. 2020 Jun 30;11(Suppl 4):S431–S441. doi: 10.1016/j.jcot.2020.06.035

Table 3.

Recommendations on various parameters for COVID1-19 patients based on evidence based literature.

Question		Recommendations based on evidences
Did countries segregate COVID patients needing fracture care from non-COVID at entry into a health care facility or did they have different COVID and non-COVID areas in a health center? What was the PPE used?		Majority had, and it’s better to have different COVID and non COVID health care facilities. If not possible; make a separated contaminated and sterile corridors in a health center (separate OPD, wards, OT, pharmacy) to decrease nosocomial infections. Separate isolation wards in emergency are a must till patient’s COVID clearance.⁵^,⁶^,⁷^,¹¹^,¹²^,¹³
Did this review consider only emergency trauma surgeries?		Fracture care in emergency was mostly available and was researched.¹^,²^,³^,⁴^,⁵^,⁶^,⁷^,⁸^,⁹^,¹⁰^,¹¹^,¹²^,¹³^,¹⁴^,¹⁵^,¹⁶^,¹⁷^,¹⁸^,¹⁹^,²⁰
What major changes have occurred in the epidemiology of fractures in the COVID 19 era?		Overall fracture incidence has decreased but new types of injuries were also seen.¹⁴^,¹⁷^,¹⁹ Contingency plans in these times need to be targeted for osteoporotic hip fractures.
Were the patients triaged? Was there any screening protocol followed in case of emergency? Should all in patients be screened and sampled? How is OT-emergency zoned. How many initially asymptomatic cases were there?		Two types of triaging needs to be done one for emergency trauma by ATLS, SHiFT scores etc.⁷ and other is on basis of COVID status. There is consensus that all admitted patients should be screened clinically into covid positive, covid suspects (clinically & pandemic zones >100/100,000 resident) and clinically covid negative at ER gate for direction to clean covid free pathways and nonclean/covid facility or zones for clearance by covid swab for RT-PCR and/or CT. BUT Operate emergency cases with universal precautions and less emergency cases after RT-PCR or CT chest scan (experienced radiologist) report.¹^,⁵^,⁶^,¹²^,¹⁵^,¹⁷
Were clinical symptoms of COVID different? What were the common modes of injury?		No Fragility fractures were seen most often.⁴^,⁶^,¹²^,¹⁵^,¹⁶
Which blood parameters were altered commonly and which were peculiar to trauma in covid?		Leucocytosis (neutrophilic) with raised CRP is common. Lymphopenia and raised D dimer were more common in fractures. LDH &D dimer are prognostic factors⁴^,⁶^,¹²^,¹³
What about sensitivity of HRCT/Chest CT and RT-PCR, should both be done, do they complement each other? Which is a better screening tool in an emergency setting? Do they prognosticate?		CT Chest though has increased radiation risk is a fast screening tool with high sensitivity in emergency settings, and is also a prognosticating tool. RT-PCR is specific, needs to be done in all and has important role in patients with equivocal CT. False positive and false negative should be avoided- use both.⁶^,¹²^,¹³^{,and 15}
Is orthopedic regional triaging beneficial?		A separate spine center/unit if developed the authors feel would reduce surgical time.¹^,⁶^,⁸
When should COVID testing be done in preoperative period?		If a patient has been tested in last seven days repeat test is not required, It’s better to do RT-PCR test 24–72 h before surgery in new patient.¹^,¹⁸
Did hospitals have outpatient-fracture clinics? How to optimize fracture care visits		It is better to have a fracture clinic with a dedicated x-ray room so that conservatively treated patients can be managed separately and swiftly. Mild cases can be sent home and followed up via telemedicine. Screening and social distancing to be practiced⁹
Were more and more fractures treated conservatively? Was skeletal traction a mode of treatment used?		Tendency of treating fractures conservatively was more. (Mildly displaced intra articular fracture distal radius) Patients who were sick/associated serious systemic problems should be managed conservatively.⁴^,¹³
Which fracture is emergency and to be operated first? Any objective tool? What was the time from presentation to surgery?		It is upto the health authorities do a risk assessment and determine whether the patient’s surgery can be postponed until COVID results return negative or positive patients are no longer infectious and if the situation is an emergency.⁵ The tier system, ACS and IOA recommendations and SHIFT tools do guide us in making this decision.⁵ Unnecessary procedures for spine trauma patients should be avoided in order to reduce complications related to surgery and to preserve ICU beds.⁶ surgery be done for emergent or urgent cases, that is fractures truly requiring operative fixation to avoid mortality or significant morbidity due to a delay of greater than 30 days”.⁹ All open fractures, hemodynamically unstable fractures, proximal femoral fragility fractures, spine fractures with increasing neurological deficit, cauda equina syndrome should be considered for urgent surgery. If fracture surgery can be delayed for 30 days without disability and life/limb risk it should be.⁹
