Impact of the COVID-19 pandemic on paediatric orthopaedic trauma workload in central London: a multi-centre longitudinal observational study over the "golden weeks"

What was the impact of COVID-19 restrictions on unintentional injuries, in Canada and globally? A scoping review investigating how lockdown measures impacted the global burden of unintentional injury

Background

Injuries are among the leading causes for hospitalizations and emergency department (ED) visits. COVID-19 restrictions ensured safety to Canadians, but also negatively impacted health outcomes, including increasing rates of certain injuries. These differences in trends have been reported internationally however the evidence is scattered and needs to be better understood to identify opportunities for public education and to prepare for future outbreaks.

Objective

A scoping review was conducted to synthesize evidence regarding the impact of COVID-19 restrictions on unintentional injuries in Canada, compared to other countries.

Methods

Studies investigating unintentional injuries among all ages during COVID-19 from any country, published in English between December 2019 and July 2021, were included. Intentional injuries and/or previous pandemics were excluded. Four databases were searched (MEDLINE, Embase, Web of Science, SPORTDiscus), and a gray literature search was also conducted.

Results

The search yielded 3,041 results, and 189 articles were selected for extraction. A total of 41 reports were included from the gray literature search. Final studies included research from: Europe (n = 85); North America (n = 44); Asia (n = 32); Oceania (n = 12); Africa (n = 8); South America (n = 4); and multi-country (n = 4). Most studies reported higher occurrence of injuries/trauma among males, and the average age across studies was 46 years. The following mechanisms of injury were reported on most frequently: motor vehicle collisions (MVCs; n = 134), falls (n = 104), sports/recreation (n = 65), non-motorized vehicle (n = 31), and occupational (n = 24). Injuries occurring at home (e.g., gardening, home improvement projects) increased, and injuries occurring at schools, workplaces, and public spaces decreased. Overall, decreases were observed in occupational injuries and those resulting from sport/recreation, pedestrian-related, and crush/trap incidents. Decreases were also seen in MVCs and burns, however the severity of injury from these causes increased during the pandemic period. Increases were observed in poisonings, non-motorized vehicle collisions, lacerations, drownings, trampoline injuries; and, foreign body ingestions.

Implications

Findings from this review can inform interventions and policies to identify gaps in public education, promote safety within the home, and decrease the negative impact of future stay-at-home measures on unintentional injury among Canadians and populations worldwide.

Influence of COVID-19 pandemic on hospitalisations at a paediatric traumatology department during 2020: a single-centre observational study and comprehensive literature review

PURPOSE

The study investigates changes in the injury characteristics of hospitalised children in a paediatric trauma centre during the COVID-19 pandemic.

METHODS

Data from injured children from the pre-pandemic year 2019 were compared to the pandemic year 2020 using Pearson's chi-squared test and the Mann-Whitney U test. The period of highly restrictive regulations (HRP) was evaluated separately. A comprehensive literature review with defined search terms resulted in a descriptive data synthesis.

RESULTS

Data from 865 patients indicated reductions in admissions of 5.6% and 54.4% during the HRP. In 2020, the hospitalisation time was longer (2.2 ± 2.7 days in 2019 vs. 2.4 ± 2.6 in 2020, p = 0.045); the proportions of wounds requiring surgical therapy (p = 0.008) and of observational treatments, primarily for mild brain injuries (p = 0.046), were higher; and conservative treatments, primarily for contusions, were lower (p = 0.005). There were no significant changes in age, location of lesions, or frequency of surgical therapy; nor were there differences in the HRP, except for fewer injuries in school and kindergarten (p < 0.001). The literature review summarises the main results of 79 studies.

CONCLUSION

Limited resources did not alter the indications for surgical therapy. Further studies should examine whether the more common injuries sustained at home were caused by excessive work/childcare demands on parents. Reduced inpatient conservative treatment implies that hospital resources possibly were overused previously. The literature offers answers to many detailed questions regarding childhood injuries during a pandemic and more efficient safe treatment. Registration Ethical committee of RWTH Aachen University EK 22-320; Center for Translational & Clinical Research RWTH Aachen University (CTC-A) 21-430.

Epidemiology of Paediatric Trauma During National Lockdown: A Retrospective Study With 12 Months of Follow-Up

Introduction The COVID-19 pandemic and its associated preventative measures such as national lockdown dramatically changed the daily activities of children. This paper aims to compare the epidemiology of paediatric orthopaedic trauma presentation, management and outcomes during the school closure period with the matched pre-pandemic period in 2019. Methods This was a retrospective cohort study of data collected from the West Yorkshire Trauma Network, comprising a major trauma centre, Leeds General Infirmary, and five peripheral trauma units. All patients aged 0-18 years who required trauma unit management during the school closure period (18 March 2020-25 May 2020) were included. Cases for the matched period in 2019 were analysed for baseline comparison. Patient demographics, mechanism and anatomical location of injury, management and follow-up were assessed. Results In the 2020 and 2019 cohorts, 286 and 575 injuries were observed, respectively. In the 2020 cohort, we observed a 50.3% (n=289) fall in paediatric trauma presentation and a significant proportional reduction in referrals from the emergency department (22% (n=63) versus 53% (n=305); p<0.001). There was also a significant reduction in the average age at presentation by more than one year (p<0.001). Sports-related injuries decreased significantly (n=16 (5.6%) versus n=127 (22.1%); p<0.001). While the proportion of ride-on injuries increased significantly, overall numbers remained similar (n=63 (22%) versus n=61 (10.6%); p<0.0001). Non-accidental injury (NAI) concerns rose significantly (n=9 (3.1%) versus n=4 (0.7%); p=0.01), but the absolute number of confirmed NAI cases stayed the same (n=2). There was a proportional increase in upper limb injuries (64.3% (n=184) versus 58.4% (n=336); p>0.05) and a proportional reduction in lower limb injuries (32.1% (n=92) versus 35.5% (n=204); p>0.05). However, the rate of tibial shaft injuries rose significantly (10.1% (n=29) versus 5.2% (n=30); p=0.02). The use of conservative management increased with a significant delay in average time to surgery from the date of injury (8.5 days versus 3.1 days; p=0.01). Patients who were only followed up with a telephone consultation rose significantly (23% (n= 66) versus 6% (n=35); p<0.001). Re-presentation rate increased significantly (1.4% (n=4) versus 0.2% (n=12); p=0.04). Conclusion Our study showed a reduction in paediatric trauma presentations during the pandemic and a significant reduction in the average age at presentation. This change has been accompanied by a shift in the mechanism and anatomical location of injury, management and subsequent follow-up.

Impact of adapting paediatric intensive care units for adult care during the COVID-19 pandemic: a scoping review

OBJECTIVES

The objectives were to categorise the evidence, map out the existing studies and explore what was known about the organisation of paediatric intensive care units (PICUs) during the first 18 months of the COVID-19 pandemic. Additionally, this review set out to identify any knowledge gaps in the literature and recommend areas for future research.

DESIGN

Scoping review.

METHODS

This study used Arksey and O'Malley's six-stage scoping review framework. A comprehensive search was conducted using the following databases, CINAHL Complete; MEDLINE; PsycINFO; PsycARTICLES and EMBASE and grey literature search engines. A search strategy with predefined inclusion criteria was used to uncover relevant research in this area. Screening and data collection were done in duplicate.

RESULTS

47 631 articles were obtained through searching. However, only 25 articles met the inclusion criteria and were included in the analysis. Three dominant themes emerged from the literature: (1) the reorganisation of space for managing increased capacity; (2) increased staffing and support; and (3) the resulting challenges.

CONCLUSION

COVID-19 has strained institutional resources across the globe. To relieve the burden on intensive care units (ICUs), some PICUs adjusted their units to care for critically ill adults, with other PICUs making significant changes, including the redeployment of staff to adult ICUs to provide extra care for adults. Overall, PICUs were collectively well equipped to care for adult patients, with care enhanced by implementing elements of holistic, family-centred PICU practices. The pandemic fostered a collaborative approach among PICU teams and wider hospital communities. However, specific healthcare guidelines had to be created to safely care for adult patients.

