Where Have All the Fractures Gone? The Epidemiology of Pediatric Fractures During the COVID-19 Pandemic

Have There Been any Changes in the Epidemiology and Etiology of Maxillofacial Trauma During the COVID-19 Pandemic? An Italian Multicenter Study

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Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has had a significant impact on people's behavior. The aim of this study has been to evaluate how the SARS-CoV-2 pandemic has impacted the incidence and the features of maxillofacial fractures presented at 6 Italian tertiary centers. Clinical records of all the patients diagnosed for facial fractures between February 23 and May 23, 2019 and 2020 were retrospectively reviewed. Any differences in patient number and characteristics and fracture etiology and site between the 2 groups were then statistically analyzed.

There has been a 69.1% decrease in the number of incoming patients during the pandemic. The number of foreign patients has decreased significantly (23.3% versus 9.6%, P = 0.011) while the average age has increased (38.6 versus 45.6 years old, P = 0.01). Specific statistical significant differences for accidental falls (31.8% versus 50.1%, P = 0.005) and sports injuries (16.9% versus 1.4%, P < 0.001) were found. Concerning fracture sites, significant differences have been found in relation to nasal (22.5% versus 11.4%, P = 0.009) and frontal sinus (0.9% versus 4.4%, P = 0.037) fractures. In conclusion, SARS-CoV-2 pandemic has significantly changed the epidemiology and the etiology of facial traumas.

Pediatric Trauma and the COVID-19 Pandemic: A 12-Year Comparison in a Level-1 Trauma Center

BACKGROUND

The effect of COVID-19 on pediatric trauma rates is still largely under investigation. With the potential need to reallocate human and financial resources at this challenging time, it will be useful to have detailed descriptions of the rates of pediatric trauma and understanding of how the pandemic affects these rates.

QUESTIONS/PURPOSES

We sought to describe the effect of the COVID-19 pandemic on the number of acute pediatric trauma admissions and procedures performed in a level-I trauma center in Cork University Hospital, Ireland.

METHODS

We compared the number of acute traumatic pediatric admissions and procedures that occurred during the first 4 weeks of a nationwide lockdown due to COVID-19 with that of the same 4-week period in each of the preceding 11 years. Seasonal variables were measured and controlled for using multivariate regression analysis.

RESULTS

A total of 545 pediatric patients (under 16 years of age) were included. Over 12 years, the lowest number of acute traumatic pediatric admissions and procedures was recorded during the 2020 pandemic. There was a significant correlation between the number of school days and the number of acute traumatic admissions, as well as the procedures performed. The relationship between the number of school days and the number of trauma procedures was evident even when controlling for confounder variables of seasonal variation.

CONCLUSION

The COVID-19 pandemic significantly reduced the number of acute traumatic pediatric admissions and procedures performed in our level-I trauma center, likely because of a reduction in school days. With the reopening of schools, playgrounds, and sporting events, an increase in pediatric trauma admissions is anticipated. The results of this study can help prepare institutions and regulatory bodies to plan appropriately for this new phase.

Bone fractures during the time of coronavirus

WHAT IS KNOWN AND OBJECTIVE

In response to rapid spread of coronavirus (SARS-CoV-2) and lack of vaccine or effective treatment for COVID-19 disease, governments imposed measures that resulted in a shift from work and school to isolation at home. Studies from three countries (China, Belgium and the United States) report the consequences on traumatic bone fractures.

COMMENT

The coronavirus pandemic has resulted in a widespread change to a relative sedentary lifestyle and decreased exposure to light (vitamin D). A consequence of the stay-at-home policies is a negative change in bone-health and environmental surroundings that has led to age-related changes in the number of traumatic bone fractures.

WHAT IS NEW AND CONCLUSION

A consequence of stay-at-home policies has been a decline in bone fractures for young and middle-aged adults; but an increase for the elderly. The trends are predicted to reverse, and present new problems, when isolation restrictions are removed.

Reduced Number of Pediatric Orthopedic Trauma Requiring Operative Treatment during COVID-19 Restrictions: A Nationwide Cohort Study

Background and Aims:

The coronavirus outbreak significantly changed the need of healthcare services. We hypothesized that the COVID-19 pandemic decreased the frequency of pediatric fracture operations. We also hypothesized that the frequency of emergency pediatric surgical operations decreased as well, as a result of patient-related reasons, such as neglecting or underestimating the symptoms, to avoid hospital admission.

Materials and Methods:

Nationwide data were individually collected and analyzed in all five tertiary pediatric surgical/trauma centers in Finland. Operations related to fractures, appendicitis, and acute scrotum in children aged above 16 years between March 1 and May 31 from 2017 to 2020 were identified. The monthly frequencies of operations and type of traumas were compared between prepandemic 3 years and 2020.

