, on your days off and hell you'll probably be doing push ups and sit ups in your break times too, we gotta make sure your body stays in tip top condition for work.

Looking good, but we can do better and by better I of course mean bigger. Again we need to keep your mobility in mind but I also want you to be able to lift up any patient on your own. Ive also done a quick change to your work place uniform policy, you are nolonger required to have your shirt buttoned all the way up and that's just so you don't get written up. Your pecs are gonna make sure the top buttons on your shirt can't close, and don't try to force it I'd hate for a button to fly off and hit someone in the eye.

there you go, bulging biceps and pecs to handle anything your work throws your way, but I think it's time for one final change. You made this wish to dedicate yourself to helping people and I think we'll ad an insurance policy to make sure you don't run off to make money with your body, or get too distracted having as much sex as possible.

You might feel a butterfly sensation in your pelvis but don't worry about that it's just the magic shrinking your dick all the way down, not much bigger than a one inch hard on I'd say. That should keep you from getting too horny and will definitely keep you from fucking every nurse on your floor, but what about them fucking you? hmm all that muscle did give you an ass that fills out those pants. Well to solve that I think we might add some more muscle there, make it as tight as possible, so tight a guy wouldn't be able to get his dick in there even if he had the jaws of life trying to pry it open.

And we're all done with your own operation today bro, the perfectly muscled body to comfort and lift any patient and do anything your job demands effortlessly, and as a bonus the forced sexless lifestyle to go with it to make sure your selfless wish stays that way and you remain dedicated to your job 24/7. enjoy.

[literaturepublishersjournal]

Journal of orthopedic case reports publishes Images in Orthopaedics Case Reports Journal, Orthopaedics Journal, Case Reports in Orthopaedics etc. Journal of Orthopaedics and Traumatology Case Reports provides an equal platform to orthopaedic based medicine as well as personal experience and every case report should reflect these important concepts.

[colourfulwatson]

University is being so tough lately that I haven't even made a post about it yet...... anyway tomorrow I have a traumatology exam at 15:00 :')