Missed one

[WineRN]

I am still new but I feel like I'm pretty good at screening out my fakers. I've had a little boy be sent to me every day this week for a sore foot. He was playing around at home and fell down the stairs. Normal ROM, no swelling, and most importantly I saw this little one doing jump rope in PE without ANY signs of pain. I spoke to his mom the first day and she was asked if I thought she should get checked out and I said no (because of the reasons above).

Guess who just came into my room escorted by her teacher who announced "Let's show the nurse what we have on our foot!" He has a boot on and supposedly has "multiple broken bones" per the teacher. I still haven't received any paperwork but I now feel a awful for missing it.

[OldDude]

Update: Student did have a fracture. I received a fax from the doctor's office today. "Salter Harris type 2 fracture", no restrictions, boot for 3 weeks before following up with ortho."

NO - something still ins't right. You'll never have "no restrictions" for a Salter II. That's a fracture across the growth plate and involving the metaphysis too. Usually gets casted after a few days to allow for swelling reduction, NWB.

[JenTheSchoolRN, BSN, RN]

NO - something still ins't right. You'll never have "no restrictions" for a Salter II. That's a fracture across the growth plate and involving the metaphysis too. Usually gets casted after a few days to allow for swelling reduction, NWB.

THIS.

I just had a kid with this type of fracture. He was in a boot, yes, but also on crutches and non-weight bearing for 3 weeks before a repeat x-ray. He is still in a boot and is weight-bearing now, but it is 6 weeks post initial injury.

[ruby_jane, BSN, RN]

Old Dude, I bow to your knowledge. Also I was kind of impressed that the parent didn't just boot the kid up themselves but it sounds like you have more questions than answers now...

[WineRN]

NO - something still ins't right. You'll never have "no restrictions" for a Salter II. That's a fracture across the growth plate and involving the metaphysis too. Usually gets casted after a few days to allow for swelling reduction, NWB.

I called as soon as I looked up what the fracture was, no call back from office.

Both of the parents work in the hospital where the child was seen (non medical roles), so I do agree there is something fishy about all of this

[djh123]

Jumping rope w/no s/s pain and 'multiple broken bones' in a foot. Uh-huh...

[GrumpyRN, NP]

NO - something still ins't right. You'll never have "no restrictions" for a Salter II. That's a fracture across the growth plate and involving the metaphysis too. Usually gets casted after a few days to allow for swelling reduction, NWB.

Sorry OldDude, I am going to disagree with you. I would put in moonboot with ortho follow up. No crutches and weightbear as able. Definitely would not be casting.

I was reading this and calling BS on the "multiple fractures" in the foot while no swelling/bruising and fully weightbearing.

If the child attended me as an ENP I doubt I would even have x-rayed. I would have sent home with advice.

[OldDude]

Sorry OldDude, I am going to disagree with you. I would put in moonboot with ortho follow up. No crutches and weightbear as able. Definitely would not be casting.

I was reading this and calling BS on the "multiple fractures" in the foot while no swelling/bruising and fully weightbearing.

If the child attended me as an ENP I doubt I would even have x-rayed. I would have sent home with advice.

Since I consider you my UK brother from another mother I think it's healthy for us to have different opinions about some stuff. Disagree, argue, agree to disagree and go have a few pints.

[GrumpyRN, NP]

Since I consider you my UK brother from another mother I think it's healthy for us to have different opinions about some stuff. Disagree, argue, agree to disagree and go have a few pints.

Sir, you are a gentleman.

You have taken my comment in the spirit it was intended - professional disagreement in management.

The culture in UK would allow me to miss a fracture as long as I had documented my examination completely and my decision making process was clear. Yes, even without x-ray.

In fact in the past I have missed a fracture and a complaint was made and because I could show why I missed it and why I did not x-ray, and medical staff agreed (they had helped to train me), nothing came of it.

Strangely, I was going to go for a few pints tonight but quite literally as I came up to the computer to reply to you I decided to stay at home.

Have a good weekend.

[WineRN]

Sorry OldDude, I am going to disagree with you. I would put in moonboot with ortho follow up. No crutches and weightbear as able. Definitely would not be casting.

I was reading this and calling BS on the "multiple fractures" in the foot while no swelling/bruising and fully weightbearing.

If the child attended me as an ENP I doubt I would even have x-rayed. I would have sent home with advice.

The doctor is on the same train of thought as you. Because the little one isn't exhibiting any signs of pain and has been able to bear weight since the initial injury, they only want her in the boot.

[Beldar_the_Cenobite, CNA]

If i were the school nurse evaluating the student, if I had to for safety, I'd send him home, but ask him "Can I see you tomorrow to follow up? As a nurse, we're always learning" in a nice tone to test if they were just trying to get out of school.

[Axgrinder]

You don't have xray vision, so there was no way for you to know for certain a Fx exists. The teacher should have alerted you in a way that not only maintained your dignity, but was far less pompous. What purpose is served by making you feel ashamed, or incompetent - especially in front of a student?

Professionalism would have been nice in this case, even if this particular teacher is perfect and exempt from errors.

Lot's of times we are forced to go by what evidence suggests - in this case the child was weight bearing, playing, and not crying - when we lack diagnostic equipment on the job. It sounds like mom missed it too, and asking your thoughts is no substitute for responsibility on her part to get an evaluation after an injury at home (although again, evidence suggested no Fx).

I get what you are saying and how you are feeling (I am harder on myself than nearly anyone else when I make a mistake) but sometimes we just miss things. No matter how much we strive for perfection we'll never attain this lofty goal (because we are human - therefore prone to err from time to time).

Some Fx's are easy to miss: my old PCP's MA is tiny, and her husband must be nearly 1.5 ft taller than she is - one day he accidentally stepped on her foot. She limped around for over a week C/O pain, and subjectively had ecchymosis and swelling - but the xray said no Fx. She was miserable, but weight bearing. Finally she demanded further imaging: an MRI showed 3 Fx's the xray missed. She was in a boot for nearly 2 months.

If a radiologist with imaging studies can miss a Fx, then you certainly get a pass for not having xray vision super powers.

[BeckyESRN]

Just got a call from a parent that I had spoken to yesterday. 2nd grader fell during PE, said he fell on his arm, hurting mid-forearm. No swelling, no bruising, iced, kid was itching to go back to PE. Told him to come back when PE was over for a re-check (15 minutes). He returns, no swelling, no bruising, says it feels better. I asked again how it happened, now he says that he was falling and caught himself with his arm outstretched, impact on heel of hand. Hurts to turn hand over, but no pain when holding it still. Called mom and told her that I wasn't seeing anything that needed emergent attention, but that type of impact concerns me and he should get it checked out.

He fractured both the ulna and radius...so glad I called!

ETA: still no swelling, no bruising, and mom said no complaints of pain except when she asked him to clean his room