Content of this journal is licensed under a Abstract
Objective:
The aim of this study was to compare the characteristics and distribution of trauma surgeries performed in the first phase of the COVID-19 pandemic, the second phase of the pandemic, and the normal period before the pandemic.
Methods:
Three different time periods were determined.Group 1 represented the first wave of the pandemic, in which lockdowns andrestrictions were strictly applied and only emergency and trauma surgeries wereperformed, between 1 April and 31 May 2020. Group 2 represented the second waveof the pandemic, during which restrictions were not applied and only emergencyand trauma surgeries were performed, from 1 September to 31 October 2020. Group3 represented the normal period before the pandemic, including surgeriesperformed between 1 September and 31 October 2019. In addition, patients ineach group were divided into two groups as younger than 16 or older than 16 inorder to understand the difference between paediatric and adult orthopaedictraumas. The distribution of patients and their fractures were evaluated.
Results:
In Group 1, the rates of intra-articular fractures, distal extremity fractures, and proximal humerus fractures decreased, while the rate of proximal femur fractures increased (P < 0.05 for all). The frequency of hand fractures treated in Groups 1 and 2 compared to Group 3 was reduced (P < 0.05 for both). There was no statistically significant difference between Groups 2 and 3 for fractures in different parts of the body except for hand fractures (P = 0.001 for hand fractures, P > 0.05 for the other fractures).
Conclusion:
We observed that the frequency of fractures decreased, and the distribution changed due to severe restrictions and lockdowns in the first wave of the pandemic. When the restrictions and lockdowns were removed in the second wave, the frequency of fractures decreased, but the distribution of fractures was similar to the normal period in 2019.
Level of Evidence:
Level III, Diagnostic Study
Keywords: Trauma surgery, COVID-19; First wave; Second wave; Orthopaedic trauma
Highlights
As a result of the restrictions and lockdown taken in the first wave of the pandemic, intra-articular fractures and distal extremity fractures operated in the first wave have decreased.
In the first wave, the rate of proximal humerus fractures operated decreased and the rate of proximal femur fractures operated were increased.
The rate of hand fractures operated was low during the pandemic.
In the second wave, a similar distribution of trauma was observed compared to the pre-pandemic period.
Considering the distribution and characteristics of trauma it is predicted that people can return to their normal habits when restrictions and lockdown are easing.
Introduction
The COVID-19 outbreak started with the first case reported in Wuhan, China, in December 2019, and is still continuing all over the world.1 The first case in Turkey was reported on 11 March 2020, and different social restrictions and lockdowns have been applied at different times to combat the COVID-19 pandemic.2
Measures began to be taken quickly after the first case was seen. Schools, entertainment venues, restaurants, and cafes were closed. Intercity trips were banned. A curfew was imposed on weekends. Online working applications were launched for both public and private employees. New regulations were introduced for the outpatient clinics of hospitals. Between 17 March and 6 June 2020, with the recommendation of the Ministry of Health, all elective surgeries were stopped in our city, and only emergency and trauma surgeries were performed during this period.3,4 As of June 2020, the restrictions were removed and a normalisation process started. The declining number of cases started to rise again as of August 2020. However, social restrictions such as curfews, intercity travel bans, and closure of restaurants, cafes, and entertainment venues were not applied during this period. No changes were made for public and private employees. However, elective surgeries were stopped again in hospitals, and only emergency and trauma surgeries were continued.4-6 There are many articles in the orthopaedic literature comparing the first wave of the COVID-19 pandemic with the previous periods in terms of trauma type and incidence.7,8,9,10 However, there is no publication yet comparing the first and second waves with each other and these periods with normal periods before the COVID-19 pandemic.
The aim of this study is to compare the first and second waves of the COVID-19 pandemic, where restrictions were applied differently, with each other and with the normal period before the pandemic in terms of trauma type, incidence, and surgical management of trauma. We also aim for orthopaedic surgeons to obtain new information about the course of orthopaedic trauma in different unfamiliar situations, such as in the current period, and to be better prepared for such situations in the future.
