Some input on a missed femur fracture.

[emt322632]

Just need some input on a case I recently had that's been kind of bugging me.

Recently had a 21 y.o. male involved in a car v. pedestrian accident (the car won), low speed 20-25 mph. Pt A&O x 3, no syncope, no neck or back pain, c/o only R leg pain rated at a 7/10.

Full physical exam revealed no bruising, no obvious deformity to the leg or any other body part for that matter. Fully immobilized the kid, backboard, collar. Stated the pain in his leg was worse around his knee, nowhere else. += PMSx4. Leg was slightly rotated laterally, but when I pulled gentle traction, he stated the pain increased more.

Immobilized the leg by fixation. IV, O2, etc....

So here's where I need either vindication or someone to tell me I'm an idiot....

A colleague of mine works in the particular hospital we took the patient to, and later called me to tell me I "completely missed" a huge femur fracture. The doctor on call didn't even think the kid had broken his femur, until they moved his leg to assess him, and it began to swell and bruise and the pain worsened.

Question is, how could I have missed the fracture if the physical exam I did, which I believe was as thorough as could be, examining the limb at least 3 times enroute to the hospital with no change from the initial assessment...I could only go on what I found at the scene...the fact that the doctor and the ER staff didn't believe the femur was broken also says that maybe I did right...

Any thoughts?

Title adjusted to reflect content..AK

[scratrat]

Don't let it bug you that much. If the doctor didn't catch it at first, then you probably would never have noticed. Stuff happens. Just try to be thourough each time, and if you miss something, as long as its minute, don't fret.

[Ridryder 911]

Ever hear of hair line fractures ? Some fractures are non-displaced and may not have a lot of pain especially if there is other painful areas.

Don't fret over it... live and learn. I have seen patient's with fractures that never complained of any pain and was not examined for it because of such, and then later come with complete fracture. They had went home and later became displaced. Even the Doc almost missed it. Again, probably when he laterally moved it or firmly assessed it, it then became non-intact.

R/r 911

[Dustdevil]

Pt A&O x 3, no syncope, no neck or back pain, c/o only R leg pain rated at a 7/10.

Which parameter was the patient not oriented to? His obvious disorientation certainly could have resulted in an incomplete picture for you to base your assessment upon, no fault of your own.

Question is, how could I have missed the fracture if the physical exam I did, which I believe was as thorough as could be, examining the limb at least 3 times enroute to the hospital with no change from the initial assessment...

Can you describe this exam and assessment for us, as well as the results? Perhaps you did miss something. But more than likely, as Rid said, some things still slip past our x-ray vision, despite our best efforts.

[Laura Anne]

I think I'd need a furtherexplanation of the type of assessment performed before I could comment. Otherwise, it sounds like something that could happen to anyone. Even the ER Md missed it. Let this be a lesson to you.... never leave the station without your magical crystal ball and your X-ray vision goggles so you can find every lil thing wrong and know the complete history of every patient....

Seriously, like previously posted, don't fret. It happens to all of us. 8)

BTW, hello everyone.....I'm the FNG..... enjoy.

[Code 8 Paramedic]

If it wasnt swollen, bruised or deformed.. then you had no reason to think it was fractured, and put on a traction splint. and if his knee was painful then you may have even had a contraindication to using traction... I think (from what you said) you did the right think... you were thinking about.. you checked it out... you splinted... thats why the hospital has x-rays... physical exam cant find everything.

[ERDoc]

I wouldn't sweat it. We get xrays in the hospital to confirm whether there is a fx or not. You have to guess based on assessment in the field. From what you describe it sounds like you did the right thing. As long as you had a suspicion and passed it along to the ER staff. Would you have changed you managment any?

Dust, where did it say that this guy was dioriented? It sounds like he was fine to me.

[Doczilla]

It may not have been displaced very much until it was moved at the hospital. And if an x-ray was needed to determine the presence of a fracture, then they didn't see it either.

And tell the "colleague" of yours to get back in his lane. If he had to call you to tell you about it, then he missed it too. :roll:

'zilla

[Dustdevil]

Dust, where did it say that this guy was dioriented? It sounds like he was fine to me.

In the part that I quoted, he said that the patient was oriented to only three parameters, so obviously there was at least one parameter of disorientation in the standard four-parameter assessment of a trauma victim. If the victim is disoriented to any of those parameters, then the possibility must be considered that the patient will not respond appropriately to a history taking and physical assessment either. The result could be a compromised assessment, obscuring an acute injury or condition.

I'm curious as to how well the patient was exposed.

[Code 8 Paramedic]

In the part that I quoted, he said that the patient was oriented to only three parameters, so obviously there was at least one parameter of disorientation in the standard four-parameter assessment of a trauma victim. If the victim is disoriented to any of those parameters, then the possibility must be considered that the patient will not respond appropriately to a history taking and physical assessment either. The result could be a compromised assessment, obscuring an acute injury or condition.

I'm curious as to how well the patient was exposed.

some people dont use person place time and event... some leave out event... thus x3