Managing Orthopaedic Injuries in Covid-19 Pandemic : A Consise Review

Managing Orthopaedic Injuries in Covid-19 Pandemic : A Consise Review

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Abstract

Conservative, non-operative therapeutic approach may provide an alternative in nonobligatory fractures in the current COVID-19 pandemic and perhaps later on as well. It may serve as a route for us to manage orthopaedic injuries till we tide over the peak of the pandemic and resume elective surgeries. Perhaps, the Coronavirus crises has given us this unique opportunity to rethink and revisit traditional methods of treating fractures and the tolerance to operate every limb fracture must be risen. We must realize that all the fractures do not always need operative management and the conservative management still has a certain place in our armamentarium of fracture management, in an evolving world.

I. INTRODUCTION

Coronavirus disease (COVID-19) is a novel severe acute respiratory syndrome. 1 , 2 The virus was first isolated from three people with pneumonia connected to the cluster of cases in Wuhan. It was first identified in December 2019 in Wuhan, China and has spread to the rest of the world creating a global pandemic. 3 8

Extensive measures have been taken by different countries, in order to reduce person-to-person transmission of COVID-19 in a variety of ways, in which the social distancing, lockdowns, curfew and self-isolation remaining common across the whole world. 9 13

Hence, the rate of Road Traffic Accidents (RTA's) are drastically declined due to extensive lockdown, but the rate of fragility fractures continues to be unaffected, due to more prevalent osteopenia and osteoporosis with progressive ageing. The fragility fractures and traumatic fractures require robust intensive care. 11 , 13 16

Few other injuries include – falling from standing height, fall from less than 1m height like from stool, chair or bed, fall from a bicycle or a bike, fall from a height more than 1m height like roof of the house, tree etc, high energy fracture from high height, road traffic accidents. 17

These accidental injuries not only increase the susceptibility of COVID-19 transmission but also aid in consumption of medical resources that have declined during the SARS-CoV-2 caused pandemic via the way of transmission through hospital. 18

Simplifying the management of injuries with the use of braces and boots rather than a plaster casts along with consideration for uncemented implants and un-reamed nails, have resulted in potential advantage in decreasing the respiratory complications in patients who were infected with COVID-19. Such treatments help reduce number of visits to the hospital and also exposure to ultra-dense waiting rooms which could be a breeding ground for SARS-CoV-2. 19 21

Few patients with lower limb fracture have been more susceptible to pulmonary infections with limited ambulatory capacity. 22 , 23

The COVID-19 pandemic exposed orthopaedic surgeons to manage traumatic injuries with limited resources and in safe manner whilst guarding all other healthcare professionals. 24 30

According to Fineberg 2020, the patients who have to be treated should be categorized based on the COVID-19 exposure - 31

  1. A patient who is not known to be exposed or infected at any time

2) A patient who was exposed but is currently asymptomatic

3) A patient who has recovered from COVID and could be adequately immune
  1. A patient who is possibly infected (persons with sign and symptoms consistent with infection who initially test negative)
5) A patient who is currently infected

On the basis of urgency of surgical procedures patients are categorized as: 32

Category typeProcedures should occur within
1a24 hours
1b72 hours
21month
33month
4>3months

Steps in Managing a Trauma Patient with Covid-19 Symptoms or History of Contact

An Orthopaedic surgeon has to be vigilant at all times during providing pre-operative, intra-operative as well as post-operative care to refrain cross-infection amongst surgeons as well as other healthcare professionals. 33 Thermal screening for both the patient as well their attendee should be carried out, appropriate travel history, history of any previous contact should be undertaken. A three-layer surgical mask, hand sanitizer and a pair of disposable gloves should be provided at the entry point to patients along with their attendants who require emergency care. 34 36 The door handles, chair handles, tables and other necessary material in the waiting areas should be regularly cleaned with 1% sodium hypochlorite at least 4 times a day. 37 40

A separate specialized area should be kept ready in the triage to treat COVID patients with trauma. The respective CMO's and the SMO's in the hospital should be informed immediately, in case a symptomatic patient is encountered.

Each orthopaedic surgeon along with attendants, are advised to donned PPE kits before examining every single patient, which later on should be carefully doffed off after use. 41 45

Resuscitate the patient and rule out all the injuries, also ask the patient to fill Informed consent, along with splintage of fracture limb. 33

All the necessary pre-operative investigations along with COVID-19 testing are advised.

If possible, the portable X-rays and ultrasound should be shifted to consulting room to avoid contamination of the radiology area and it also helps in decreasing movement of symptomatic patients. 35

For investigations like CT scan or MRI, we have to sterilize the respective area after investigating every patient as per centres for disease control and prevention guidelines. 35

Patients with closed fractures are advised to wait for surgical interventions until the COVID-19 results are out.