North Thames multi-centre service evaluation: Ethical considerations during COVID-19

Objectives

During the COVID-19 pandemic, healthcare resources including staff were diverted from paediatric services to support COVID-positive adult patients. Hospital visiting restrictions and reductions in face-to-face paediatric care were also enforced. We investigated the impact of service changes during the first wave of the pandemic on children and young people (CYP), to inform recommendations for maintaining their care during future pandemics.

Design

A multi-centre service evaluation was performed through a survey of consultant paediatricians working within the North Thames Paediatric Network, a group of paediatric services in London. We investigated six areas: redeployment, visiting restrictions, patient safety, vulnerable children, virtual care and ethical issues.

Results

Survey responses were received from 47 paediatricians across six National Health Service Trusts. Children's right to health was largely believed to be compromised by the prioritisation of adults during the pandemic (81%; n = 33). Sub-optimal paediatric care due to redeployment (61%; n = 28) and the impact of visiting restrictions on CYP's mental health (79%; n = 37) were reported. Decreased hospital attendances of CYP were associated with parental fear of COVID-19 infection-risks (96%; n = 45) and government 'stay at home' advice (89%; n = 42). Reductions in face-to-face care were noted to have disadvantaged those with complex needs, disabilities and safeguarding concerns.

Conclusion

Consultant paediatricians perceived that paediatric care was compromised during the first wave of the pandemic, resulting in harm to children. This harm must be minimised in subsequent pandemics. Recommendations for future practice which were developed from our findings are provided, including maintaining face-to-face care for vulnerable children.

Epidemiological shift of paediatric fracture characteristics during COVID-19 in Hong Kong – a reflection on bone health crisis

Introduction

Since the beginning of Coronavirus disease 2019 (COVID-19) pandemic, schools in Hong Kong were suspended intermittently as part of the anti-epidemic measure. This study aims to investigate the impact of COVID-19 pandemic on the epidemiology of paediatric fracture and bone health of children.

Methods

We recruited patients aged 3–17 admitted to tertiary paediatric orthopaedic trauma centres for fractures from 1st February 2020 till 4th March 2021 during COVID-19 period as study group and compared with patients admitted from 1st February 2019 till 31st January 2020 before COVID-19 as control group.

Results

Total number of admissions due to fracture was reduced by 49% (pre-COVID period: 345, COVID period: 177). Demographic data such as age, age group distribution, sex, location of fractures, energy of injury, prior history of fracture were comparable in the two groups. There was no statistically significant difference in the proportion of patients requiring operative treatment. Significant change was found in injury mechanisms, with injury related to body-powered vehicles (33.7%, n = 58) becoming the leading cause of injury during COVID period ( p < 0.001). There was significant drop in proportion of patient with injury from level ground fall ( p < 0.001) and sports ( p < 0.001). The percentage of obese children increased significantly ( p = 0.009) during the COVID period (32.7%, n = 48) than pre-COVID period (21.0%, n = 67). The proportion of patients with hypocalcaemia was found to be higher ( p = 0.002) during COVID period.

Conclusions

This study reflects paediatric bone health issues during COVID-19 pandemic. We postulate the reduction in fracture incidence, change in the distribution of injury mechanisms, and more obesity could be related to a more sedentary lifestyle during COVID period. Hypocalcaemia can be associated with reduced sunlight exposure, obesity, and lack of physical activities. If the problem is left neglected, it can lead to long-term bone health problems.

Did the COVID-19 pandemic lead to increased pediatric musculoskeletal nonaccidental trauma? A cross-sectional study

Lockdowns due to COVID-19 increased known risk factors for nonaccidental trauma (NAT), including economic instability and parental stress. We sought to evaluate potential changes in the frequency and types of fractures associated with NAT during the COVID-19 pandemic. A retrospective cross-sectional study was conducted using de-identified data obtained from the IBM Watson Health Explorys Cohort Discovery database. Systematized Nomenclature of Medicine-Clinical Terms were used to query the database for victims of NAT in 2019 and 2020. Within this cohort of patients, we then identified those who were also diagnosed with a fracture within 21 days of the NAT event. Demographic data were compared between 2019 and 2020 where possible using chi-squared testing, and relative risks for various fracture diagnoses were calculated with 95% confidence intervals. There were 9500 records overall of pediatric NAT in 2019 compared to 9350 in 2020. Of those, in 2019 550 were associated with a diagnosis of fracture versus 570 in 2020. The relative risk of fracture due to NAT in 2020 when compared to 2019 was not significantly higher [relative risk, 1.05 (95% confidence interval, 0.94-1.17)]. The relative risk for each category of fracture diagnosis in 2020 was slightly higher, but not to a statistically significant degree. Despite increasing known risk factors, the frequency of NAT remained unchanged as the result of the COVID-19 pandemic. We also did not identify significant changes in the risk of fracture due to NAT, nor any changes in the associated types of fractures.

The effect of COVID-19 lockdowns on paediatric lower limb orthopaedic presentations

INTRODUCTION

As the COVID-19 pandemic was spreading in 2020, the government imposed national lockdowns. We considered the effects these lockdowns had on the paediatric population, with a specific focus on lower limb orthopaedic trauma. We hypothesise that these restrictions will have altered the mechanisms of injury and reduced the number of referrals.

MATERIALS AND METHODS

We retrospectively analysed data from 28/08/19 to 01/04/21, considering the variations in referrals and operations during these times, and analysed these data using an online statistical calculator. We examined the rate of referrals, types of fractures referred to the centre, mechanism of injury, volume of operations performed, and average wait times to undergo an operation. The data were compared in pre-lockdown and lockdown times.

RESULTS

67 paediatric patients with lower limb fractures were included in this study. Throughout the lockdown periods, the mean age of children referred was younger (6.9 from 11.1) and they were less likely to be injured as a result of sport (p = 0.0493). They were more likely to fracture their lower leg (p = 0.0016) when compared with other anatomical regions. The average weekly rate of referrals dropped (0.84-0.68), but the rate of operations almost quartered (0.39-0.16). The average wait times for operations dropped significantly, with patients waiting 80% less time from the date of their injury.

CONCLUSION

This study highlights the impact of the coronavirus pandemic on the prevalence and management of lower limb paediatric trauma. The demographics and mechanisms of injury which presented to the trust over the pandemic and associated national lockdowns were significantly different. There was a drop in the number of referrals and a preference to non-operative management when patients did present.

Effect of COVID 19 pandemic on time to care, use of ambulance, admission characteristics, demography, injury characteristics, management and outcome of Paediatric Orthopaedic trauma patients admitted to the trauma centre

Background: Lockdown imposed to limit the spread of COVID 19 may have had a significant effect on the time to care, demography, injury causation, injury characteristics, volume and nature of admission, management and outcome of paediatric orthopaedic trauma patients. Objective: To document the effect of lockdown on the time to care at KGMU, use of ambulance, volume and type of admissions, demography, injury causation, injury characteristics,  management and outcome of paediatric orthopaedic trauma patients. Methods:. This record review compared age, sex, type of admission, mechanism of injury, injury characteristics, type of treatment, vehicle used for transport, and outcome among patients admitted in pre-lockdown, lockdown and post lockdown.  Results: Lockdown was associated with decrease in the number of cases (p<0.01), increase in the time since injury to reception (p<0.040), a rise in the share of referred admission (p<0.040), time since reception at KGMU, time to definitive care (p<0.001), high energy falls (p<0.001), injuries at home (p<0.001), higher ISS (p<0.001), non operative treatment (p=0.038) and greater use of ambulance  (p=0.003). Conclusion: Lockdown resulted in a significant change in the causation and management of injury, significant delays in timeliness of care, reduction in the volume of admissions, an increase in injury severity and share of referral admissions.

Impact of COVID-19 on outpatient appointments in children and young people in England: an observational study

OBJECTIVES

To describe the impact of the COVID-19 pandemic on outpatient appointments for children and young people.

SETTING

All National Health Service (public) hospitals in England.

PARTICIPANTS

All people in England aged <25 years.

OUTCOME MEASURES

Outpatient department attendance numbers, rates and modes (face to face vs telephone) by age group, sex and socioeconomic deprivation.