Materials and Methods
The study was begun after receiving the approval of the Ministry of Health and the hospital ethics committee (Ministry of Health Ethics Committee: 2020-11-02T19_30_15, date: 03/11/2020; Hospital Ethics Committee: E1-20-1350, date: 23/12/2020). Our hospital is one of the largest level 1 trauma centres and COVID-19 pandemic referral hospitals in the country. For this reason, the frequency of trauma patients is always very high.
First, three different time periods were determined and grouped. Group 1 represented the first wave of the pandemic, in which lockdowns and restrictions were strictly applied and only emergency and trauma surgeries were performed, between 1 April and 31 May 2020. Group 2 represented the second wave of the epidemic, during which restrictions were not applied and only emergency and trauma surgeries were performed, from 1 September to 31 October 2020. Group 3 represented the normal period before the pandemic, from 1 September to 31 October 2019. In addition, patients in each group were divided into two groups as younger than 16 years or older than 16 years in order to understand the difference between paediatric and adult orthopaedic traumas. Our hospital and clinical digital archives were evaluated retrospectively. All trauma patients who applied to our clinic and were operated on in the specified periods were included in the study. Patients who did not want to participate in the study, patients who could not be operated on despite hospitalisation, patients who were operated on in another centre and required revision surgery, and patients who were treated conservatively were excluded from the study.
A total of 714 trauma patients operated on in these three different periods were evaluated. A total of 8 (1.1%) patients [1 patient (0.1%) in the first wave, 2 patients (0.3%) in the second wave, and 5 patients (0.7%) in the pre-pandemic period] who underwent primary surgery in another centre but had revision surgery in our hospital were excluded from the study. Thus, a total 706 patients were included in the study. Patients with open fractures, severe ecchymosis, confirmed or suspected neurological injury, swelling requiring follow-up, multiple fractures, other additional systemic injuries, lower extremity fractures, pelvis-acetabulum fractures, vertebral fractures, and polytrauma were hospitalised from the emergency department, and preoperative preparations for these patients were made in the hospital. Patients with upper extremity fractures without these complications were prepared in the outpatient clinic and hospitalised. Both trauma patients who consulted the emergency service and patients who came to the outpatient clinic were evaluated. To avoid duplication, if a patient had more than one application to the hospital, it was calculated as a single application. Although most of the operated patients consulted the emergency service, there were also patients who were evaluated in the outpatient clinic. The age and gender of the patients in each group were noted. Fractured bones, locations, and types were evaluated and recorded individually for each patient. As stated in the Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification for extremities and the clavicle, fractures were classified according to their location (proximal, diaphyseal, and distal segment) and type (diaphysis, metaphysis, and intra-articular).
Polymerase Chain Reaction (PCR) testing was applied to all patients who were operated on during the pandemic period before surgery and patients were operated on after the results were obtained. Patients whose complaints, physical examinations, and laboratory and radiological findings indicated COVID-19 infection in spite of a negative PCR test were considered suspicious. The same approach was applied to suspicious patients as for PCR-positive patients. The patients who had open fractures and those requiring urgent intervention were operated on without waiting for PCR test results. Patients with positive PCR test results for whom it was not appropriate to wait for a negative test were also operated on. Personal protective equipment was used in the operations of all patients whose test results were suspicious or positive. No surgeons, anaesthesiologists, or staff who had COVID-19 contact, suspicion, and/or PCR positivity came into contact with the patients during the perioperative or follow-up periods.
Statistical analysis
The Shapiro–Wilk test was used to examine the conformity of continuous variables to normal distribution. Numerical variables were summarised by mean ± standard deviation and median (minimum; maximum), and categorical variables were summarised by frequency (percentage). After testing the necessary assumptions, the Kruskal– Wallis test was used to compare numerical variables in the groups. If a significant difference was determined, Dunn’s Bonferroni corrected pairwise comparison results were interpreted. For categorical variables, the Pearson chi-square test was used for comparison between groups, and the Monte Carlo Pearson chi-square test result was given when the number of subjects in the cell was low. SPSS 21.0 for Windows was used for statistical analysis (IBM SPSS Corp.; Armonk, NY, USA), and the statistical significance level was accepted as P < 0.05.
