Expert consensus on management principles of orthopedic emergency in the epidemic of coronavirus disease 2019

Since December 2019, many patients in Wuhan sustained pneumonia with unknown causes.^[1,2] A part of severe patients developed acute respiratory distress syndrome or septic shock, and even death. On January 7, 2020, Chinese researchers have for the first time detected a new coronavirus. On January 20, 2020, the National Health Commission issued Announcement No. 1 of 2020, which included the new coronavirus pneumonia as a Class B infectious disease, and conducted epidemic prevention and control according to the Class A infectious disease. This new kind of pneumonia has been named coronavirus disease 2019 (COVID-19). The sixth edition of “Diagnosis and Treatment Scheme for New Coronavirus Infected Pneumonia” points out that the main transmission routes include respiratory droplets and close contact transmission. There is a possibility of aerosol transmission in a relatively closed environment with prolonged exposure to high concentrations of aerosol. New coronavirus pneumonia has a certain incubation period.

Strict measures were adopted across the country to limit the movement and travel of people and strengthen protective measures. The spread of the epidemic was effectively prevented. With the decrease of mobility and travel of people, the number of patients with fractures caused by high-energy trauma is significantly reduced. Meanwhile, low-energy fractures caused by accidental falls at home often occur. Among these patients, there may be close contacts, virus carriers or asymptomatic infected patients. Along with the resumption of work and production, the mobility of the population will increase, and patients suffering from fractures resulted from traffic accidents and work injuries will inevitably increase. This requires orthopedic surgeons to further increase awareness of epidemic prevention and adopt standardized preventive measures for diagnosis and treatment to avoid outbreaks in the hospital. Based on the current situation of epidemic prevention and control in China, the expert group from the Chinese Orthopedic Association and Chinese Association of Orthopedic Surgeons formulated an expert consensus on the diagnosis and treatment of orthopedic emergency surgery during the outbreak of COVID-19, which has been published in the Chinese Journal of Orthopedic Trauma in Chinese [Supplementary file 1 is this consensus statement in English].^[3]

The expert consensus categorized the orthopedic patients into four types. Type I patients had not traveled in the epidemic area within 14 days and had no history of direct or indirect contact with suspected or confirmed cases. Type II patients had a history of direct or indirect contact with people from the epidemic area within 14 days, or patients live in same neighborhoods with suspected or confirmed cases. However, the patients had no clinical symptoms and all examinations were negative. Type III patients are diagnosed as a suspected case of COVID-19. Type IV patients were diagnosed as a confirmed case.

The expert consensus has systematically summarized the epidemic prevention measures during the diagnosis and treatment of orthopedic emergency patients from three aspects: the admission of orthopedic patients, perioperative management and the choice of treatment methods. When admitting orthopedic patients, medical staff should diagnose and treat patients under strict protective measures. In addition to orthopedic specialist evaluation, all patients should be evaluated for the risk of new coronavirus infection and classified into five types according to the standards. Prevention and control measures of infections are carried out in strict accordance with different risk levels. For Type I patients, the medical staff adopt first-level protection measures. For Type II patients, the second-level protection measures should be adopted accordingly. Single ward and specially-assigned medical staff for treatment and nursing is preferred for the kind of patients. Regular review and repeated examinations are suggested to be conducted. The operating room and anesthesiology department staff should be informed about the patient condition. A separate negative pressure operating room should be prepared for operations on type II patients. Two kinds of disinfectants should be used to completely disinfect the operating room after surgery.

In case of fever or respiratory symptoms from type II patients, relevant inspections should be performed in a timely manner. Once the diagnosis of COVID-19 is suspected or confirmed, the patients should be re-classified as type III or IV case. For Type III and IV patients, they should be transferred to the new coronavirus pneumonia designated hospital for treatment. When the specialist assessment does not support transportation of type III and IV patients due to serious injuries and poor conditions, the medical staff should adopt third-level protection measures. Patients also need to wear surgical masks, goggles, disposable sleeves and socks and avoid direct contact with any stretcher, elevator or other items during the diagnosis and treatment. If the same doctor is responsible for many patients, it is necessary to change the isolation gown, outer gloves, and shoe covers in a timely manner after each patient check to prevent cross infection. For orthopedic emergency patients suspected or confirmed to be infected with the new coronavirus, multidisciplinary collaboration from respiratory department, intensive care unit, and anesthesia department are required to evaluate the patient's general condition and perioperative risks. On the basis of professional protective measures, the proper treatment can be done following orthopedic principles. Manual reduction and brace or plaster fixation can be tried for the majority of traumatic fractures of four extremities. Minimally invasive techniques are also recommended for fracture fixation in a fast fashion.