RESULTS

Compared with the average for January 2017 to December 2019, there was a 3.8 million appointment shortfall (23.5%) for the under-25 population in England between March 2020 and February 2021, despite a total rise in phone appointments of 2.6 million during that time. This was true for each age group, sex and deprivation fifth, but there were smaller decreases in face to face and total appointments for babies under 1 year. For all ages combined, around one in six first and one in four follow-up appointments were by phone in the most recent period. The proportion of appointments attended was high, at over 95% for telephone and over 90% for face-to-face appointments for all ages.

CONCLUSIONS

COVID-19 led to a dramatic fall in total outpatient appointments and a large rise in the proportion of those appointments conducted by telephone. The impact that this has had on patient outcomes is still unknown. The differential impact of COVID-19 on outpatient activity in different sociodemographic groups may also inform design of paediatric outpatient services in the post-COVID period.

Nurturing care during COVID-19: a rapid review of early evidence

OBJECTIVES

The COVID-19 pandemic has brought significant changes to family life, society and essential health and other services. A rapid review of evidence was conducted to examine emerging evidence on the effects of the pandemic on three components of nurturing care, including responsive caregiving, early learning, and safety and security.

DESIGN

Two academic databases, organisational websites and reference lists were searched for original studies published between 1 January and 25 October 2020. A single reviewer completed the study selection and data extraction with verification by a second reviewer.

INTERVENTIONS

We included studies with a complete methodology and reporting on quantitative or qualitative evidence related to nurturing care during the pandemic.

PRIMARY AND SECONDARY OUTCOME MEASURES

Studies reporting on outcomes related to responsive caregiving, early learning, and safety and security were included.

RESULTS

The search yielded 4410 citations in total, and 112 studies from over 30 countries met our eligibility criteria. The early evidence base is weighted towards studies in high-income countries, studies related to caregiver mental health and those using quantitative survey designs. Studies reveal issues of concern related to increases in parent and caregiver stress and mental health difficulties during the pandemic, which was linked to harsher and less warm or responsive parenting in some studies. A relatively large number of studies examined child safety and security and indicate a reduction in maltreatment referrals. Lastly, studies suggest that fathers' engagement in caregiving increased during the early phase of the pandemic, children's outdoor play and physical activity decreased (while screen time increased), and emergency room visits for child injuries decreased.

CONCLUSION

The results highlight key evidence gaps (ie, breastfeeding support and opportunities for early learning) and suggest the need for increased support and evidence-based interventions to ensure young children and other caregivers are supported and protected during the pandemic.

Organisation of care in paediatric intensive care units during the first 18 months of the COVID-19 pandemic: a scoping review protocol

INTRODUCTION

The emergence of COVID-19 has had a significant impact on hospital services, particularly care delivered to those in intensive care units (ICUs) and paediatric ICUs (PICUs) across the world. Although much has been written about healthcare delivery and the healthcare setting since COVID-19 began, to the authors' knowledge, this is the first scoping review to investigate the organisation of care and changes implemented in PICUs during the COVID-19 pandemic. The aim is to conduct a scoping review of the literature to map out the existing studies about care delivery in PICUs during the COVID-19 pandemic and the changes made to the organisation of care in these units during the first 18 months of the pandemic. This review will also identify gaps in current knowledge in this area.

METHODS AND ANALYSIS

This study will be guided by the Joanna Briggs Institute's methodology for scoping reviews, using Arksey and O'Malley's six-stage scoping review framework: (1) identifying the research question; (2) identifying relevant studies; (3) selecting the studies; (4) data charting; (5) collating, summarising and reporting results; and (6) consulting with experts. A comprehensive search will be conducted using the following databases: CINAHL Complete; MEDLINE; PsycINFO; PsycARTICLES and EMBASE. A search strategy with predefined inclusion and exclusion criteria will be used to uncover relevant research in this area. This study will include quantitative, qualitative and mixed research methods studies published in English from 2019 to May 2021.

ETHICS AND DISSEMINATION

Ethical approval is not required for this scoping review. The results from this study will be disseminated through conferences and in peer-reviewed academic journals for those working in the healthcare arena.

Global Impact of the COVID-19 Pandemic on Orthopedics and the Implications of Telemedicine: A Systematic Review of the Literature

This study aimed to systematically review the literature on the impact of the coronavirus disease (COVID-19) pandemic on the orthopedics field by focusing on multiple aspects, including orthopedic training and application, performance, work loading, change of practice, research work, and other psychological factors. Published articles were searched using the PubMed database. Articles were selected in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Of 58 studies published between 1 January 2020 and 1 October 2021, 57 peer-reviewed original articles were included. Nearly 90% of students experienced an impact of the pandemic on application. The impact on training stemmed from redeployment rates of 20.9–23.1%. The rate of emergency or outpatient visits decreased from 18% to 58.6%. The rates of all surgeries or emergency surgeries decreased by 15.6–49.4%, while the rates of elective surgeries decreased by 43.5–100%. The rate of work loading ranged from 33% to 66%. Approximately 50–100% of surgeons had a change of practice. A total of 40.5% of orthopedic surgeons experienced mild psychological pressure. Approximately 64% had stopped research participant recruitment. Most of the included studies were conducted in Europe, followed by Asia and North America. It is suggested orthopedic surgeons prepare more sufficient, flexible, and reservable staffing measures, proper preventive strategies and surgical scheduling algorithms, and set up dedicated venues and equipment for routine telemedicine with staff training for virtual teaching or consultations in case of future impacts on orthopedics.

Orthopaedic, trauma surgery, and Covid-2019 pandemic: clinical panorama and future prospective in Europe

Purpose

This study investigated the impact of the Covid-19 pandemic in Europe on consultations, surgeries, and traumas in the field of orthopaedic and trauma surgery. Strategies to resume the clinical activities were also discussed.

Methods

This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the 2020 PRISMA statement. All the comparative studies reporting data on the impact of Covid-19 in the field of orthopaedic and trauma surgery in Europe were accessed. Only comparative clinical studies which investigated the year 2020 versus 2019 were eligible.

Results

57 clinical investigations were included in the present study. Eight studies reported a reduction of the orthopaedic consultations, which decreased between 20.9 and 90.1%. Seven studies reported the number of emergency and trauma consultations, which were decreased between 37.7 and 74.2%. Fifteen studies reported information with regard to the reasons for orthopaedic and trauma admissions. The number of polytraumas decreased between 5.6 and 77.1%, fractures between 3.9 and 63.1%. Traffic accidents admissions dropped by up to 88.9%, and sports-related injuries dropped in a range of 59.3% to 100%. The overall reduction of the surgical interventions ranged from 5.4 to 88.8%.

Conclusion

The overall trend of consultations, surgeries, and rate of traumas and fragility fractures appear to decrease during the 2020 European COVID pandemic compared to the pre-pandemic era. Given the heterogeneities in the clinical evidence, results from the present study should be considered carefully.

Level of evidence

Level IV, systematic review.

Impact of the First COVID Lockdown on Accident- and Injury-Related Pediatric Intensive Care Admissions in Germany—A Multicenter Study

Children’s and adolescents’ lives drastically changed during COVID lockdowns worldwide. To compare accident- and injury-related admissions to pediatric intensive care units (PICU) during the first German COVID lockdown with previous years, we conducted a retrospective multicenter study among 37 PICUs (21.5% of German PICU capacities). A total of 1444 admissions after accidents or injuries during the first lockdown period and matched periods of 2017–2019 were reported and standardized morbidity ratios (SMR) were calculated. Total PICU admissions due to accidents/injuries declined from an average of 366 to 346 (SMR 0.95 (CI 0.85–1.05)). Admissions with trauma increased from 196 to 212 (1.07 (0.93–1.23). Traffic accidents and school/kindergarten accidents decreased (0.77 (0.57–1.02 and 0.26 (0.05–0.75)), whereas household and leisure accidents increased (1.33 (1.06–1.66) and 1.34 (1.06–1.67)). Less neurosurgeries and more visceral surgeries were performed (0.69 (0.38–1.16) and 2.09 (1.19–3.39)). Non-accidental non-suicidal injuries declined (0.73 (0.42–1.17)). Suicide attempts increased in adolescent boys (1.38 (0.51–3.02)), but decreased in adolescent girls (0.56 (0.32–0.79)). In summary, changed trauma mechanisms entailed different surgeries compared to previous years. We found no evidence for an increase in child abuse cases requiring intensive care. The increase in suicide attempts among boys demands investigation.

