Missed a fracture.

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7th grade girl came in, banged her hand in gym. She had no swelling, good movement, good hand grasps and low pain level. I gave her ice since hands tend to bruise and sent her on her way. She came back later in the day holding her hand like a wounded baby bird.

I called her parents immediately, but ugh. They are not easy parents.

I feel like an idiot.

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Specializes in Peds/Neo CCT,Flight, ER, Hem/Onc.

What! Was your x-ray vision broken that day? I hope you got it fixed immediately!!!! ;)

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My best friend who is not a nurse said the same thing. Thank you.

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Hands/feet are tricky!!! I have been fooled before. You did the right thing.

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Specializes in School nursing.
What! Was your x-ray vision broken that day? I hope you got it fixed immediately!!!! ;)

THIS. Seriously, we are human and fractures in kids can be tough. They can compensate well and sometimes evidence of a fracture isn't seen until 2 days later. I have gotten to the point where I am presented an injury and asked "is it broken?" and I answer with "well, my x-ray machine is out for repair so..." Don't beat yourself up on this one at all.

Ugh on the not easy parents though. I have some parents I will call for every bump because if something like this happens, I will hear about it...:banghead:

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Specializes in Emergency Department.
7th grade girl came in, banged her hand in gym. She had no swelling, good movement, good hand grasps and low pain level. I gave her ice since hands tend to bruise and sent her on her way. She came back later in the day holding her hand like a wounded baby bird.

I called her parents immediately, but ugh. They are not easy parents.

I feel like an idiot.

It's easy to miss fractures if they're greenstick/non-displaced. They may not present with much swelling, have good movement, have good hand grasp, etc because the bones are still partially intact. I was trained as an athletic trainer and athletic trainers use a few more techniques to help rule-out fracture. If I have a tuning fork, they can be quite helpful and usually even greenstick fractures will be come apparent with this. If not, I sometimes will tap the bones along the longitudinal axis. Any increased pain means there's damage, and a fracture is suspected because tapping shouldn't cause any pain whatsoever. I just prefer the tuning fork because you can put the handle on small bones and test them specifically.

Fortunately for some fractures, the treatment is exactly the same as a sprain... just splint it. Casting is not always necessary.

Oh, yeah: don't beat yourself up over missing a small fracture... even with the advanced training that I have in this area, I miss them too. Sometimes those darned fractures can only truly be seen on an x-ray and sometimes it takes a very, very experienced radiologist to find them.

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Don't beat yourself up on this one. I am an orthopedic nurse practitioner and I get surprised ever few weeks by an X-ray that I would have sworn was going to come back negative.

In someone in her age group so long as there was no tenting of the skin or pulse, motor or sensory deficits she is going to be just fine.

Using a a tuning fork has limitations and isn't sensative enough to completely ruin a fracture.

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No worries my friend :yes:. You absolutely did the right thing. If a student comes to me because they banged a limb I usually see if they can move it. If the ROM is intact I give them ice and tell them to return if swelling occurs and/or the pain is too much to handle. I have called parents on a few occasion because the pain was too much to bare as per the student. When I first started one of my 7th graders banged her hand in the locker. I called even though it appeared minor (plus I was super brand new and figured that was the right thing too). Turns out the student has fractured that same arm every year. The student continued on with her day but, low and behold the next day the mom calls and tells me it was indeed fractured again. That was sheer luck on my part but, now I am not so quick to call unless the student is super uncomfortable or the limb looks suspicious (swelling, discoloration, limited mobility). Parents can be tough to deal with but, we can only do our best with limited resources and they fail to understand that while also thinking that their child is the only student you care for in a school with over 1200 kids and 1 lonely nurse (that be me!).

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Specializes in Pediatrics.

Don't worry, you notified the parents the same day right?

My a year ago my son was at summer camp (14y/o) he fell off the rope swing, hurt his ankle, went to the camp nurse, she gave him IBU and ice. He went back to the nurse multiple times over the next 2.5 days.

She gave IBU and ice each time, never got a call

When I saw him 3 days later his foot was twice the size of his other one black and blue, but he kept on walking on it at summer camp.

His ankle was broken in 3 places had to have an ORIF with 3 pins.

So if you re assessed and notified the parents the same day don't worry about it.

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Specializes in Community Health/School Nursing.

Kids are so hard to figure out! You will have kids walking around on a fracture with minimal pain. We only have so much to work with in our clinical setting and you did everything you knew to do. At that time there was no need to call parents or send her home....when she came back you did exactly what you should have done...called parents. I have a 3rd grader who fractured her ankle when a door closed on it. I wasn't at school that day but the teacher said there was no swelling and she was walking pretty good and said she wasn't in much pain. That night per parents she went to gymnastics class and practiced for an hour on that ankle. At the end of the class she finally broke down and cried saying her ankle was hurting. Her parents just thought she was being dramatic but took her to the doctor the next day for xray. Yep, a nice little fracture. They put a cast on for 6 weeks and then a walking boot for a few weeks after.

Again, kids show signs of pain differently. Not all fractures swell or cause significant pain. We just do the best we can! Hang in there!

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Specializes in LTC.

When a camp nurse I saw a boy that had fallen and hurt his arm. Same thing good movement, no swelling tender but not painful. I told kid and counselor, if it gets worse come back. Next day kid comes back with swelling pain and bruising. I felt horrid. Mom came and picked kid up and sure enough....fractured. Kid came back to camp later that day in a cast!

Often times fx's don't present themselves immediately.

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I am on the same page as everyone else! These things happen!

I have had situations go both ways-- Thumb swelled up instantaneously, no ROM, called parents saying to pick kid up and have it checked immediately.

Then last year on field day had a kid (huge drama kid) fall and I had him up and walk inside with me and ice it. He asked to return to field day and I had him go. His teachers confirmed he was outside jumping, running, ect and next day, mom called and said he came home with it swollen up and turns out there was a fracture. She wasn't upset (I had called to say that he had gotten hurt but seemed fine).

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