Acknowledgements

Members for consensus formulating (sorted by last name): Wei-Jun An, Zheng-Gang BI, Shan-Bao Cai, Xian-Hua Cai, Xue-Cheng Cao, Bing-Fang Cao, Yi-Min Chai, Ai-Min Chen, Hua Chen, Wei-Gao Chen, Yan-Xi Chen, Yun-Zhen Chen, Zhong Chen, Bin Chen, Peng Chen, Lei-Ting Chi, Xiao-Qian Dang, Zhen-Qi Ding, Jing-Ming Dong, Guo-Feng Fan, Shi-Yuan Fang, Gao-Peng Fu, Li-Qiang Gu, Rong-Guang Guo, Xiao-Shan Guo, Yang Guo, Xiao-Dong Guo, Zhi-Yong Hou, Fu-Guo Huang, Lei Huang, Yan-Jun Hu, Ji-Hong Ji, Ji-Fang Quan, Shi-Kong Jia, Yan-Fei Jia, Bao-Guo Jiang, Xie-Yuan Jiang, Yu-Hua Jing, Qing-Lin Kang, Rong Kong, Jun Li, Kai-Nan Li, Lin-Qi Li, Wei-Xu Li, Jia-Li Liang, Qi-Lin Liao, Fei Feng, Peng Lin, Sheng-Yuan Lin, Ye Liu, Guang-Yao Liu, Guo-Hui Liu, Li-Min Liu, Yong Liu, Zhi-Luo Liu, Cong-Feng Luo, De-Cheng Lyu, Gang Lyu, Xin Lyu, Zhi Lyu, Bao-Tong Ma, Xian-Zhong Ma, Xin-Long Ma, Jiang-Dong Ni, Wei-Dong Ni, Zhi-Jun Pan, Guo-Xian Pei, A-Qin Peng, Jian Qi, Hong-Bo Qian, Yong-Jun Rui, Xi-Guang Sang, Jian Shang, Lin Shao, Zeng-Wu Shao, Qing-Xuan Shi, Heng-Sheng Shu, Zhao-Hui Song, Da-Hui Sun, Yu-Qiang Sun, Yue-Hua Sun, Xin Tang, Jian Tang, Pei-Fu Tang, Ran Tao, Yu-Liang Wang, Ai-Guo Wang, Bao-Jun Wang, Dong Wang, Gang Wang, Guang-Lin Wang, Guo-Xuan Wang, Lei Wang, Li-Min Wang, Man-Yi Wang, Peng-Cheng Wang, Qiu-Gen Wang, Yue Wang, Jun-Wen Wang, Bo-Wei Wang, Liang-Yuan Wen, Bo Wu, Dan-Kai Wu, Duo-Qing Wu, Ke-Jian Wu, Xin-Bao Wu, De-Ming Xiao, Zeng-Ru Xie, Zhao Xie, Ming-Guo Xu, Wei-Guo Xu, Yong-Qing Xu, Xin Xing, Hua-Qing Yang, Jun Yang, Lei Yang, Ming-Hui Yang, Sheng-Song Yang, Qi Yao, Fa-Gang Ye, Jun-Jian Ye, Bin Yu, Bao-Qing Yu, Ai-Xi Yu, Zhi Yuan, Ying-Chao Yin, Bao-Zhong Zhang, Dian-Ying Zhang, Jian-Ning Zhang, Jian-Zheng Zhang, Jin-Li Zhang, Kun Zhang, Li-Hai Zhang, Qun Zhang, Shu-Ming Zhang, Wei Zhang, Ya-Kui Zhang, Yi Zhang, Ying-Ze Zhang, Chang-Qing Zhang, Ping Zhang, Jin-Min Zhao, Wen Zhao, Zhe Zhao, Long-Po Zheng, Dong-Sheng Zhou, Fang Zhou, Jun-Lin Zhou, Shi-Wen Zhu, Yong Zhu, Yan-Bin Zhu, Yan Zhuang, Yun-Qiang Zhuang

Conflicts of interest

None.