Impact of the Coronavirus Disease Pandemic on Patients with Head Injuries in South Korea

Objective

The coronavirus disease 2019 (COVID-19) pandemic is affecting the characteristics of patients with head injuries. This study aimed to evaluate the effect of the COVID-19 pandemic on patients with head injuries at a regional emergency medical center in South Korea.

Methods

From April 2019 to November 2020, 350 patients with head injuries were admitted to our hospital. The study period was divided into the pre-COVID-19 (n=169) and COVID-19 (n=181) eras (10 months each). Patients with severe head injuries requiring surgery (n=74) were categorized into those who underwent surgery (n=41) and those who refused surgery (n=33).

Results

Head injuries in pediatric patients (<3 years) were more frequent in the COVID-19 era than in the pre-COVID-19 era (8.8% vs. 3.6%, p=0.048). More patients refused surgery in the COVID-19 era than in the pre-COVID-19 era (57.9% vs. 30.6%, p=0.021). Refusal of surgery was associated with old age (67.7±14.5 vs. 52.4±19.1, p<0.001), marital status (married, 84.8% vs. 61.0%, p=0.037), unemployment (42.4% vs. 68.3%, p=0.034), COVID-19 era (66.7% vs. 39.0%, p=0.021), and lower Glasgow coma scale scores (6.12±3.08 vs. 10.6±3.80, p<0.001). Multivariable logistic regression analysis revealed that refusal of surgery was independently associated with old age (adjusted odds ratio [OR], 1.084; 95% confidence interval [CI], 1.030–1.140; p=0.002), COVID-19 era (adjusted OR, 6.869; 95% CI, 1.624–29.054; p=0.009), and lower Glasgow coma scale scores (adjusted OR, 0.694; 95% CI, 0.568–0.848; p<0.001).

Conclusion

We observed an increased prevalence of head injuries in pediatric patients (<3 years) during the COVID-19 pandemic. Additionally, among patients with severe head injuries requiring surgery, more patients refused to undergo surgery during the COVID-19 pandemic.

Course of Treatment and Short-Term Outcome of Surgically Treated Paediatric Upper Limb Fractures during the COVID-19 Pandemic—Experiences of a Level 1 Trauma Centre in Central Europe

The COVID-19 pandemic and the resulting restrictions led to a reduced number of surgeries. This study examines its impact on the course of treatment and clinical outcome of surgically treated paediatric upper limb fractures during that specific period. This retrospective cohort study evaluated all children aged 0–18 years presenting with an upper limb fracture treated surgically at the level 1 trauma centre of the University Clinic of Orthopaedics and Trauma Surgery of Vienna within lockdown from 16 March to 29 May 2020 (definition applied through corresponding legislation) compared to the same period from 2015 to 2019. A total number of 127 children (m:63; f:44) were included. The lockdown did not lead to a significant increase in complications during and after initial surgery. Time until removal of implant was not significantly prolonged (p = 0.068; p = 0.46). The clinical outcome did not significantly differ compared to previous years. The experience of a level 1 trauma centre showed that despite reduced surgical capacity during the COVID-19 pandemic, no negative differences concerning course of treatment and clinical outcome of surgically treated paediatric upper limb fractures were present. These findings are still of importance since the COVID-19 pandemic continues and several countries in Central Europe are currently under their fourth lockdown.

Seasonal variation in paediatric orthopaedic trauma Patients - A single centre experience from Turkey

PURPOSE

It is known that the incidence of paediatric orthopaedic trauma peaks in the summer months as a result of increased and uncontrolled physical activity. The aim of this study was to review the experience of a single centre with paediatric orthopaedic traumas and determine the relationship between the severity and the variations in the incidence of traumas in relation to the seasons and temperatures during the study period.

MATERIALS AND METHODS

A single institutional review of the historical data of all patients aged 0-16 years who presented for orthopaedic trauma between January 2018 and December 2020 in the emergency department of Level 1 tertiary orthopaedic trauma centre was conducted. 65,182 paediatric orthopaedic trauma cases had been retrieved from the hospital data base during the 3 -year study period. We classified the traumas according to the variants of the patients' and by holidays, seasons, school days and weekends, months and in which part of the body it occurred.

RESULTS

After excluding the summer vacation, 77% of paediatric orthopaedic trauma patients attended to the hospital on weekdays and 23% on weekends. While it was observed that hot weather had a statistically positive effect on trauma attendance, rainy weather had an negative effect (p < 0.05). Trauma attendances were found to be statistically higher in summer months, except for injuries that may occur with indoor activities such as metacarpal fracture, phalanx fracture and pulled elbow (p < 0.05).

CONCLUSION

Orthopaedic trauma at a Level 1 tertiary health care trauma center do vary significantly with the weather and are highest in the summer season. Therefore, it should focus more attention on preventive strategies for paediatric trauma in the summer season.

COVID-19 Pandemic Impact on Orthopaedic Trauma Practice: A Global Perspective

BACKGROUND AND OBJECTIVE

We conducted a systematic review to evaluate the global impact on orthopaedic trauma admissions during the COVID-19 crisis and compare it to that in Saudi Arabia.

METHODS

We conducted an extensive search of the PubMed and the Cochrane Central Register of Clinical Trials databases for articles published on orthopaedic trauma during the pandemic. We used the terms "orthopaedic trauma", "coronavirus", "covid-19", and "Sars-cov-2" for the search. We retrieved data to assess the impact of COVID-19 on orthopaedic and trauma patients attending hospitals during the pandemic. Secondary outcomes included reports from various regions of the world, differences in patient age, gender, and comparison to the nonlockdown period. We excluded questionnaires, surveys, reviews, and meta-analyses. The studies were divided based on where they were conducted: the Americas; the United Kingdom; Europe; Asia; the Middle East; and Australia, including New Zealand.

RESULTS

We retrieved 763 studies using the keywords and initially analyzed 70. We chose 23 studies for final analysis, which were all retrospective studies, from which we extracted 50% of our preset data. These articles included 16,383 patients who sought advice related to orthopaedic and trauma necessities during the pandemic. Before the pandemic, 61,559 patients sought advice for orthopaedic and trauma necessities. Most of the reports focused on adults, and in three studies, researchers reported on paediatric on orthopaedic patients. The average decrease in patients seeking orthopaedic and trauma assistance during the pandemic was 45.5 ± 20.4 (range 18.9-86%, p < 0.001). The largest decrease in patients seeking advice occurred in Asia (>60%), and the lowest occurred in Australia and New Zealand (about 20%, p < 0.001).

CONCLUSION

Presentations of orthopaedic trauma during the COVID-19 during pandemic lockdown was less but not as profoundly as one may have expected.

Epidemiology and incidence of paediatric orthopaedic trauma workload during the COVID-19 pandemic: A multicenter cohort study of 3171 patients

BACKGROUND

Coronavirus disease 2019 (COVID-19) has a major influence on all parts of society.

AIM

To examine the consequences of the national lockdown and political initiatives during the first surge of the COVID-19 pandemic expressed by changes in incidences of musculoskeletal paediatric injuries.

METHODS

Study design was a retrospective multicenter cohort study. A ‘pandemic’ cohort was established from 16 March 2020 to 21 April 2020, where all institutions including day care and schools were closed. A ‘pre-pandemic’ cohort was established from the same period in 2019 for comparison. Included were all patients admitted at the emergency departments with paediatric musculoskeletal injuries (aged 0-15 years) identified by a relevant musculoskeletal ICD-10 diagnosis (DSxxx), concussions (DZ033D), or burns (DT2xx).

RESULTS

The ‘pre-pandemic’ cohort consisted of 2101 patients, and the ‘pandemic’ cohort consisted of 1070 patients, indicating a decrease of paediatric musculoskeletal injuries of 51%. The incidence of paediatric injury in the ‘pre-pandemic’ cohort was 10460/100000/year. In the ‘pandemic’ cohort, the incidence was 5344/100000/year.

