Missed a break

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A student came In today after falling in PE and twisting his ankle. I kept it iced and elevated for 35 min before sending him back to class. No swelling or bruising noted. I told him to come back at the start of his lunch recess (approx 15min later) for more ice. He came back 3min after recess was done. No swelling so he got sent back to class quickly. Told again to come at the start of recess. Teacher called to say he was not a complainer and was crying in class. Brought him back to the office and there's notable swelling and his ankle has started to get discolored. Parents came to pick him up and hour later and took him to the we for X-rays. Hairline fracture to the growth plate.

I hate that I basically dismissed him for the bulk of the day. I don't know what he did on it during his lunch recess, he said he rested. No way to know if it was broken in pe or maybe aggravated at recess. Being a nurse and not a doctor I know I'm not supposed to diagnose but I can't help but think I missed this one. How do you handle this?

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Specializes in School Nurse, past Med Surge.

You don't have x-ray vision (do you?). How was he walking initally? How was his range of motion? I missed a wrist fx this year. I also sent a kid off for x-rays that turned out to be just a sprain. Of course you feel bad, but it sounds like you handled it the same way most of us likely would have. In the end, you called the parents & he got the treatment he needed. It's unlikely that the few hours lag did any damage. Don't beat yourself up over this.

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Specializes in school nursing/ maternal/child hospital based.

It happens to all of us. Don't beat yourself up!!! I always joke with parents, I say" If I could have one super power as a nurse, it would be to have x-ray vision."

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Specializes in school nursing, ortho, trauma.

Don't dwell on it. Some fractures are very obvious. Some are tricky. If it wasn't swollen or bruised and he was feeling better after 35 minutes in your office and able to walk on it, then most of us would have probably told him the same thing - come back in a bit so i can check it again.

My rule of thumb is that if they are still complaining after 20 minutes of ice (meaning "does it feel any better" student: *cuing up the dramatic music for i think i broke it, the musical* "NO") then i call right away and give the parents an FYI call. If the student states it feels better, i tell them to return in a bit. I call the parent after the second visit anyhow. I've been burned too many times. Not necessarily by missed fractures, but by parents not getting calls for minor "hit by the ball" or "bumped arm into wall" and i didn't queue the medivac. (same parents, for the record that are impossible to get when their child MUST be picked up because they are running a raging fever)

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Specializes in Pediatrics Retired.

I would handle it just like you've already handled it. If it was hurting the kid would have let you know. If there's nothing to see there's nothing to see; until there was something to see. It could be the PE injury was aggravated by participating in recess and it could be the recess injury was a separate incident. But...you don't know so you're interventions were based on your assessments - that's it, end of story. Other than being able to foresee the future, what could you have done differently based on what you saw at the time?

OK, so you've already beat yourself up enough...let it go, and move on.

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Specializes in ICU/community health/school nursing.
Don't dwell on it. Some fractures are very obvious. Some are tricky. If it wasn't swollen or bruised and he was feeling better after 35 minutes in your office and able to walk on it, then most of us would have probably told him the same thing - come back in a bit so i can check it again.

^ That. ^

I had one like this a few years ago - teenager with no appreciable swelling, slight gait impairment, did not rest, did not elevate like I told him to, and did not check back in after lunch. Then went home with an ankle the size of a grapefruit. And his mom SENT A PICTURE to the principal with a caption - "We're at the emergency room now."

The principal and I reviewed my documentation, which was intact....but from that day on, I've called for everything ortho that happens on campus, even when the kid leaves "in no acute distress." Hang in there! You really didn't "miss" what you can't see.

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Specializes in School nursing.
^ That. ^

I had one like this a few years ago - teenager with no appreciable swelling, slight gait impairment, did not rest, did not elevate like I told him to, and did not check back in after lunch. Then went home with an ankle the size of a grapefruit. And his mom SENT A PICTURE to the principal with a caption - "We're at the emergency room now."

The principal and I reviewed my documentation, which was intact....but from that day on, I've called for everything ortho that happens on campus, even when the kid leaves "in no acute distress." Hang in there! You really didn't "miss" what you can't see.

This.

I've also sent out for x-rays for things that turned out to be a severe sprain. It happens. If the injury happened during gym, though, I will usually give an FYI call home to a parent. Swelling can happens hours or even days after an injury and kid compensate well. Don't beat yourself up about it at all!!

Flip side: I've seen more than 1 student enter my office on Monday with an ankle or wrist swollen like a grapefruit. Injury usually occurred on Saturday or Sunday. No swelling until they woke up this morning, and parent told student to "see the school nurse." And then I call home and the parent will say "but do really think it is broken?" Um, I have no idea, my x-ray vision is non-existent, so you need to take your child to either urgent care or the ER. I've even had a parent assume I could x-ray it at school. C'mon now!

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Ha ha ha! "But do you really think it's broken".

No it's broken for fake... Jeez be late for your appt and take him to the doctor..

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Not saying you did anything wrong but next time if there is swelling, call the parents asap and don't let the kid go back to class. Ask the parents what they want to do and then go from there. I have gotten calls from the school on things that I feel are silly but it could be serious so I am glad for the call. With swelling, it means something is going on underneath, you usually won't be able to see or feel what it is, so don't put all the pressure on yourself to take care of stuff without the proper equipment etc.

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Specializes in Pediatrics Retired.
Not saying you did anything wrong but next time if there is swelling, call the parents asap and don't let the kid go back to class. Ask the parents what they want to do and then go from there. I have gotten calls from the school on things that I feel are silly but it could be serious so I am glad for the call. With swelling, it means something is going on underneath, you usually won't be able to see or feel what it is, so don't put all the pressure on yourself to take care of stuff without the proper equipment etc.

Just to clarify...calling the parents when the child presented with swelling of the ankle is exactly what she did. Prior presentation that day revealed no abnormality.

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Thanks for all the support. The kids dad is pissed and questioning my skills at diagnosing. Assumed that because the sock was on when he got there at the end of the day that it had never been off. And assumed it was swollen when he came in. He emailed the teacher all of this.

She supported me and suggested he email me with any problems. Explained to him that there are 600 kids in the school and how are we (the nurse and health aide) supposed to know that his kid is a tough kid that knows hurt vs an injury.

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Specializes in School nursing.
Thanks for all the support. The kids dad is pissed and questioning my skills at diagnosing.

What the what? Nurses don't diagnosis, parent. It is not in our scope of practice. Some parents are just...ugh.

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