Is proximal femoral fracture an emergency for surgery. Is surgery beneficial and what is the best		Yes, unless patient is unfit for surgery (PO2,temperature, SHiFT tool may act as guides).⁸In principle, active surgical treatment should be performed unless the patient’s health condition is very poor, the patient cannot tolerate the operation, the risk of death during the operation is very high or postoperative nursing would be very difficult It improved O2 saturation and assisted respiratory support⁴^,⁸^,¹²^,¹⁵^,¹⁷^,¹⁹^,²¹ Dictum: Operate within 24 h reduce blood loss and early respiratory rehab to avoid ICU.¹²
Is spine fracture an emergency? How to proceed after primary survey and immobilization?		Spine fractures with increasing deficit, incomplete deficit, cauda equina syndrome in unstable fracture, or cervical fractures should be operated but All Non urgent spine surgery should be stopped or should be planned for non lockdown after critical assessment, as it carries more risk of pneumonia.¹¹^,¹⁸ TIMELINE: • Cervical displacement, any AIS: Urgent Early < 12 h • Any worsening of AIS: Urgent Early < 12 h • Any level, AIS B, C, D: Urgent < 24–36 h • Spinal cord injury with previous cervical spondylosis: • Middle Urgent < 36–48 h • Any level, AIS A/E stable: Planned < 72–96 h
What cases did anaesthetist refuse (risky/red flags) or were there some systemic indicators that dictate against surgery?		Each facility can develop their own recommendations but pO2, ASA grades and temperature should be a part of all criteria.¹¹
Was there any special PAC advise or preoperative advice? Antiviral and chemotherapy-what and when to start -preop or postop?		It is agreed upon that all antiviral, hydroxychloroquine and oxygen support should be started as soon as possible in fracture with COVID. Steroids can be used in spine, head injury with deficit though not recommended due to its impairing effect on immune system³^,⁴^,⁶^,⁸^,¹¹^,¹²^,¹³^,¹⁴^,¹⁵^,¹⁶
Were fractures due to fall more common for the reason of febrile patient’s general or systemic weakness? Was there a need for health education by media? Were any new fracture patterns seen?	Yes, may be due to febrile fatigue fractures can occur due to fall. Health education in preventing falls will reduce¹⁶ number of osteoporotic hip fracture. The panic, depression, or irritability during the epidemic/lockdown period is also a topic that needs to be counselled¹⁵^,¹⁶
What was the influence on fracture care of associated systemic injuries?	Thus, the decision was based on individual patient considerations, and was surgeon based, though more inclined towards conservative treatment for fractures.⁴^,⁶^,¹³
Was the OT setup different or it required change/refurbishing for COVID with fracture Airflow, negative suction and zoning	COVID and non COVID facility to be separate and OT to be zoned according to sterility and utility, Negative suction and air changes are essential for treating COVID with fracture. Isolation areas to be setup separately. Postop HDU to have less and only needy patients, daily assessment for speedy turnover. HEPA filter and AC of closed type as per norm.⁴^,⁵^,¹¹^,¹⁶
How much interval time should be there between operative cases or breathing space for OT between cases;How many OT were used at a time	There should be 30 min wait after surgery for aerosol to settle before deep cleaning of OT is started. All agree on breathing time for OT though vary from 1 to 4 h for sanitization and cleaning. Zoning of OT a must. (donning in area,a sterile passage and doffing area).Air exchangers to function before anyone who has no respirator protection enters the room and before environment cleaning.¹¹^,²²
What was the details of PPE kit used in OT. How many persons should be there in OT	In Emergency/unknown/unconscious unstable patients complete PPE should be used by surgeon &anaesthetist (positive pressure hood, water repellant gowns n95 respirators, face shields and antiviral latex disposable gloves). Covid negative: anesthesia given complete ppe and rest n95, latex gloves, hood and standard precautions (as may be in window period); Minimize the number of person in the OR. Maximum of 8 people to should be there for any procedure, including anesthesia, surgical team, nursing and technicians.²^,⁴^,⁵^,⁸
