Missed it

Specialties School

Published

I missed a wrist fracture.

Kid came in, had fallen. We iced. ROM was fine, no swelling or bruising while he was in the clinic, grip strength was good. I sent him along. Never heard anything more, but it was close to the end of the day.

Mom comes in yesterday afternoon upset I didn't contact her. I explain that I didn't see anything to report, he had no signs of a fracture. I offered to contact her every single time he crosses my threshold. He was playing while we talked, and I still didn't see anything out of the norm. Was grasping with both hands, turning and twisting his wrists. Then, the note came this morning it was indeed a fracture.

Part of me feels like crap; I honestly didn't see anything and would have (and have called) if I saw anything to suspect an injury. I hate that I missed it. I keep trying to think of what I didn't check that might have clued me in.

Part of me is a little pissed; mom comes in, mad at me. But, she waited all weekend to take him in to be examined. The office is the same one I use, and is open every day with extended hours. Not to mention all the Urgent Care clinics and two ERs in the area. If she was as concerned as she claims, why wait?

How do you handle joint injuries? What else could I assess?

TIA virtual co-workers!

Specializes in Urgent Care, Oncology.

I am not a school nurse, but....

It happens. You don't have x-ray vision.

My brother broke his wrist when he was 8 at school. Went to school nurse, told him it was fine, no swelling, pain, etc. 10 days later he fell on the tennis court and that time it swelled and was bruised. My mom took him to the ER and the x-ray showed signs of a healing fracture in his wrist and a new, separate fracture. My mom (a RN) felt so guilty for not taking him the first time. Again, it happens...

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Do you have "x-ray" vision? Please let it go. Anyone could have missed it.

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Specializes in Private Duty Pediatrics.

I had a broken wrist (radius) as a child, and the only sign was that I couldn't touch my thumb to my little finger.

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I suggest not even using this word "missed" in regards to non-displaced fractures where everything remains functional and the only anything is some swelling - which is not specific to fracture (as I know you know). Just don't even entertain that verbiage. Tell the crazy yahoos that you diagnose neither fracture nor "no fracture" and that unless there's a jagged bone sticking out or the appendage is dangling in a way it shouldn't be, you won't even pretend to say something is or isn't fractured.

Get a good old fashioned knowledge campaign going. Every single kid you deal with that has a r/o fx sort of complaint - tell them that you can't and won't try to guess whether something could be fractured. You have WebMD working against you and telling everyone that a broken bone (without any specification/clarification) is a "medical emergency."

I mean, it's either a spread-the-word campaign or else get yourself a tuning fork and have at it... ;)

****

Out of all the things we put up with in the ED, I just don't know if I could handle parents who fly into the school all enraged about stuff like this. I would lose my job instantly.

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A lot could have happened over that weekend. Kid could have been fine and maybe fell and that's what caused the break. I've seen that happen. Fine, full ROM, goes home, fall, swells, hospital, x-ray. I was thinking that you didn't miss anything. Kid could have injured himself on Mom's watch and you're just the convenient one to take it out on.

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Specializes in school nursing, ortho, trauma.

I mean, it's either a spread-the-word campaign or else get yourself a tuning fork and have at it... ;)

i love my tuning fork. i keep one within arms reach on my desk and one in my go bag

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Specializes in 8 years as a school nurse.

I "missed" my own kid's broken wrist this year too. Just didn't believe him that it hurt as bad as he said, or that it could have broken from the way he fell. No swelling, no bruising, no deformity whatsoever, full ROM. For 3 days! Then took him in because I got tired of him whining about it. yep- broken! I did the same thing to my husband a few years back and he had broken BOTH wrists, one requiring ORIF. (I felt horrible about both times, BTW)

Oh how I wish I had x-ray vision!! Don't beat yourself up, it's not an easy thing to tell if it is or isn't broken. We see so many bumps and hurts that are not broken, that we tend to gravitate toward this as a likely outcome for the non-obvious injuries. Just do your best to evaluate, give the facts and let the parents decide their course of action from then on out.

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Specializes in Occupational Health.

I mean, it's either a spread-the-word campaign or else get yourself a tuning fork and have at it... ;)

I've never heard of that before! Love learning new things.

This has been a lesson in not getting too bent on things I can't control. It's been great to come back today and see the outpouring.

Also, yesterday I stayed busy with vomit and bathroom accidents. No better way snap right out of a pity party than with puke! :wtf:

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Specializes in NICU.

You poor thing ,dont feel bad,I had to call my insurance co for approval to go to er after a bad fall ,my arm was hurting ,swollen,but the telephone triage nurse with the big bad insurance company said it is not broken.

But guess what ,it most certainly was broken.

Sigh,one of those days.....

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I had a student a couple of weeks ago that hurt her wrist at home. Good range of motion, no swelling. She returned for several days requesting ice for pain, which I reported to the parents. After 1 week they took her in for an xray and of course there was a fracture. The kicker both parents, who were with her when the injury happened, are physicians. NO ONE has xray vision.

There we go!!! This should make us all feel better.

I hate wrists!!! I do tend to call parents on most wrist injuries just in case - a "it looks ok but you may want to keep an eye on it" call goes a long way.

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