All cases that need urgent management like an open fracture, vascular injuries, compartment syndrome or mangled limb; and cannot wait until COVID reports. These patients should be treated as COVID positive patients unless proven otherwise and strict precautions should be taken while treating them so as to avoid transmission to healthcare professionals or to other patients. 33 35

If the reports are positive keep the patient in the COVID isolation ward until the results are negative and take the help of the COVID response team of the hospital. If the results are negative shift the patient to the orthopaedic ward and then discharge as early as possible. 33 35

Care must be taken during the hospital stay to physiotherapy, bedsores and DVT prevention.

II. EMERGENCY TRIAGE

Patients presented to the emergency triage with an orthopaedic emergency such as joint dislocations, compartment syndrome, open fractures, mangled extremity, polytrauma with Full Endoscopic Spine Surgery (FESS) should be managed according to a specific guidelines during global health emergencies like a pandemic of COVID-19. 46 49

These orthopaedic emergencies require effective outpatient, inpatient and surgical care besides avoiding transmission of infection to fellow patients and health care givers.

The injuries that cannot be managed by the non-operative approach, should be corrected immediately with the surgical approach, with minimum usage or if possible by, completely avoiding Aerosol-Generating Procedures and with proper usage of Personal Protective Equipments with minimum assistants in the operatory. 20 , 50 53

Patient Triaging Guidelines for Orthopaedic Surgeries: 54

Orthopaedic SubspecialityOperative ManagementNon-Operative Management Indications
Absolute IndicationsRelative Indications
Trauma & General OrthopaedicsOpen FracturesPolytrauma Trauma With Neurovascular InjuriesIrreducible FractureDislocations Compartment SyndromeCrush InjuriesSeptic Arthritis AcuteOsteomyelitis Amputations For GangreneFemur Fractures (Shaft/Neck/Distal Femur)Unstable Pelvic/Acetabular FracturesIntraarticular/ Forearm FracturesUnstable Tibial Shaft FracturesCommunited/Complex FracturesUnstable Upper Limb FracturesDiabetic FootStable Tibial Shaft FracturesClavicle FracturesStable Upper Limb FracturesNon UnionsMalunionsInfected Non UnionsChronic Osteomyelitis
HandCrush HandReplantation SurgeriesInfectionsTendon InjuriesCommunited/ Unstable FracturesFracture -DislocationIrreducible DislocationsCompressive NeuropathiesTendinitisStable Fractures
SpineCauda Equina SyndromeEpidural AbscessDiscitis PyogenicSpine Fracture Unstable With ParaplegiaAcute/Progressive Compressive MyelopathyUnstable Spine Fracture With Neural DeficitScoliosis With Neural DeficitAcute RadiculopathyLow Back PainNeck PainFlat Back SyndromeScoliosis Without Neural DeficitSpine Fracture Stable
ArthroplastyProsthetic Joint InfectionsProsthetic Joint DislocationsPeriprosthetic FracturesChronic Hip/Knee Pains
Orthopaedic OncologyInfection Including Infected JointsSarcoma/Malignancy In Chemo/Radiation WindowBenign Aggressive Tumours Like GctImpending Pathological FracturesBenign Soft Tissue TumorsBenign Bone Tumours
SportsMultiligamentous Injuries With Neurovascular DeficitMultiligamentous InjuryRotator Cuff Repairs (Young)Major Muscle TearChronic Knee, Elbow, Shoulder, Wrist, Hip PainsRecurrent Sprains/ DislocationsAcl/Pcl Tear

The Expert group from the Chinese Orthopaedic Association and Chinese Association of Orthopaedic Surgeons formulated an expert consensus on the diagnosis and treatment of orthopaedic emergency surgery during the outbreak of COVID-19, which has been published within the Chinese Journal of Orthopaedic Trauma in Chinese. 55

The expert consensus categorized the orthopaedic patients into four types: 55

Type I- Patients had not travelled within the in the epidemic area within 14 days and had no history of direct or indirect contact with suspected or confirmed cases.

Type II- Patients had a history of direct or indirect contact with people from the epidemic area within 14 days, or patients board same neighbourhoods with suspected or confirmed cases. However, the patients had no clinical symptoms and every examinations were negative.

Type III- Patients are diagnosed as a suspected case of COVID-19.