Results:

Altogether, 1755 patients were identified in five tertiary hospitals who had an emergency operation during the investigation period. There was a significant decrease (31%, p = 0.03) in trauma operations. It was mostly due to reduction in lower limb trauma operations (32%, p = 0.006). Daycare, school, and organized sports–related injuries decreased significantly during the pandemic. These reductions were observed in March and in April. The frequencies of appendectomies and scrotal explorations remained constant.

Conclusion:

According to the postulation, a great decrease in the need of trauma operations was observed during the peak of COVID-19 pandemic. In the future, in case similar public restrictions are ordered, the spared resources could be deployed to other clinical areas. However, the need of pediatric surgical emergencies held stable during the COVID-19 restrictions.

Universal Screening for COVID-19 in Children Undergoing Orthopaedic Surgery: A Multicenter Report

BACKGROUND

The COVID-19 pandemic has substantially altered the typical process around performing surgery to ensure protection of health care workers, patients, and their families. One safety precaution has been the implementation of universal preoperative screening for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This study examines the results of universal screening on children undergoing orthopaedic surgery.

METHODS

This is a retrospective cohort study evaluating the incidence and symptomatology of COVID-19 in all patients presenting for orthopaedic surgery at 3 pediatric tertiary care children's hospitals during the COVID-19 pandemic (March to June 2020). All patients underwent universal screening with a nasopharyngeal swab to detect presence of SARS-CoV-2. Bivariate and multivariate logistic regression analysis was performed to identify risk factors for positive COVID-19 screening.

RESULTS

In total, 1198 patients underwent preoperative screening across all 3 institutions and 7 (0.58%) had detection of SARS-CoV-2. The majority of patients (1/7, 86%) were asymptomatic. Patients that tested positive were significantly more likely to be Hispanic (P=0.046) and had greater number of medical comorbidities (P=0.013), as scored on the American Society of Anesthesiologists (ASA) physical status score. A known COVID-19 positive contact was found to be a significant risk factor in the multivariate analysis (P=0.004).

CONCLUSIONS

Early results of universal preoperative screening for COVID-19 demonstrates a low incidence and high rate of asymptomatic patients. Health care professionals, especially those at higher risk for the virus, should be aware of the challenges related to screening based solely on symptoms or travel history and consider universal screening for patients undergoing elective surgery.

LEVEL OF EVIDENCE

Level II.

Impact of COVID-19-related social restrictions on orthopaedic trauma in a level 1 trauma centre in Sydney: the first wave

Background

The coronavirus disease 2019 (COVID‐19) pandemic has affected communities worldwide. This study examines the impact that public health measures to control viral spread have had on orthopaedic trauma presenting to an Australian level 1 trauma centre. We hypothesized that the volume of orthopaedic trauma in the period of social distancing would decrease, and the mechanisms of injury differ, compared to pre‐pandemic times.

Methods

We performed a retrospective analysis of patients requiring emergency orthopaedic surgery between 16 March and 21 April 2020 (the period after social distancing and lockdown commenced), and compared it to the group of patients from the same period in 2019. We collected demographic data, as well as injury type, anatomical location, mechanism of injury and surgical logistics.

Results

During the COVID‐19 period, total emergency operations performed decreased by 15.6% compared to the same period in 2019. Orthopaedic admissions decreased by 30.8%. Demographics of the groups were unchanged. Anaesthetic time decreased, but total time spent in the operating theatre was unchanged. Road trauma comprised a similar proportion of cases overall; however, cycling‐related accidents increased significantly, making up 11% of presentations during COVID‐19. Sporting injuries, work‐related injuries and multi‐traumas reduced during the pandemic.

Conclusion

The impact of COVID‐19‐related lockdown measures and social distancing on orthopaedic trauma in Australia has been an overall decrease in volume of cases, combined with significant changes in the mechanisms of injury necessitating surgery.

Complications and mortality of cardiovascular emergency admissions during COVID-19 associated restrictive measures