CONCLUSION

A resource re-allocation to help serve the COVID-19 patients might be possible without reducing the level of care for injury-related paediatric patients.

Multi-day delay to care identified in pediatric trauma cases during COVID-19

This study aims to establish how pediatric fracture patterns were altered at a level 1 trauma center in a state that implemented a shutdown during the initial height of COVID-19. After IRB approval, we identified 2017 patients treated at a pediatric institution for definitive management of a fracture between 26 March and 31 May 2018, 2019, or 2020. Dates were chosen based on statewide stay-at-home orders for Colorado. Patients were excluded for treatment at another institution (n = 148), no fracture noted in clinic (n = 18), or other (n = 13). Data were retrospectively collected from the remaining 1838 patients regarding demographics, fracture injury, mechanism, and treatment. Odds ratios (ORs) were calculated for each variable during COVID-19 relative to prior years. The number of fractures during 2020 decreased by 26% relative to 2019 and 23% to 2018. A larger proportion of patients experienced at least a 5-day delay to definitive treatment [OR: 1.55, confidence interval (CI): 1.23-1.96, P = 0.0002]. Rates of non-accidental trauma (NAT) increased non-significantly (OR: 2.67, CI: 0.86-8.32, P = 0.0900) during 2020 (1.2%) relative to 2018 (0.6%) and 2019 (0.3%). Fractures occurring at home increased to 79.9% (OR: 6.44, CI: 5.04-8.22, P < 0.0001). Despite less overall trauma during shelter-in-place orders, greater fracture numbers were seen among younger children and severe fractures were likely among older children. Patients may hesitate to seek care during 2020. Rates of NAT doubled during 2020. As communities prepare for future waves, treatment centers should warn against common fracture mechanisms and raise awareness of NAT.

The Impact of the COVID-19 Pandemic on the Most Common Diagnoses in Pediatric Surgery: Abdominal Pain, Acute Scrotum, Upper and Lower Extremity Injuries-Tertiary Center Experience

OBJECTIVE

The coronavirus disease-19 pandemic has brought new patterns of behavior among patients and their parents. The reorganization of the health care system has reduced the number of elective surgical procedures in Croatia. In our study, we were interested in whether the pandemic has caused a statistically significant decrease in the number of examinations of children in the emergency department according to the most common diagnoses in pediatric surgery and whether there was a decrease in the number of emergency surgeries.

MATERIALS AND METHODS

We retrospectively analyzed data from the Hospital Information System. The analysis included 15 months of the pre-coronavirus disease-19 period and 15 months of the coronavirus disease-19 period. The primary outcome of the study was to determine the cumulative number of all examinations and then to determine the number of examinations according to the most common diagnoses and, consequently, to determine whether there was a statistically significant decrease. The secondary outcome was to determine the cumulative number of all operations and then to determine the number of the most common emergency operations and, consequently, to see if there was a statistically significant decrease.

RESULTS

In the 15 months of the pre- coronavirus disease-19 period, a total of 33 646 children were examined in the emergency department, while in the coronavirus disease-19 period, 26 831 were examined (P = .010). Although a decrease was recorded in all categories, a statistically significant decrease was recorded for diagnoses of abdominal pain (P = .007) and lower extremity injuries (P = .014). The total number of operations, due to strict measures and reduction of the elective program, decreased statistically significantly in the coronavirus disease-19 period (P < .0001). The number of most common emergency operations did not decrease statistically significantly.

CONCLUSION

This study represents the first longer, 15-month experience of a pandemic in the only and largest children's hospital in Croatia. There is no doubt that coronavirus disease-19 had the effect of reducing the number of examinations in the emergency department for all the most common diagnoses, but the number of operations did not change significantly.

Impact of the National Lockdown Due to the COVID-19 Pandemic On Upper Limb Trauma Workload in Central London: A Multi-Centre Longitudinal Observational Study During Implementation and Ease of National Lockdown

BACKGROUND

This study assessed the impact of the COVID-19 pandemic on acute upper limb referrals and operative case-mix at the beginning and ease of British lockdown.

METHODS

A longitudinal multicentre observational cohort study was conducted for both upper limb trauma referrals and operative case-mix over a 12-week period (6 weeks from the beginning and 6 weeks from the ease of the national lockdown). Statistical analysis included median (± median absolute deviation), risk and odds ratios, and Fisher's exact test to calculate the statistical significance, set at p ≤ 0.05.

RESULTS

There was a 158% (n = 456 vs. 177) increase in upper limb referrals and 133% (n = 91 vs. 39) increase in the operative trauma caseload at the ease of lockdown compared with its commencement. An increase in sporting injuries was demonstrated (p=0.02), specifically cycling (p=0.004, OR=2.58). A significant increase in COVID-19 testing was demonstrated during the ease of lockdown (p=0.0001) with more patients having their management changed during the beginning of the pandemic (9.6% vs. 0.7%, p=0.0001). Of these patients, 47% went on to have delayed surgery within 6 months. No patients who underwent surgery tested positive for COVID-19 infection within 14 days post-operatively and no mortalities were recorded at 30 days.

CONCLUSION

The ease of lockdown has seen upper limb referrals and operations more than double compared to early lockdown. With no patients testing positive for COVID-19 within 14 days of the procedure, this demonstrates that having upper limb surgery during the current pandemic is safe.

Natural language processing of radiology reports to investigate the effects of the COVID-19 pandemic on the incidence and age distribution of fractures

OBJECTIVE

During the COVID-19 pandemic, the number of patients presenting in hospitals because of emergency conditions decreased. Radiology is thus confronted with the effects of the pandemic. The aim of this study was to use natural language processing (NLP) to automatically analyze the number and distribution of fractures during the pandemic and in the 5 years before the pandemic.

MATERIALS AND METHODS

We used a pre-trained commercially available NLP engine to automatically categorize 5397 radiological reports of radiographs (hand/wrist, elbow, shoulder, ankle, knee, pelvis/hip) within a 6-week period from March to April in 2015-2020 into "fracture affirmed" or "fracture not affirmed." The NLP engine achieved an F₁ score of 0.81 compared to human annotators.

RESULTS

In 2020, we found a significant decrease of fractures in general (p < 0.001); the average number of fractures in 2015-2019 was 295, whereas it was 233 in 2020. In children and adolescents (p < 0.001), and in adults up to 65 years (p = 0.006), significantly fewer fractures were reported in 2020. The number of fractures in the elderly did not change (p = 0.15). The number of hand/wrist fractures (p < 0.001) and fractures of the elbow (p < 0.001) was significantly lower in 2020 compared with the average in the years 2015-2019.

CONCLUSION

NLP can be used to identify relevant changes in the number of pathologies as shown here for the use case fracture detection. This may trigger root cause analysis and enable automated real-time monitoring in radiology.

The Impact of COVID-19 Pandemic During Lockdown on the Veterinary Profession in Romania: A Questionnaire-Based Survey

The lockdown period in Romania lasted for 60 days and had the purpose of limiting the spread of SARS-CoV-2 virus outbreak and manage its consequences through emergency measures on many important areas of activity. This study aimed to gather, assess, analyze and disseminate relevant social, economic, and medical aspects on the impact of COVID-19 pandemic during lockdown on the veterinary profession in Romania. A survey was created using an online questionnaire platform, and disseminated. The survey was completed by a total of 409 individuals. A high number of respondents (71.64%; n = 293) felt exposed to medium or high risk of infection with SARS-CoV-2 at their workplace and many (56.97%; n = 233) felt that their professional environment was more stressful than usual during lockdown. Almost all respondents (89.73%; n = 367) declared the implementation of several control measures recommended by FECAVA and FVE (e.g., social distancing, wearing protective equipment, hand washing), but few mentioned the opportunity of remote work or visiting restrictions. Overall, the results show that the impact of lockdown lies directly on four main categories of importance on veterinarian professional's life—human resource, activity management, relationship between veterinarian and authorities, and continuing education.

