Second-guessing myself

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Wednesday at 1:20 I had a 3rd grade student come in bawling and holding his arm after a fall on the playground. Initially he was able to move it and squeeze my fingers, but after about 20 minutes he said it hurt too much and refused. He was crying and yelling the whole time he was in my clinic, about 40 minutes, saying it hurt too much. No swelling, no blood, no bruising, no obvious breaks, full cap refill, etc. Instant ice pack applied, after about 15 minutes it was warm to the touch and his skin felt warm too, so I gave another one.

I called parents after about 10 minutes (when it became obvious he wasn't calming down), but they didn't get there until 30 minutes after I called. He'd calm down a little while walking (to get his bag) and when I told him he couldn't have water while crying due to risk of choking, but as soon as another person appeared the screaming would start up again. His dad said "he's a little sensitive," but he hadn't come to my clinic before now, so I had no idea what he was "normally" like.

Well long story short, he's got a fracture just above the elbow, still not back at school because the children's hospital has done two temporary casts and is doing a permanent one today. I feel horrible, like I should have told dad "take him to the doctor RIGHT AWAY," or at least "give him some ibuprofen RIGHT AWAY," but I didn't. I just keep thinking over it, wondering if there was something I was missing that would have told me he definitely had a break, something I should have assessed but didn't.

On the other hand, this is my first year as a school nurse, and my first fracture at school, so maybe I'm just being too hard on myself and need to take it as a lesson for the future? I don't know. Any advice would be much appreciated.

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Specializes in kids.

Sounds like they took him to the MD anyway so ease up on yourself! You called the parent and they him picked up, I would be more concerned if you had not called and kept him in school that day.

My mantra is "I cannot tell if it is fractured-if he is no better I would call your PCP and/or go to the ER"

Seeing the PCP or seeking emergent care is always an option (or directive)

Have a great day!

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Specializes in Complex pedi to LTC/SA & now a manager.

You called parents within 10 min. Parents came and took to doctor. Ibuprofen recommendation likely wouldn't have helped as needed fracture care.

With little ones fractures don't always present the way you expect....if a non displaced the fracture may not be evident until a second x-ray taken a few weeks later when bone healing is visible. Ask me how I know....

A few years ago I was leaving for work on a Thursday. There was a thump from my sons bedroom. He & and my mom were being silly as he got ready for school (he had about 1.5hrs before the bus was to arrive. I ask what happened, is everyone ok? Of course "nothing. We're fine" is called to me by mom & son.

I'm at work with my pedi home care patient. Get the first call that 4th grade son is in nurses office complaining of shoulder/arm pain, ice applied. No swelling. No movement restriction. Appears to be at baseline for motion. I asked and he was supposed to be taking a test (he has special needs and a tendency for work avoidance when he is anxious about tests. He also has an altered perception of pain) nurse says nothing obvious. Barely wincing. Do you want to get him or send him back to class? Spoke with para, back to class.

Second call a couple of hrs later from nurse....he's back. Says that "I know" what happened. So he's put on the phone. I ask for details now he claims he was pushed ( in play ) out of bed by my mom & hurt his arm/shoulder. I ask if ice helping ( yes). Nurse reports exam WNL. Not even obvious tender to touch. He won't take pain killers. So he chooses to go back to class. Nurse says he can take ice pack to class.

Saturday...asks to go to doctor. Pedi sees mild tenderness and mild swelling. Go for X-ray just in case. OTC pain offered (son refuses as DARE says don't do drugs...whatever). X-Ray nothing obvious. Son still complaining so pedi refers to ortho as my kid almost never complains of pain (had a strep throat so swollen he was drooling/ couldn't physically swallow and swore it didn't hurt)

Pedi ortho now 7 days post fall. Agrees original x-Ray is equivocal. Repeat x-ray evidence of distal clavicle fracture with edema in the shoulder joint. The PA-C was awesome. My mom insisted we were nuts and he couldn't possibly have a broken bone as it hurts so much more (she broke same bone previously). PA-C called my mom with a smile to tell her that she did in fact break her grandson.

Upon return to school the nurse called apologizing that she didn't catch the fracture. I reminded her she did what she could and notified me. There was no obvious abnormalities on exam. My son has unique issues. She followed standard protocol and even made extra calls due to my son's unique challenges. & needs.

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Wow, that is wild that it took a week to show up on the x-ray!

You guys are right, I did what I could I guess. I think I'm going to keep repeating that phrase to myself - "I cannot tell if it is fractured-if he is no better I would call your PCP and/or go to the ER" - so I can use it next time. I'm never quite sure when talking to parents what's going beyond what I can say -- very poor population, so if I recommend a doctor visit and it turns out to be nothing I'm going to have very angry parents for spending $$. But I don't want to NOT recommend either.