While hospital admissions for myocardial infarction (MI) and pulmonary embolism (PE) are decreased during the COVID-19 pandemic, controversy remains about respective complication and mortality rates. This study evaluated admission rates, complications, and intrahospital mortality for selected life-threatening cardiovascular emergencies (MI, PE, and acute aortic dissection (AAD)) during COVID-19-associated restrictive social measures (RM) in Styria, Austria. By screening a patient information system for International Statistical Classification of Diseases and Related Health Problems (ICD) diagnosis codes covering more than 85% of acute hospital admissions in the state of Styria (~1.24 million inhabitants), we retrospectively identified patients with admission diagnoses for MI (I21, I22), PE (I26), and AAD (I71). Rates of complications such as cardiogenic shock and cardiopulmonary resuscitation, treatment escalations (thrombolysis for PE), and mortality were analyzed by patient chart review during 6 weeks following onset of COVID-19 associated RM, and during respective time frames in the years 2016 to 2019. 1,668 patients were included. Cumulative admissions for MI, PE and AAD decreased (RR 0.77; p<0.001) during RM compared to previous years. In contrast, intrahospital mortality increased by 65% (RR 1.65; p = 0.041), mainly driven by mortality following MI (RR 1.80; p = 0.042). PE patients received more frequently thrombolysis treatment (RR 3.63; p = 0.006), while rates of cardiogenic shock and cardiopulmonary resuscitation remained unchanged. Of 226 patients hospitalized during RM, 81 patients with suspected COVID-19 disease were screened for SARS-CoV-2 infection with only 5 testing positive. Thus, cumulative hospital admissions for cardiovascular emergencies decreased during COVID-19 associated RM while intrahospital mortality increased.

Underutilization of the Emergency Department During the COVID-19 Pandemic

INTRODUCTION

The novel coronavirus 2019 (COVID-19) pandemic in the United States (US) prompted widespread containment measures such as shelter-in-place (SIP) orders. The goal of our study was to determine whether there was a significant change in overall volume and proportion of emergency department (ED) encounters since SIP measures began.

METHODS

This was a retrospective, observational, cross-sectional study using billing data from January 1, 2017-April 20, 2020. We received data from 141 EDs across 16 states, encompassing a convenience sample of 26,223,438 ED encounters. We used a generalized least squares regression approach to ascertain changes for overall ED encounters, hospital admissions, and New York University ED visit algorithm categories.

RESULTS

ED encounters decreased significantly in the post-SIP period. Overall, there was a 39.6% decrease in ED encounters compared to expected volume in the pre-SIP period. Emergent encounters decreased by 35.8%, while non-emergent encounters decreased by 52.1%. Psychiatric encounters decreased by 30.2%. Encounters related to drugs and alcohol decreased the least, by 9.3% and 27.5%, respectively.

CONCLUSION

There was a significant overall reduction in ED utilization in the post-SIP period. There was a greater reduction in lower acuity encounters than higher acuity encounters. Of all subtypes of ED encounters, substance abuse- and alcohol-related encounters reduced the least, and injury-related encounters reduced the most.

The impact of COVID-19 on shoulder and elbow trauma in a skeletally immature population: an Italian survey

Background

The aim of this study was to evaluate the impact of COVID-19 on the shoulder and elbow trauma in a skeletally immature population in 30 days starting from March 8, 2020, the first day of restrictions in Italy, and to compare it with the same period of 2019.

Materials and methods

All the skeletally immature (younger than 18 years) patients managed in the emergency unit of our hospital between March 8, 2020, and April 8, 2020 (COVID-19 [C19] period), for a shoulder and elbow trauma were retrospectively included and compared with patients with similar ages admitted in the same period of 2019 (no COVID-19 period). Six categories of diagnosis were distinguished: (1) contusions, (2) no physeal fractures, (3) physeal fractures (Salter-Harris), (4) sprains/subluxations, (5) dislocations, and (6) others (tendinitis, wounds, low back pain, and joint inflammation). According to the mechanism of injury, we arbitrarily distinguished 5 subgroups: (1) accidental fall; (2) sport trauma; (3) accident at school; (4) high-energy trauma occurred by car, public transport, and pedestrian investment; and (5) fall from height.

Results

During the C19 period, the number of total accesses in our trauma center steeply decreased: two-thirds less. Regardless of the patient age, we performed 65% less first aid shoulder/elbow services. The number of skeletally immature patients treated at our trauma center for all types of injuries was 350 during the no COVID-19 period and 54 during the C19 period; therefore, the influx of pediatric patients during the C19 period decreased by 84.6%. Furthermore, during the C19 period, (1) there were no cases of fractures, physeal fractures, and dislocations of the shoulder; (2) there were no cases of contusion, physeal fractures, and dislocations of the elbow; and (3) we observed the absence of high-energy, sports, and school injuries; and (4) during the pandemic, shoulder and elbow injuries mainly occurred as a result of accidental fall at home.

Conclusions

The pandemic forced us to become aware of the ways and places where skeletally immature subjects report shoulder and elbow traumas; therefore, it would be desirable that more considerable attention be directed toward the prevention of injury in areas at risk.

The Effects of Lockdown During the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Pandemic on Neurotrauma-Related Hospital Admissions

Background

The response to the global severe acute respiratory syndrome coronavirus 2 pandemic culminated in mandatory isolation throughout the world, with nationwide confinement orders issued to decrease viral spread. These drastic measures were successful in “flattening the curve” and maintaining the previous rate of coronavirus disease 2019 infections and deaths. To date, the effects of the coronavirus disease 2019 pandemic on neurotrauma has not been reported.