The overall impact of COVID-19 on healthcare during the pandemic: A multidisciplinary point of view

BACKGROUND AND AIMS

The Coronavirus disease 2019 (COVID-19) pandemic globally changed the priorities of medical and surgical procedures. It has caused many healthcare systems to stop performing their routine screenings. Altering medical clinics to COVID-19 referral centers, lockdowns, and the public fear to refer to medical centers caused a significant reduction in the referral rate; especially in the elderly. This short review article highlights the transform in clinical practice during the post-COVID era and the need for future medical revolutions.

METHODS

A comprehensive literature search was separately performed by both authors. The articles published between 2019 and August 2021 were included in this study and selected according to a quality appraisal method.

RESULTS

We have summarized the possible corresponding changes in the diagnosis and treatment of all fields of medical care including internal medicine, surgical, and minor subcategories after the COVID-19 pandemic. We have also discussed the potential impacts of the pandemic on all these different categories and subcategories of medicine, including the outpatient setting and clinical work. We do believe that the lack of routine check-ups has led to an increase in the stage of disease in patients with a previously diagnosed problem. On the other hand, the dramatic change in the lifestyle of the population including restricted mobility and increased consumption of unhealthy food has caused metabolic syndrome and other new diseases that have not been diagnosed and properly managed.

CONCLUSION

Our findings revealed the urgent need for public health awareness. It indicated the need to carry out both psychological and screening approaches in the post-COVID era to not miss patients with a chronic disease and new cases who were undiagnosed during the COVID pandemic.

Neck of Femur Fractures in the First Eight Months of the COVID-19 Pandemic: A UK Systematic Review and Meta-Analysis

Neck of femur (NOF) fracture patients have significant 30-day mortality. The incidence of NOF fractures remained high during the coronavirus disease 2019 (COVID-19) pandemic in the United Kingdom. Consequently, numerous cases were complicated with concurrent severe acute respiratory syndrome coronavirus 2 infection. We performed a systematic review and meta-analysis of all studies from the United Kingdom related to NOF fractures and 30-day mortality outcomes during the pandemic.   A systematic review and meta-analysis was performed and reported as per the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Two reviewers independently searched on Medline for studies that were published between the 1st of March 2020 and the 1st of November 2020 in the United Kingdom. The following outcomes were compared: 30-day mortality, time to surgery, and anaesthetic risk.   A total of five articles were included in this review. In total, 286 patients with NOF fractures and COVID-19 infection were identified, with 30-day mortality ranging from 30.5% to 50% (odds ratio = 6.02; 95% confidence interval = 4.10-8.85; χ² = 4.82; I² = 58%). Increased time to surgery due to COVID-19-related delays was also noted for the majority of patients in some studies. Mortality scores (Charlson Comorbidity Index, Nottingham Hip Fracture Score) failed to accurately predict the mortality risk. Concurrent infection of COVID-19 in patients with NOF fractures increases the 30-day mortality sixfold compared to the COVID-19-negative group. Efforts should be made to optimise time to surgery as well as consideration of postoperative care in higher dependency units. Future updates in mortality predicting scores should include COVID-19 infection as a significant factor.

Reduced presentations with fractures or orthopaedic infections to a major children's hospital during a national COVID-19 elimination strategy

Background

From 26 March 2020, New Zealand implemented a COVID‐19 elimination strategy which initially involved substantive limitations on public movement and assembly, and closure of non‐essential businesses. We asked what effect this had on acute paediatric orthopaedic presentations to a tertiary children's hospital.

Method

The numbers, age and gender of patients with orthopaedic presentations, seen by either the Children's Emergency Department (CED) or the orthopaedic service during the study period, were compared with the equivalent 2019 period.

Results

During the first 64 days of lockdown, 708 patients were seen in CED with orthopaedic presentations compared with 1124 patients in the same period in 2019 (37% reduction). We found a 55% reduction in musculoskeletal infections (from 135 to 61), a 40% reduction in total fractures (from 446 to 268) and a 27% reduction in soft tissue injuries (from 520 to 380). In 2020, similar proportions of patients were admitted for operating room procedures (15%) or had fractures reduced under sedation in CED (17%), however, increased numbers of soft tissue injuries were managed through CED under procedural sedation.

Conclusion

A national COVID‐19 elimination strategy, closing all but essential businesses, limiting public movement, physical distancing and focusing on hand hygiene, led to reduced presentations not only with fractures and soft tissue injuries but also musculoskeletal infections. Increased numbers of patients had procedural sedation for soft tissue injuries, but there was no significant change in the proportion of patients admitted for surgery.

Telemedicine trends in orthopaedics and trauma during the COVID-19 pandemic: A bibliometric analysis and review

Objectives

In the wake of recent widespread interest in telemedicine during the COVID-19 era, many orthopaedic surgeons may be unfamiliar with clinical examination skills, patients’ safety, data security, and implementation-related concerns in telemedicine. We present a bibliometric analysis and review of the telemedicine-related publications concerning orthopaedics care during the COVID-19 pandemic. Such analysis can help orthopaedic surgeons become acquainted with the recent developments in telemedicine and its usage in regular orthopaedics practice.

Methods

We systematically searched the database of Thomson Reuters Web of Science for telemedicine-related articles in orthopaedics published during the COVID-19 pandemic. The selected articles were analysed for their source journals, corresponding authors, investigating institutions, countries of the corresponding authors, number of citations, study types, levels of evidence, and a qualitative review.

Results

Fifty-nine articles meeting the inclusion criteria were published in 28 journals. Three hundred forty-two authors contributed to these research papers. The United States (US) contributed the most number of articles to the telemedicine-related orthopaedics research during the COVID-19 era. All articles combined had a total of 383 citations and 66.1% were related to the Economic and Decision-making Analyses of telemedicine implementation. By and large, level IV evidence was predominant in our review.

Conclusion

Telemedicine can satisfactorily cover a major proportion of patients' visits to outpatient departments, thus limiting hospitals’ physical workload. Telemedicine has a potential future role in emergency orthopaedics and inpatient care through virtual aids. The issues related to patient privacy, data security, medicolegal, and reimbursement-related aspects need to be addressed through precise national or regional guidelines. Lastly, the orthopaedic physical examination is a weak link in telemedicine and needs to be strengthened.

Incidence of pediatric injury visits decreased while trauma surgeries remained stable during the first and second waves of the COVID-19 pandemic in Finland: a register-based study

Introduction

The COVID-19 pandemic has reduced pediatric emergency department (ED) visits and surgeries. This study evaluates the incidence of pediatric trauma ED visits and surgeries in Finland during the first and second waves of the pandemic.

Methods

Three large Finnish hospitals, covering one-sixth of the Finnish pediatric population, participated. Data on all ED visits and trauma surgeries between January 2017 and December 2020 were collected from hospital discharge registers. Monthly incidences with 95% CI were calculated per 100 000 person-months by Poisson exact method and compared by incidence rate ratio (IRR).

Results

During the lockdown the incidence of head injuries (IRR 0.19, 95% CI 0.04 to 0.87), sprains (IRR 0.25, 95% CI 0.14 to 0.46), and fractures (IRR 0.36, 95% CI 0.25 to 0.51) decreased in the 13–17 years age group. In the 4–12 years age group a 55% decrease (IRR 0.45, 95% CI 0.22 to 0.96) in head injuries was observed. During the period of regional restrictions a subtle decrease in head injuries was seen in the 13–17 years age group (IRR 0.26, 95% CI 0.09 to 0.78). During the lockdown in March 2020 the incidence of fractures decreased in the oldest age group (13–17 years) (IRR 0.62, 95% CI 0.46 to 0.85), while a rebound in incidence was seen at the end of the lockdown period in June.

Conclusion

The nationwide lockdown and the cancellation of sports and other hobbies markedly decreased the injuries among children aged 13–17 years, while the decrease was lower among children aged 4–12 years. Cancellation of sports and hobbies did not affect patients under 4 years of age.

Caring for a sick or injured child during the COVID-19 pandemic lockdown in 2020 in the UK: An online survey of parents' experiences

BACKGROUND

During the COVID-19 pandemic, the first UK lockdown (March to May 2020) witnessed a dramatic reduction in children presenting to primary/emergency care, creating concern that fear of the virus was resulting in children presenting late.