Results
There was no statistically significant difference between the groups in terms of age, child–adult population, gender, or number of patients with multiple fractures (P = 0.122, 0.973, 0.983, and 0.201, respectively). Patients’ demographic information is shown in Table 1. Total combined number of patients evaluated in the outpatient clinic and the emergency room during these time periods was 3093, 9224, and 12,028 in Groups 1-3, respectively. Compared to Group 3, the total number of patients evaluated decreased by 74.3% in Group 1 and 23.3% in Group 2. The number of trauma patients consulting the emergency department decreased by 37.5% in Group 1 compared to Group 3 but increased by 22.7% in Group 2 compared to Group 3. The total number of patients who were operated on in Groups 1-3 was 123, 250, and 333, respectively. The distribution of the number of patients by groups and age is shown in Figure 1. When the ratios of patients who were COVID-19-positive or suspicious were compared between Groups 1 and 2, there was no statistically significant difference (P = 0.611) (Table 1).
Figure 1.
Chart of the number and percentage of trauma patients.
Table 1.
Demographic Information of Patients Operated on
| Group 1 (First wave) (April – May 2020) | Group 2 (Second wave) (Sept. – Oct.2020) | Group 3 (Pre-pandemic) (Sept. – Oct.2019) | P | |
|---|---|---|---|---|
| Number of patients operated on | 123 | 250 | 333 | |
| Number of fractures operated on | 131 | 264 | 341 | |
| Age | ||||
| Mean ± SD | 46.31 ± 28.52 | 39.82 ± 24.73 | 40.85 ± 25.81 | 0.122£ |
| Median (min; max) | 48 (1; 95) | 36.5 (1; 92) | 36 (1; 93) | |
| Age group n (%) | ||||
| ≤ 16 years old | 25 (20.3) | 53 (21.2) | 71 (21.3) | 0.973# |
| >16 years old | 98 (79.7) | 197 (78.8) | 262 (78.7) | |
| Gender n (%) | ||||
| Male | 80 (65.0) | 164 (65.6) | 216 (64.9) | 0.983# |
| Female | 43 (35.0) | 86 (34.4) | 117 (35.1) | |
| COVID-19 n (%) | ||||
| Positive/suspicious | 7 (5.7) | 11 (4.4) | 0.611# | |
| Negative | 116 (94.3) | 239 (95.6) | ||
| Number of patients with | 5 (4.1) | 13 (5.2) | 8 (2.4) | 0.201# |
| n (%) multiple fractures | ||||
| Open fractures n (%) | 6 (4.9) | 14 (5.6) | 18 (5.4) | 0.958# |
|
£Kruskal–Wallis test. #Pearson Chi-square test. Mean ± SD: Mean ± Standard Deviation; min; max: Minimum; Maximum; n (%): Frequency (Percentage of Column). | ||||
There was a statistically significant difference between the groups in terms of the relationship of the fractures with the joints and affected bone segments in the long bones (P = 0.048 and 0.035, respectively). The rate of intra-articular fractures and distal segment fractures of long bones in Group 1 was statistically significantly lower than Groups 2 and 3 (P = 0.048 and P = 0.021, respectively). There was no statistically significant difference between Groups 2 and 3 in terms of metaphyseal fractures, diaphyseal fractures, and proximal segment fractures of long bones (P = 0.220) (Table 2).
Table 2.