Methods

We retrospectively analyzed hospital admissions from Ryder Trauma Center at Jackson Memorial Hospital, during the months of March and April from 2016 to 2020. Specifically, we identified all patients who had cranial neurotrauma consisting of traumatic brain injury and/or skull fractures, as well as spinal neurotrauma consisting of vertebral fractures and/or spinal cord injury. We then performed chart review to determine mechanism of injury and if emergent surgical intervention was required.

Results

Compared with previous years, we saw a significant decline in the number of neurotraumas during the pandemic, with a 62% decline after the lockdown began. The number of emergent neurotrauma surgical cases also significantly decreased by 84% in the month of April. Interestingly, although the number of vehicular traumas decreased by 77%, there was a significant 100% increase in the number of gunshot wounds.

Conclusions

Population seclusion had a direct effect on the frequency of neurotrauma, whereas the change in relative proportion of certain mechanisms may be associated with the psychosocial effects of social distancing and quarantine.

Effect of COVID-19 pandemic on the fracture demographics: Data from a tertiary care hospital in Turkey

OBJECTIVE

The purpose of this study was to evaluate the types and the frequency of fractures, both in the pediatric and adult population during the COVID-19 pandemic and to find out the differences in comparison to the non-pandemic period.

METHODS

Patients who were admitted to the hospital with a new fracture during pandemic period (March 16 to May 22, 2020) were evaluated. Control group consisted of patients with new fractures admitted to the hospital in the same date range in 2018 and 2019. The patients were divided into two groups as ≤16 years old (group 1) and >16 years old (group 2). The evaluation was based on the age and gender of the patients and localization of the fractures. Hospitalized and surgically treated patients were evaluated as well.

RESULTS

A total of 1794, 1747, and 670 fractures were observed in 2018, 2019, and 2020, respectively. Mean age of the patients in group 1 was found to have decreased in the pandemic period (p<0.001). The most common fracture sites in the pediatric population were the distal forearm and distal arm, whereas hand, distal forearm, and foot were most common fracture sites in adults, in both pandemic and non-pandemic periods. The proportional increase in femoral and tibial shaft fractures in group 1, and toe, tibial shaft, and metacarpal fractures in group 2 was found to be statistically significantly (p<0.05). In group 1; 6.8%, 7.7%, and 14.6% of the fractures were treated surgically in 2018, 2019, and 2020, respectively (p<0.001). For group 2, these rates were 20.1%, 18.6%, and 18.1%, respectively (p=0.67). There were 48, 29, and 26 open fractures in 2018, 2019 and 2020, respectively (p=0.066). In pandemic period, duration of the hospital stay was significantly shorter for distal humerus and proximal femur fractures (p values= 0.001 and 0.017, respectively).

CONCLUSION

We observed that the frequency of fractures decreased by approximately one-third during the pandemic period compared with that in the non-pandemic period. The mean age of the patients with a fracture in the pediatric group was found to have decreased also. Finger fractures in pediatric patients and metatarsal fractures in adult patients were found to have significantly decreased during the pandemic.

LEVEL OF EVIDENCE

Level III, Diagnostic study.

Arthroscopy and COVID-19: Impact of the pandemic on our surgical practices

The aim of this article is to study systematically current evidence on status of arthroscopic surgeries during the COVID-19 pandemic. We aim to study (1) changes in global arthroscopic practices, (2) recommendations on reducing risk to patients and health care workers (HCW), (3) changes in follow-up protocols of these patients. Systematic search was carried out by two different reviewers using three different online databases for all studies published in the English language before April 2020. The total number of abstracts screened initially was 314. After screening of these abstracts, a total of 13 studies were included for the systematic review. Numbers of orthopaedic injuries have seen a sharp fall during this time. Most elective surgical facilities were also closed at this time. Most studies have recommended telemedicine as an essential medium of providing continued care to patients during COVID-19. Studies have recommended that a conservative approach should be preferred for most patients with ligament injuries, and alternative procedures that have less requirement for an operating room should be explored. Common recommendation in all studies is that procedures of more elective nature should be postponed to a safer time frame when the transmission of COVID-19 virus in the population has declined. When surgeries are resumed, there is a need for triage of arthroscopy procedures from more important or urgent to less important ones. Elective surgical procedures should preferably be started with patients with no co-morbidities and lesser risk of peri-operative complications. All patients undergoing surgery and health care personnels should have some screening for disease. Attempts should be made to have shortest hospital stay. Choice of anaesthetic procedure should emphasize on minimal aerosolization of the virus. Regional anaesthesia is the preferred choice as far as possible. Most guidelines have recommended that patient follow up should be made telephonically or on video-conferencing.