METHODS

An online survey was co-developed with UK parents to understand the impact of the lockdown on parents' help-seeking for, and care of, their sick/injured child(ren). The survey was advertised through social media and snowballing to parents whose children had been ill/injured during the lockdown. Analysis used descriptive statistics, SPSSv25 and thematic analysis.

RESULTS

The survey was fully completed by 198 UK parents. The majority asked for help (144/198): from their family doctor (78), national helplines (48) or an Emergency Department (23). Most reported that their decision-making had not changed, although how they sought help had changed. A few parents reported that the severity and duration of illness had increased because of uncertainty about and/or difficulty accessing services. Parents did not always report seeking help for symptoms rated red or amber by the Royal College of Paediatrics and Child Health. Parents reported accessing information through the internet or using information that they already had.

PARENT CONTRIBUTION

This was a collaboration with parents from survey development to dissemination, with two parents being integral members of our research team.

CONCLUSIONS

Our questionnaire was completed by parents who were not deterred from seeking help for their sick or injured children. Even for these parents, the lockdown changes to services created uncertainty about, and barriers to, accessing medical help for their children.

Does the Covid-19 pandemic affect ankle fracture incidence? Moderate decrease in Sweden

Background and purpose - While many other countries implemented strict regulations and restrictions for their citizens during the 1st wave of the Covid-19 pandemic, Sweden maintained a more restrained approach. The Swedish Public Health Agency emphasized individual responsibility and pushed for behavioral changes. With strict lockdown a 77% decrease in ankle fracture incidence has been reported. We investigated whether there was a change in the incidence of ankle fractures seen at 7 selected hospitals during the Covid-19 pandemic 2020.Patients and methods - Data on all ankle fractures treated at 7 selected departments during March 15 through June 15, 2020, and for the same period in the preceding 3 years (2017-2019), was retrieved from the Swedish Fracture Register. The number of fractures during the whole period and subsequent 30-day periods were compared between 2020 and 2017-2019, including subgroup analyses of age and sex.Results - The monthly rate of ankle fractures was reduced by 14% in 2020 (139 fractures) compared with 2017-2019 (161 fractures). Women had a 16% decrease and patients aged > 70 years had a 29% decrease. During the 1st 30-day period, a 26% decrease in fractures was seen.Interpretation - During the 1st wave of the Covid-19 pandemic, a moderate decline in the number of ankle fractures was seen. Women and patients aged > 70 years displayed the greatest reduction. The greatest reduction in incidence of fractures was seen during the 1st 30-day period. This indicates greater adherence to government recommendations regarding social distancing in these subgroups and during the 1st month of the pandemic. Changes in ankle fracture incidence may be a measure of lockdown extent.

Management of neurotrauma during COVID-19: a single centre experience and lessons for the future

INTRODUCTION

Traumatic brain injury (TBI) is amongst the leading causes of morbidity and mortality worldwide. The unprecedented emergence of COVID-19 has mandated neurosurgeons to limit viral spread and spare hospital resources whilst trying to adapt management plans for TBI. We aimed to characterize how this affects decision-making on TBI management and drive strategies to cope with future expected waves.

METHODS

Retrospective TBI data collection from a single tertiary referral unit was performed between: 01/04/2019 - 30/06/2019 ('Pre-Epidemic') and 01/04/2020 - 30/06/20 ('Epidemic'). Demographics, mechanism of injury, TBI severity, radiological findings, alcohol/anticoagulants/antiplatelets use, and management decisions were extracted.

RESULTS

646 TBI referrals were received in 'Pre-Epidemic' (N = 317) and 'Epidemic' (N = 280) groups. There was reduction in RTA-associated TBI (14.8 vs 9.3%; p = .04) and increase in patients on anticoagulants (14.2 vs 23.6%; p = .003) in the 'Epidemic' group. Despite similarities between other TBI-associated variables, a significantly greater proportion of patients were managed conservatively in local referring units without neurosurgical services (39.1 vs 56.8%; p < .0001), predominantly constituted by mild TBI.

CONCLUSION

Despite COVID-19 public health measures, the burden of TBI remains eminent. Increases in local TBI management warrant vigilance from primary healthcare services to meet post-TBI needs in the community.

Resilience Against COVID-19: How Italy Faced the Pandemic in Pediatric Orthopedics and Traumatology

Background: We aimed to investigate the variation of medical and surgical activities in pediatric orthopedics in Italy, during the year of the COVID-19 pandemic, in comparison with data from the previous two years. The differences among the first wave, phase 2 and second wave were also analyzed. Methods: We conducted a retrospective multicenter study regarding the clinical and surgical activities in pediatric orthopedics during the pandemic and pre-pandemic period. The hospital databases of seven tertiary referral centers for pediatric orthopedics and traumatology were queried for events regarding pediatric orthopedic patients from 1 March 2018 to 28 February 2021. Surgical procedures were classified according to the “SITOP Priority Panel”. An additional classification in “high-priority” and “low-priority” surgery was also applied. Results: Overall, in 2020, we observed a significant drop in surgical volumes compared to the previous two years. The decrease was different across the different classes of priority, with “high-priority” surgery being less influenced. The decrease in emergency department visits was almost three-fold greater than the decrease in trauma surgery. During the second wave, a lower decline in surgical interventions and a noticeable resumption of “low-priority” surgery and outpatient visits were observed. Conclusion: Our study represents the first nationwide survey quantifying the impact of the COVID-19 pandemic on pediatric orthopedics and traumatology during the first and second wave.

Epidemiology of pediatric trauma during the COVID-19 pandemic shelter in place

Introduction

The first COVID-19 cases occurred in the US in January of 2020, leading to the implementation of shelter in place. This study seeks to define the impact of shelter in place on the epidemiology of pediatric trauma.

Methods

We examined pediatric trauma admissions at 5 Level 1 and 1 Level 2 US pediatric trauma centers between January 1 and June 30, 2017–2020. Demographic and injury data were compared between pre– and post–shelter in place patient cohorts.

Results

A total of 8772 pediatric trauma activations were reviewed. There was a 13% decrease in trauma volume in 2020, with a nadir at 16 days following implementation of shelter in place. Injury severity scores were higher in the post–shelter in place cohort. The incidence of nonmotorized vehicle accidents and gunshot wounds increased in the post–shelter in place cohort.

Conclusion

We found an overall decrease in pediatric trauma volume following shelter in place. However, injuries tended to be more severe. Our findings help inform targeted injury prevention campaigns during future pandemics.

•

Shelter-in-place policies led to a 13% decrease in overall pediatric trauma volume.

•

Biggest decrease occurred in the 30 days surrounding the start of shelter in place.

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Nonmotorized vehicle accidents and gunshot wounds increased with shelter in place.

•

Injury severity was higher among the shelter-in-place cohort compared to controls.

•

The incidence of nonaccidental trauma did not change with shelter in place.

Increased proportion of physical child abuse injuries at a level I pediatric trauma center during the Covid-19 pandemic

BACKGROUND AND OBJECTIVES

The Covid-19 pandemic has forced mass closures of childcare facilities and schools. While these measures are necessary to slow virus transmission, little is known regarding the secondary health consequences of social distancing. The purpose of this study is to assess the proportion of injuries secondary to physical child abuse (PCA) at a level I pediatric trauma center during the Covid-19 pandemic.

METHODS

A retrospective review of patients at our center was conducted to identify injuries caused by PCA in the month following the statewide closure of childcare facilities in Maryland. The proportion of PCA patients treated during the Covid-19 era were compared to the corresponding period in the preceding two years by Fisher's exact test. Demographics, injury profiles, and outcomes were described for each period.

RESULTS

Eight patients with PCA injuries were treated during the Covid-19 period (13 % of total trauma patients), compared to four in 2019 (4 %, p < 0.05) and three in 2018 (3 %, p < 0.05). The median age of patients in the Covid-19 period was 11.5 months (IQR 6.8-24.5). Most patients were black (75 %) with public health insurance (75 %). All injuries were caused by blunt trauma, resulting in scalp/face contusions (63 %), skull fractures (50 %), intracranial hemorrhage (38 %), and long bone fractures (25 %).

CONCLUSIONS

There was an increase in the proportion of traumatic injuries caused by physical child abuse at our center during the Covid-19 pandemic. Strategies to mitigate this secondary effect of social distancing should be thoughtfully implemented.