Distribution of Fractures
| Fracture Location n (%) | ||||
|---|---|---|---|---|
| Intra-articular | 50 (38.8) a | 136 (51.9) a,b | 184(54.1) b | |
| Metaphysis | 44 (34.1) a | 76 (29.0) a | 89(26.2) a | 0.048 |
| Diaphysis | 35 (27.1) a | 50 (19.1) a | 67(19.7) a | |
| Segment of long bones n (%) | ||||
| Proximal | 47 (43.9) a | 67 (32.2) a | 86 (32.9) a | |
| Shaft | 26 (24.3) a | 38 (18.3) a | 62 (23.8) a | 0.035 |
| Distal | 34 (31.8) a | 103 (49.5) b | 113 (43.3) b | |
|
#Pearson Chi-square test. a,bThe different letter indicates difference at 0.05 significance level between respective column proportions. n (%): Frequency (Percentage of Column). | ||||
The difference between groups was evaluated for each of the surgically treated fractures. Although there was no statistically significant difference regarding the distribution of the number of operated paediatric fractures in three groups (P = 0.071), there was statistically significant difference in terms of the number of operated proximal femur and proximal humerus fractures in the adult patients between the three groups (P = 0.011 and P = 0.043, respectively). In paired comparisons, there was no statistically significant difference between Groups 2 and 3 in terms of the ratio of these fractures (P = 0.432). However, in Group 1, the ratio of proximal humerus fractures was statistically significantly lower than in Groups 2 and 3 (P = 0.028 and P = 0.040, respectively). Also, in Group 1, the ratio of proximal femur fractures was statistically significantly higher than in Groups 2 and 3 (P = 0.005 and P = 0.012, respectively) (Table 3).
Table 3.
Distribution of Operated Fractures in Groups 1-3
| Group 1 (First Wave) (April-May 2020) | Group 2 (Second Wave) (September-October 2020) | Group 3 (Pre-Pandemic) (September-October 2019) | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| ≤16 Years | Old>16 Years Old | Total | ≤16 Years Old | >16 Years Old | Total | ≤16 Years Old | >16 Years Old | Total | |||
| Humerus | 13 (59.0) | 5 (4.6)a | 18 (13.7) | 23 (42.6) | 21 (10.0)b | 44 (16.7) | 24 (33.8) | 34 (12.6)b | 58 (17.0) | ||
| Forearm (both bone) | 4 (18.2) | 2 (1.8 | 6 (4.6) | 9 (16.7) | 7 (3.3) | 16 (6.1) | 17 (23.9) | 2 (0.7) | 19 (5.6) | ||
| Radius | 0 (0) | 11 (10.1) | 11 (8.4) | 3 (5.6) | 28 (13.3) | 31 (11.7) | 4 (5.6) | 28 (10.4) | 32 (9.4) | ||
| Ulna | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 3 (1.4) | 3 (1.1) | 5 (7.1) | 3 (1.1) | 8 (2.3) | ||
| Femur | 3 (13.6) | 47 (43.2)a | 50 (38.2) | 5 (9.3) | 50 (23.8)b | 55 (20.8) | 5 (7.1) | 73 (27.0)b | 78 (22.9) | ||
| Patella | 0 (0) | 1 (0.9) | 1 (0.8) | 0 (0) | 3 (1.4) | 3 (1.1) | 0 (0) | 4 (1.5) | 4 (1.2) | ||
| Tibia | 1 (4.5) | 14 (12.8) | 15 (11.5) | 9 (16.7) | 27 (12.9) | 36 (13.6) | 8 (11.3) | 33 (12.2) | 41 (12.0) | ||
| Malleol | 0 (0) | 4 (3.7) | 4 (3.1) | 1 (1.9) | 14 (6.7) | 15 (5.7) | 1 (1.4) | 13 (4.8) | 14 (4.1) | ||
| Vertebra | 0 (0) | 2 (1.8) | 2 (1.5) | 0 (0) | 2(0.9) | 2 (0.8) | 1 (1.4) | 0 (0) | 1 (0.3) | ||
| Pelvis | 0 (0) | 3 (2.8) | 3 (2.3) | 0 (0) | 3 (1.4) | 3 (1.1) | 1 (1.4) | 1 (0.4) | 2 (0.6) | ||
| Acetabulum | 0 (0) | 2 (1.8) | 2 (1.5) | 0 (0) | 8 (3.8) | 8 (3.0) | 1 (1.4) | 4 (1.5) | 5 (1.5) | ||
| Hand | 1 (4.5) | 11 (10.1)a | 12 (9.2) | 1 (1.8) | 25 (11.9)a | 26 (9.9) | 4 (5.6) | 58 (21.5)b | 62 (18.1) | ||
| Foot | 0 (0) | 6 (5.6) | 6 (4.6) | 2 (3.7) | 13 (6.2) | 15 (5.7) | 0 (0) | 11 (4.1) | 11 (3.2) | ||
| Clavicle | 0 (0) | 1 (0.9) | 1 (0.8) | 1 (1.8) | 6 (2.8) | 7 (2.7) | 0 (0) | 6 (2.2) | 6 (1.8) | ||
| Total | 22 | 109 | 131 | 54 | 210 | 264 | 71 | 270 | 341 | ||
| a,b Different letter indicates that there is 0.05 significance level difference between the respective column proportions. | |||||||||||
Additionally, while there was no significant difference between Groups 1 and 2 in hand fractures including carpal bones, metacarpals, and phalanges (P = 0.715), the rate of cases in both groups was statistically significantly lower than in Group 3 (P = 0.004 for Groups 1 and 3; P = 0.001 for Groups 2 and 3). There was no statistically significant difference between Groups 2 and 3 between fractures in different parts of the body except hand fractures (P = 0.195).