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Specializes in Complex pedi to LTC/SA & now a manager.

You can choose your words "Johnny is complaining of arm pain and is crying difficult to console. I requested x-ray vision last birthday but it didn't come through so I cannot tell if there is a break or other serious injury. You can call your pediatrician for advice or an appointment to find out what is going on"

Even low income kids are usually covered by CHiP/Medicaid. Though in most areas a non life-or-death illness/injury requires a call or visit to PCP before going to the ED. Many of the clinics that accept CHiP in my area have lab. & X-ray on site (to increase follow up/ patient compliance with testing as well as increase revenue as the HMOs give bonus points for offering one stop shopping). I know the school nurses in my area can admin OTCs under physician protocol & parent permission but cannot advise a parent to give a child OTC pain meds as that is a treatment. The nurses recommend follow up with PCP or specialist. In some areas the school nurse can assist the family in getting an urgent appointment by calling the PCP (similar to a PCP office calling a specialist to introduce a patient & getting a quicker appointment)

I'd check with school protocol about what you are permitted to recommend to parents other than consult PCP, call 911, Suzie failed the vision screening & needs follow up with an eye doctor

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Specializes in school nursing, ortho, trauma.

with no obvious signs of fracture, all you can really go on is level of pain. You made this determination within 10 minutes and the child was out of your office in under an hour. I'd say you did everything right. Don't be so hard on yourself.

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Specializes in Acute Care, CM, School Nursing.

Those little bones can be tricky!

My daughter fell while jumping over the baby gate, when she was in kindergarten. Complained of some arm pain for a few minutes, but nothing crazy. She even laid down on the couch on the side that the hurt arm is! I figured she had to be OK. No swelling, no bruise, she was moving it. She didn't make another peep about it until the next afternoon. I was putting her jacket on, and she told me she couldn't move her arm back, to put it in the sleeve. I asked if she was serious, she said yes. Took her to urgent care. She had a buckle fracture! I felt like the biggest jerk. But the doctor there told me that often with a buckle fracture, the child doesn't complain of pain until the next day. That was my lesson in pediatric bones. LOL

I think you did everything right. :)

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Broken bones are one of the tricky things in our business. We often see kids right after the accident and often even swelling hasn't started. If a child does not settle down about the pain quickly I always call home and let them know about range of motion, strength, inability to console and tell them I unfortunately cannot tell if something is broken but they may want to get it checked out. I make the referral and then the parent can decide. With my own child he fell out of bed, cried, but could move his hand/wrist/arm and was complaining of pain but not major, He had no swelling or bruising. We iced it and he sat and watched tv and then fell asleep. The next day he complained that it hurt worse but could still move it freely, no swelling or anything but I said I think it might be broken. Took him for x-rays and sure enough broken radius and ulna straight through and displaced, a total wreck in there. Without a picture you can't know what's going on in there. You did the right thing.

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I had a ximiliar situation except I failed to call the parents. There was no visible injury but the kid ended up with a fx to his middle finger. I never made that mistake again! From then on I always call the parent and advise them to nave the child seen by their PCP. Lesson learned.

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Specializes in kids.
I had a ximiliar situation except I failed to call the parents. There was no visible injury but the kid ended up with a fx to his middle finger. I never made that mistake again! From then on I always call the parent and advise them to nave the child seen by their PCP. Lesson learned.

Finger fracture can be very deceiving....cannot tell you how many times kids "jam" their fingers....all good in a day or two....but sometimes they require surgery....I hate that I missed that one.....

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Specializes in Community Health/School Nursing.

Just a little bit of info to keep in the back of your mind if needed: It is very common for a child to complain of pain in the antecubital area if there is a fracture present. Our ER informed us of this and also we had 2 children with an injury in our district whose only complaint was antecubital pain and they both had arm fractures.

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Well it's hard to diagnose a fx without an xray... and remember you cannot diagnose anyway! You called the parents, which is what you should have done. I've had similar things happen, I've taken to calling parents more when kids come in for sprains/strains/bones just so I can say I did my due diligence just IN CASE the kid has broken something. Because right after an injury happens you often can't tell what's going on just by looking at it. I had a kid last week that came in for having his hand shoved against a locker (2 9th graders horseplaying in the hallway) and he wasn't even in that much pain, not even swollen. I called mom and she wanted him to stay in school - it was the end of the day anyway. He ended up going to ED with his grandpa that evening, and later went to an orttho, and they "think" he fractured a growth plate in his arm, but even the xray is showing no fracture. So how could I, with 0 diagnostic equipment other than my eyes, have been able to tell!? You did everything right, you're fine :)

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