What is the type of anesthesia used/preferred:	Regional anesthesia preferred unless as in indicated. Blood loss was minimized by avoiding fluid overload and managing patients who had hemoglobin values of <F9 g/dL with concentrated red blood-cell transfusion.¹²^,¹⁵^,¹⁶
What were the instructions to surgical team during administration of anesthesia	Surgeons should stay out of the operation room during induction, intubation or extubation of anesthesia procedure⁵^,⁸
What was criteria of selection of Implants type used or were they same:	There were no special recommendations. The authors suggest that to decrease AGP hand drill and hand reamers with frequent stop and closed suction, self-drilling self-tapping screws, unreamed nails, swift MIPPO technique and use K wire where possible.⁸^,¹²
Was minimally invasive surgery preferred	It’s preferred if you have or are proficient at it but don’t be adamant on doing minimally invasive as decreasing surgical time is essence (decrease AGP).⁶^,¹⁶
How to decrease aerosol -virus and is it transmitted by blood in surgery	Hand tools may be preferred as aforesaid though decreasing surgical time is essence so use electrosurgical instrument at least power and with closed suction. For use of Drain - No change⁵^,⁹^,¹⁴
What were the type of sutures preferred	Resorbable self-locking sutures, transparent dressings. Teleservices/instruction video for self or nearby care provider removes sutures.⁵^,⁹
Has the surgical time increased for fractures with COVID	The surgical time should be minimized - avoid experiments during surgeries, a well-known approach or procedure to the surgeon should be done⁸
How many patients required ICU/setup, Is their any score to predict it preoperatively.	Spine surgery and high risk surgery will need shifting to ICU and extubation may be done in isolation ward or ICU for such cases.Local scores/guidelines be developed.⁶^,⁸
What was the Cause of postoperative fever/aggravation- is it iatrogenic/nosocomial/asymptomatic flare up or patient was in incubation period	Patients (asymptomatic also) should be watched in ward for worsening or development of new symptoms⁴^,¹⁵
Did fracture increase mortality in COVID patient, What fracture did to COVID, Was there any deterioration postop kidney function, DVT, embolism etc. asymptomatic patients became symptomatic?	Fracture with COVID carry increase mortality so be vigilant and have HDU as prophylactic post op wards and high risk patients intubated as in aforesaid till patient stabilizes. Asymptomatic may become symptomatic/develop pneumonia.¹¹^,¹³
What was the Rate of nosocomial infection	Nosocomial infection does occur, Doctors, nurses, patients, and families should be wearing protective devices such as an N95 respirator and goggles to decrease this complication.⁴
What were the Rehab protocol/practices? Was post op weight bearing delayed or same	Rehabilitation should started as early as possible to avoid hypostatic pneumonia and respiratory rehabilitation is required to increase the capacity of lungs. Give handouts for physiotherapy and counseling for telehealth services.⁵^,⁹^,¹²^,¹⁸
What was discharge time, mean hospital stay	Variable depends upon patient stability. However as early as possible particularly in non COVID patients⁶^,⁸
What were the postop medical prescription -antibiotic used, antiviral, HCQS, anticoagulant prophylaxis	Yes antivirals (Oseltamivir, lopinavir, ritonavir), Azithromycin and HCQS were used by several authors in various combinations and regimens, as per institution, as mentioned in results. These are evolving and authors suggest readers to consult recent literature updates.¹²^,¹³
Are there any risk factors or preop screening tools to suggest increased mortality/morbidity risk-fracture type, polytrauma? Is smoking,diabetes, immunosuppressive disorder or drug-a factor?	Spine surgery, elderly comorbid hip fracture surgery, patient with COVID pneumonia, polytrauma all carried increased risk. Preoperativiely pO2 <90 and temperature > po2 deg.C, SHIFT tool>13, ASA grade >4, smokinig etc increased risk.⁶^,¹¹^,¹²^,¹⁹
What is the mortality rate of COVID with fracture/spine/hip	In our review of 44 cases of COVID with fracture, there were total 16 deaths; mostly due to respiratory failure (one case had hematuria also). Pneumonia and respiratory failure, kidney dysfunction were common cause of death.¹^,²^,³^,⁴^,⁵^,⁶^,⁷^,⁸^,⁹^,¹⁰^,¹¹^,¹²^,¹³^,¹⁴^,¹⁵^,¹⁶^,¹⁷^,¹⁸^,¹⁹