Discussion
With the COVID-19 pandemic, there have been serious changes in orthopaedic trauma practice, as in every field of medicine. It can be understood from the publications to date that this process has caused a change in the number of patients, fracture types, and the surgeon’s approach.7,10–14 Although it is predicted that fracture frequencies may decrease with the decrease in the mobility of people, the effects of restrictions applied differently in different periods of the COVID-19 pandemic on trauma are not fully known. The most important finding of this study is that the distribution and localization of fractures indicated for surgery differ between the first wave of the pandemic, the second wave of the pandemic, and normal periods. While the frequency of surgically treated intra-articular and distal extremity fractures decreased in the first wave of the pandemic, proximal femur fractures increased and proximal humerus fractures decreased proportionally. The frequency of surgically treated hand fractures decreased in the first and second waves of the pandemic compared to the normal period. This is the first study in the literature that evaluates the second wave of the COVID-19 pandemic in terms of orthopaedic trauma and compares it with the first wave and the prepandemic period.
In the literature, there are no articles comparing the first and second waves of the pandemic in terms of orthopaedic trauma. However, there are many studies comparing the first wave with normal periods. These comparisons often address hip fractures. Arafa et al. compared the periods of March-May 2019 and 2020 and reported that, during the pandemic period, hip fractures increased by 61.7% compared to the normal period.15 In a study from China, Yu et al. compared the period of January-March 2020 with the same period in 2019, before the pandemic. They reported that, compared to the same period in 2019, there was a 42% decrease in the number of fracture patients in 2020. At the same time, they found that the incidences of forearm, hip, hand, and foot fractures increased during the COVID-19 outbreak.16 Turgut et al. compared the demographic aspects of the fractures that they followed conservatively and surgically in March-May of 2020 and of 2018 and 2019. They reported that finger fractures in paediatric patients and metatarsal fractures in adult patients significantly decreased during the pandemic.7 Ann et al. compared 2 months of trauma surgery during the pandemic period with the homologous period of 2019. As a result, they found that, unlike other fractures, the number of surgically treated hip fractures did not decrease; in fact, this rate statistically increased. In addition, they reported that surgically treated hand injuries and sports-related injuries were significantly reduced.17 In a study from Italy, Gumina et al. compared the March-April 2020 pandemic period with the homologous period in 2019 in terms of shoulder and elbow injuries. As a result, they stated that although the frequency of shoulder-elbow injuries decreased, the rate of proximal humerus fractures remained unchanged (6.57% in the non-COVID period and 7.72% during the pandemic).18 In the current study, intra-articular fractures and distal segment fractures of long bones decreased proportionally in the first wave compared to the second wave and the normal period (P < 0.05 for both). This could possibly be related to severe restrictions and reduced mobility of people. Consistent with the literature, the number of patients with trauma in the first wave decreased and the rate of hip fractures increased. However, unlike the literature, the rate of proximal fractures of long bones operated on in the first wave decreased compared to the second wave and the normal period. Another difference is hand fractures. For surgically treated hand fractures, there was a significant decrease in both the first and second waves compared to the normal period. In addition, it was observed that fracture patterns in the second wave were similar to the same period of the pre-pandemic period, except for hand fractures. Easing the restrictions in the second wave can be seen as the most likely cause of this situation.