Type IV- Patients were diagnosed as a confirmed case. On the advent of COVID-19 pandemic, it has been acknowledged by the British Orthopaedic Association (BOA) emergency COVID-19 and the

National Health Service England (NHSE) guidelines to manage urgent orthopaedic and trauma conditions pragmatically balancing optimum treatment of patients against clinical safety with resource utilization. 56 , 57

Non-Operative Management of Paediatric Fractures and Dislocations during Coronavirus Crises: 56 , 57

Limb injuries in children and adolescentsPreferred IndicationsEquivocal IndicationsContraindications
Hand Limb TraumaClavicle FracturesProximal humerus fracturesShaft-humerus fractures with angulation of less than 45°Supracondylar fractures (Undisplaced/ minimally displaced)Extra-articular distal radius fractureHand FracturesReducible dislocationsDisplaced Fractures.Eg. Supracondylar humerus, lateral condyle humerusDislocationsFracture-dislocationUnreduced dislocationsFractures with vascular deficitsCompound FracturesCrush InjuriesCompartment Syndrome
Lower Limb TraumaShaft-femur fractures with acceptable angulation and displacementsFractures around KneeShaft-tibial fracturesPhalanx FracturesMetatarsal FracturesCalcaneus FracturesReducible dislocationsFracture – dislocationsDislocationsDisplaced Fractures.Eg. Neck of Femur, Shaft Femur, Fractures around the ankleUnreduced dislocationsFractures with neurovascular deficitsCompound FracturesCrush InjuriesCompartment Syndrome
Pelvic Acetabular TraumaStable/ Minimally displaced fracturesOpen book type of injuriesUnstable fracturesCompound Fractures

Non-Operative Management of Fractures and Dislocations in Adults during Coronavirus Crises: 56 , 57 , 58

Limb and Spinal Injuries in AdultsPreferred IndicationsEquivocal IndicationsContraindications
Upper limbClavicle fracturesAC joint dislocationsScapula fracturesFractures without gross displacements; eg; proximal humerus, humeral shaft, humeral-supracondylarExtra-articular distal radius fracturesScaphoid FracturesMetacarpal FracturesPhalanx FracturesReducible DislocationsFractures with significant displacement; Eg., Proximal humerus, humeral shaft, intercondylar humerus, olecranonRadius and Ulna shaft fracturesPathological FracturesPeri-prosthetic FracturesSevere compound fracturesSevere Crush InjuriesFractures involving vascular injuriesIrreducible dislocationsGrossly comminuted and displaced intra-articular fracturesCompartment syndrome
SpineStable fracturesUnstable spine Fractures with neural deficitStable Spine FracturesFractures with Progressive/ acute neurologic deficit
Lower LimbPubic rami fracturesUndisplaced pelvic-acetabular FracturesUndisplaced Fractures around kneeCalcaneous Fractures without gross displacementPelvic - acetabular Fractures with significant displacementInter-trochanteric FracturesIntercondylar FracturesTibial-shaft FracturesTibial-Condyle FracturesFracture of neck of FemurFemur Shaft FracturesSevere Compound FracturesSevere Crush InjuriesFractures with vascular injuriesCompartment syndromeGrossly comminuted and
Metatarsal FracturesPhalanx FracturesPatella FracturesTalar FracturesCalcaneous Fractures with gross displacementLis Franc InjuriesPeri-prosthetic FracturesPathological Fracturesdisplaced intra-articular fracturesIrreducible dislocations

III. CONCLUSION

The COVID-19 pandemic has substantially led to decrease in operative management of trauma, in order to optimize medical resource allocation and also to help prevent the spread of COVID. The coronavirus crises has led to depletion in the surgical volume, and preference of non-operative management of trauma over operative. On the contrary, orthopaedic surgeons must remain vigilant all the time and be prepared to provide optimal care to the injured patients.

Conflict of Interest: None

Author Contribution: All authors have equally contributed for completion of this manuscript.

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Funding

No external funding was declared for this work.

Conflict of Interest

The authors declare no conflict of interest.

Ethical Approval

No ethics committee approval was required for this article type.

Data Availability

Not applicable for this article.

How to Cite This Article

Dr. Sagar Chaudhari, Dr. Ajit Govind Jangale, Dr. Sheetal Ajit Jangale, Dr. Sharayu Dhande. 2021. "Managing Orthopaedic Injuries in Covid-19 Pandemic : A Consise Review". Global Journal of Medical Research - H: Orthopedic & Musculoskeletal System GJMR-H Volume 21 (GJMR Volume 21 Issue H2).

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Elevate your understanding of managing orthopedic injuries during the COVID-19 pandemic with expert insights.
Journal Specifications

Crossref Journal DOI 10.17406/gjmra

Print ISSN 0975-5888

e-ISSN 2249-4618

Keywords
Classification
GJMR-H Classification NLMC Code: WE 168
Version of record

v1.2

Issue date
September 15, 2021

Language
English
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Managing Orthopaedic Injuries in Covid-19 Pandemic : A Consise Review

Dr. Chaudhari
Dr. Chaudhari
Dr. Jangale
Dr. Jangale
Dr. Jangale
Dr. Jangale
Dr. Dhande
Dr. Dhande