Maintaining Medical Resources to Treat Paediatric Injuries during COVID-19 Lockdown Is Essential-An Epidemiological Analysis of a Level 1 Trauma Centre in Central Europe

Background: This study examined the effect of the COVID-19 pandemic and the resulting decrease in the incidence of various categories of injuries, with the main focus on fractures and mild traumatic brain injuries in a paediatric population. Methods: This retrospective cohort study evaluated all children from 0 to 18 years of age presenting with an injury at the level 1 trauma centre of the University Clinic of Orthopaedics and Trauma Surgery in Vienna during the lockdown from 16 March to 29 May 2020 compared to records over the same timeframe from 2015 to 2019. Results: In total, 14,707 patients with injuries were included. The lockdown did not lead to a significant decrease in fractures but, instead, yielded a highly significant increase in mild traumatic brain injuries when compared to all injuries that occurred (p = 0.082 and p = 0.0001) as well as acute injuries (excluding contusions, distortions and miscellaneous non-acute injuries) (p = 0.309 and p = 0.034). Conclusions: The percentage of paediatric fractures did not decrease at the level 1 trauma centre, and a highly significant proportional increase in paediatric patients with mild traumatic brain injuries was observed during the COVID-19 lockdown. Therefore, medical resources should be maintained to treat paediatric trauma patients and provide neurological monitoring during pandemic lockdowns.

Impact of the Covid-19 Pandemic on Orthopaedic and Trauma Surgery - A Systematic Review of the Current Literature

BACKGROUND/AIM

The Coronavirus disease 2019 (COVID-19) has led to significant disruptions in various medical specialties. We herein aimed to provide a systematic review of the published literature on the impact by the Covid-19 pandemic on orthopaedic and traumatological care by focusing on the number of clinical visits, surgeries and reasons for consultation.

MATERIALS AND METHODS

The published literature was reviewed using PubMed. Of 349 studies published between December 1, 2019 and October 1, 2020, 36 original articles met the inclusion criteria. Articles were selected on the basis of the PRISMA guidelines. October 1, 2020 was used as the concluding date of publication.

RESULTS

The number of elective visits declined by 50.0% to 74.0%. The number of emergency and trauma visits showed a decrease of 37.7% to 74.2%. Trauma surgery decreased by 21.2% to 66.7% and elective surgeries by 33.3% to 100%.

CONCLUSION

Orthopaedic and trauma surgery is clearly influenced by the pandemic. It will be important to maintain treatment and surgical care of patients in order to avoid negative effects on treatment progress.

A multicentre national study of the effectiveness of virtual fracture clinic management of orthopaedic trauma during the COVID-19 pandemic (MAVCOV): a cross-sectional study protocol

Aims

Virtual fracture clinics (VFCs) are advocated by recent British Orthopaedic Association Standards for Trauma and Orthopaedics (BOASTs) to efficiently manage injuries during the COVID-19 pandemic. The primary aim of this national study is to assess the impact of these standards on patient satisfaction and clinical outcome amid the pandemic. The secondary aims are to determine the impact of the pandemic on the demographic details of injuries presenting to the VFC, and to compare outcomes and satisfaction when the BOAST guidelines were first introduced with a subsequent period when local practice would be familiar with these guidelines.

Methods

This is a national cross-sectional cohort study comprising centres with VFC services across the UK. All consecutive adult patients assessed in VFC in a two-week period pre-lockdown (6 May 2019 to 19 May 2019) and in the same two-week period at the peak of the first lockdown (4 May 2020 to 17 May 2020), and a randomly selected sample during the ‘second wave’ (October 2020) will be eligible for the study. Data comprising local VFC practice, patient and injury characteristics, unplanned re-attendances, and complications will be collected by local investigators for all time periods. A telephone questionnaire will be used to determine patient satisfaction and patient-reported outcomes for patients who were discharged following VFC assessment without face-to-face consultation.

Ethics and dissemination

The study results will identify changes in case-mix and numbers of patients managed through VFCs and whether this is safe and associated with patient satisfaction. These data will provide key information for future expert-led consensus on management of trauma injuries through the VFC. The protocol will be disseminated through conferences and peer-reviewed publication. This protocol has been reviewed by the South East Scotland Research Ethics Service and is classified as a multicentre audit.

Cite this article: Bone Jt Open 2021;2(3):211–215.

Association between COVID-19 public health interventions and major trauma presentation in the northern region of New Zealand

Background

The New Zealand government implemented restrictive public health interventions to eradicate Covid‐19. Early reports suggest that one downstream ramification is a change in trauma presentations. The aim of this study is to evaluate the effect these public health measures had on major trauma admissions in the Northern Region, New Zealand.

Methods

A retrospective comparative cohort study was performed. Two cohorts were identified: 16 March to 8 June 2020 and the same period in 2019. Data was extracted from the New Zealand Major Trauma Registry which prospectively collects data on all major trauma in New Zealand. All patients who presented to a hospital in the Northern Region with major trauma and met the Registry inclusion criteria were included.

Results

There were 163 major trauma admissions in 2019 and 123 in 2020, a reduction of 25% (rate ratio 0.75, 95% confidence interval 0.6–0.95; P = 0.018). There was no significant difference in mechanism of injury (P = 0.442), type of injury (P = 0.062) or intent of injury (P = 0.971). There was a significant difference in place of injury (P = 0.004) with 20% of injuries happening at home in 2019 compared with 35% in 2020.

Conclusion

This study has shown that public health interventions to prevent the spread of COVID‐19 reduced major trauma admissions in the Northern Region of New Zealand. There was a variation in effect a between institutions within the region and a change in pattern of injury.

Decreased volume of hip fractures observed during COVID-19 lockdown

INTRODUCTION

The aim was to study the incidence and characteristics of fragility hip fractures admitted during COVID-19 lockdown.

MATERIALS AND METHODS

We analysed socio-demographic and baseline characteristics of patients suffering fragility hip fractures between March 1st and May 1st 2020, period most affected by COVID-19 confinement measures. Cases (n = 64) were compared with controls (n = 172) from corresponding periods in 2018 and 2019. Poisson Generalised Linear Model regression analysis was performed to compare daily case counts, and LOESS curves compared time series.

RESULTS

No differences were found regarding age or gender distributions, pre-fracture living, ambulatory, functional or cognitive status. More patients in 2020 had a high-risk ASA score. Fewer cases [Reduction = 26% (95% CI 1-44%)] were admitted in 2020. The reduction seemed to correspond with confinement.

CONCLUSIONS

Approximately, one quarter less fragility hip fractures were admitted to our hospital during lockdown. Patients' baseline status and socio-demographic characteristics were similar.

Trends in hospital admissions for childhood fractures in England

PURPOSE

Fractures to the axial and appendicular skeleton are common in children causing loss of opportunities and disability. There are relatively few studies available to quantify the number of children who have their fractures diagnosed in the emergency department and are then admitted to hospital for ongoing management. The purpose of this study is to explore trends of frequency, types and age of children sustaining fractures who were admitted for intervention to National Health Service (NHS) hospitals.

DESIGN

The study uses data from the Hospital Episode Statistics and Office for National Statistics from 2012 to 2019 to calculate the annual incidence of hospital admission for limb, spine, facial and skull fractures per 100 000 children.

RESULTS

During 2012-2019, 368 120 children were admitted to English NHS hospitals with a fracture. 256 008 (69.5%) were upper limb fractures, 85 737 (23.3%) were lower limb fractures and 20 939 (5.7%) were skull or facial fractures. The annual incidence of upper limb fractures was highest in children aged 5-9 (348.3 per 100 000 children) and the highest incidence of lower limb fractures was in children aged 10-15 (126.5 per 100 000 children). The incidence of skull and facial fractures in preschool (age 0-4) children has been increasing at a rate of 0.629 per 100 000 children per year.

IMPLICATIONS

The annual incidence of hospital admission for fractures in children has been shown to be consistent for several fracture types between 2012 and 2019. An increasing trend of admissions with preschool skull fractures was observed, though the study data do not have sufficient granularity to demonstrate if this is due to changes in practice or to accidental or non-accidental causes.