Missed a fracture

[Buggus]

I'm feeling so deflated right now. On Friday, I had a teacher send me a student to get checked out after falling off the monkey bars. She hit her right arm so I checked it out. No complaints of pain, I touched her arm up and down and she denied pain and had no signs of pain on her face whatsoever. There was no swelling, no redness, no bruising, no changes in color. I did some exercises with her to test her ROM and she had full ROM, once again no signs of pain with movement. There were no changes while I had her there in clinic and the arm looked completely normal and equal to her other arm. So I gave her ice and sent her back to class and wrote on the pass for the teacher to send her back if she had any complaints. I did not call home as nothing in the assessment seemed abnormal and the student had no further complaints for the rest of the day. Mom comes in today yelling How did you not see her arm was broken? What kind of a nurse are you?” and all kinds of other stuff. Mom says that around midnight (12 hrs after the incident), she saw that her child was trying not to use her right arm and noticed that her forearm was white. She took her to the ER and it turns out it was fractured. I was truly shocked to hear this…the principal and teacher came in and we sat down to discuss the incident. I had my documentation with me and showed the principal and the mother. The principal agreed that I had assessed fully and appropriately and followed protocol and told mom that I don't normally call home for every bump/fall/pain and that based on my assessment, there would not have been a reason to call home. The teacher supported my findings by adding that the student not only had no complaints for the rest of the day (3 hrs) but that the student was also doing all her classwork/writing/coloring with the affected arm (she's right handed) and was doing so without difficulty and she had not seen swelling to the arm. The ER doc apparently told mom that the fracture would've bubbled up” right away so I guess this made mom feel like her child came in with all these obvious signs and I just ignored them when in reality this student had absolutely no signs at all and the assessment was normal and she even continued to function normally in class. Oh by the way, another reason mom's extremely upset is that the ER called CPS on her over the situation…

I just feel so terrible about this. Terrible because this poor little girl went 12 hrs with an untreated fracture and terrible for mom who now has CPS on her case. We told her we'd back her with whatever documentation CPS needed to explain that the injury did indeed happen at school but that doesn't take away the stress of the situation right now. I also am afraid of what this means for me…but at the same time I feel like I assessed properly and, short of having xray vision, there would've been no way to know it would turn into all this. I don't normally call for every fall on an arm, leg, knee, elbow, etc, when everything else in the assessment looks normal, but now I think I will just in case it could be a fracture.

[OldDude]

Don't beat up on yourself with Monday morning quarterbacking. I'm completely confident in your assessment and intervention. I would have done the same thing and would not have notified the parent. Besides, something doesn't add up here. You're not getting the full story. I suspect something else happened after school and you're taking the heat. Why on earth would CPS be called over a kid falling on the playground and mom seeking medical attention for it? Happens all the time and CPS isn't called for that. Let us know if you ever get the real story.

[lhflanurseNP, APRN]

When I was young, I broke my wrist. My father, a MD did not catch it. No one caught it until 3 weeks later when it started to swell! Don't fret. This is a good learning tool that falls need further investigation...like x-rays.

[djh123]

Sounds like you did everything right. I agree with OldDude - that maybe you didn't get the whole story.

Or here's another possibility (maybe not very likely, but still). If the fracture was hairline, and the kid accidentally did something to the arm *after* leaving school, and made the break worse, and THEN had swelling/etc. ... that's not exactly what happened when I broke my collarbone a long time ago, but it's somewhat related.

I also had a resident who had a very fine fracture that had no s/s of pain until the next day.

[kidzcare]

You're not getting the full story. I suspect something else happened after school and you're taking the heat. Why on earth would CPS be called over a kid falling on the playground and mom seeking medical attention for it? Happens all the time and CPS isn't called for that. Let us know if you ever get the real story.

Absolutely. Something is not adding up here. Kids break bones all the time with no call to CPS. I don't think you posted the age of the child, but if she is in school and able to play and do school work, she is old enough to say to the ER staff "I fell at school, this did not happen at home". Something happened that they didn't buy the story mom was trying to sell. Or mom is lying about CPS.

Related side note- my daughter broker her arm in May with no call to CPS. She was at the park (with no adult supervision) and fell from a tree. I arrived 2 minutes after she called me (thank God for cell phones!) and called an ambulance. Not once did anyone question our story. Really makes me wonder what happened that someone would doubt this mom's story that the injury occurred at school (especially when that can be so easily verified by calling you or the teacher).

[kidzcare]

Oh, one more thing-- WE ALL MISS FRACTURES!!! This may be the first time, but it's unlikely to be the last. I sent a kid out to field day with a hairline fracture to his lower leg. I was shocked when I found out the next day. He was a major drama kid- sat in my office with ice for 10 minutes and then asked to go back to field day. Many staff members saw him jumping rope and going in the bounce house for the rest of the day.

I have also sent out injuries that I was 100% certain were breaks and ended up being sprains.

[BeckyESRN]

That feeling of "I should have known" is the worst! You did everything that you could do. The assessment was negative, the student didn't return, there was nothing else to be done. Until those X-Ray specs from the back of the comic books start working, we are all relying on our skills and our "gut feeling". You did good:)

[Supernrse01, BSN]

There is definitely more to the ER story, if CPS was called. I can tell you that my own child has broken her arm(s) 4 different times. YES 4, and never once has CPS been notified.

I am so sorry that happened but trust me, it has happened to all of us. I missed a fracture my very first year as a school nurse. Use it as a learning tool. In my experience, it is better to just call and give the parent a "heads up". I normally just give them a brief rundown of what I have assessed and end the convo with something like, "I just wanted to be sure you were aware in case your child has more complaints later this evening." You did a great job with your assessment and your documentation, btw! Don't beat yourself up!!

[offlabel]

Any prohibition on taking pictures for documentation purposes? It'd be a good way to show what the arm looked like in the morning vs that night.

[JerseyTomatoMDCrab, BSN]

I had a very similar situation at the end of last year. Of course, my AN buddies made me feel better but it's still an awful feeling.

The CPS thing is causing me to scratch my head and it sure isn't lice. I've sent out a few fractures and had ones go to the ER after school but never heard of CPS being involved. Maybe during the X-ray they found some healing fractures of different degrees on the same arm. That's a red flag as far as abuse goes.

I KNOW how awful you feel. It sucks! But it will pass. Try to focus on all the good you do for the kids at your school. You'll feel better with time, promise.

[OldDude]

I've told this story on myself before but now is a good time to tell it again. Many years ago when the kids would come in for complaints of pain from injuries that offered no sign of trauma I would give them an ice pack and tell the to "bring it back when it stops hurting." My idea was I would plant the seed that the ice pack was going to make it stop hurting and all would be fine and dandy. Sometimes they would remember to bring the ice packs back and sometimes they wouldn't. Well I got a call one Monday from a dad who's son I saw in the clinic the previously Friday for a thumb injury from recess. I had not notified him of the injury. He said his son had told him I had instructed his son to bring the ice pack back when his thumb stopped hurting and that's what he did. His thumb never stopped hurting so he took the warm ice pack home with him, told his dad about it, dad went to ER for x-ray, and found out it was fractured. From that phone conversation with that dad forward to today I say..."bring the ice pack back when it's not cool anymore and let me know how you are feeling."

[bgxyrnf, MSN, RN]

Only one way to determine if there's a fracture and that's by radiological studies. Whether irradiation is warranted is determined by the clinical examination. It sounds like it was initially unwarranted but later presented itself.

However, the CPS thing is suspicious. There's nothing about it that should have provoked a call to CPS... unless there is a history of which you're unaware or that the injury which presented at the ED was different than what presented to you.

You did just fine.