Another issue that draws attention during the pandemic period is the decreasing number of patients and operations in orthopaedic trauma. Although there are no articles on the second wave on this subject, there are many articles on the first wave.10,19,20 Wong et al. compared January-March 2020 with the previous 4 years in a large-scale epidemiological study. When they examined all patients admitted to hospitals, a total of 928,278 patients were evaluated, and they reported that orthopaedic surgery had decreased by 44%, with surgery for upper extremity fractures decreasing by 23% and surgery for lower extremity fractures by 20%.10 Waseem et al., in their study in which they reviewed 665 articles about orthopaedic trauma during the COVID-19 pandemic, reported that although trauma cases decreased by 20.3% to 84.6%, there was no significant change in the number of operated trauma patients.21 In the only article comparing the first and second waves, it was said that the second wave had more severe consequences in Europe and that elective surgery was reduced by 70% in the second wave, but there was no comment about trauma.22 In this study, the number of patients evaluated during the pandemic period decreased by 74.3% and 23.3% for the first and second waves, respectively, compared to the normal period. However, the number of trauma patients consulting the emergency department increased by 22.7% in the second wave compared to the normal period. The number of trauma operations decreased by 63.1% in the first wave compared to the normal period and by 24.9% in the second wave. However, the rate of trauma surgeries performed according to the number of evaluated patients was the highest in the first wave at 3.98%. The second wave and normal period were relatively similar in this respect, at 2.71% and 2.77%, respectively. Furthermore, in studies evaluating paediatric patients in the first wave of the pandemic, it was reported that the number of paediatric patients decreased. Bram et al. found that paediatric fracture volume has decreased 2.5-fold during the first wave of the pandemic when compared to the previous years.12 In their study, Turgut et al. stated that paediatric fractures decreased to approximately one-third of the previous years in the first wave of the pandemic.7 Similar to the literature, in our study, the number of operated paediatric fractures decreased to approximately one-third of the normal period in the first wave and to two-thirds of the normal period in the second wave. However, there was no statistically significant difference between the three groups in terms of paediatric-adult patients’ ratio and the distribution of operated paediatric fractures (P = 0.973 and P = 0.071, respectively).
Our study has several limitations. The first of these is that the study is a retrospective and single-centre study. Another limitation is that although this study has the first and highest number of patients in the literature in terms of evaluating the second wave and trauma characteristics, the number of patients is still relatively low compared to multicentre studies.
In conclusion, according to the results of this study, in the first wave of the COVID-19 pandemic, surgically treated fractures of the intraarticular and distal parts of the extremities decreased in number, the rate of operations for proximal humerus fractures also decreased, and the rate of proximal femoral fractures increased. The rate of operated hand fractures decreased in both the first and second waves. In the second wave, where restrictions and lockdowns were not applied, the trauma pattern had the same features as the normal period. This result gives the impression that people have adapted to the pandemic process and are returning to their normal habits. There is a need for larger multicentre studies examining the second wave and orthopaedic trauma characteristics.
Funding Statement
The authors declared that this study has received no financial support
Footnotes
Ethics Committee Approval: Ethics committee approval was received for this study from the Ministry of Health and the Ethics Committee of Ankara Bilkent City Hospital (Ministry of Health Ethics Committee: 2020-11-02T19_30_15 date:03/11/2020, Hospital Ethics Committee: E1-20-1350 date: 23/12/2020).
Informed Consent: N/A.
Author Contributions: Concept - İ.A.Y.; Design - İ.A.Y, A.Ö.Y; Supervision - İ.A.Y., A.Ö. Y.; Materials - İ.A.Y., Y.K., T.A., B.G., O.B.; Data Collection and/or Processing - İ.A.Y., Y. K., T.A., B.G., O.B.; Analysis and/or Interpretation - İ.A.Y., A.Ö.Y.; Literature Review - İ. A.Y., Y.K., T.A., B.G, O.B.; Writing - İ.A.Y.; Critical Review - İ.A.Y., A.Ö.Y.
Conflict of Interest: The authors have no conflicts of interest to declare.
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