ABSTRACT

Objective

The aim of this study was to compare emergency orthopedic trauma admissions between the pre- and pandemic periods and detect changes in orthopedic trauma epidemiology.

Methods

A total of 40,700 patients admitted within 1 year between March 2019 and March 2020 comprised the pre-pandemic group and 16,935 patients admitted between March 2020 and March 2021 comprised the pandemic group. Demographic characteristics of the patients, such as age and gender, were recorded. In addition, the injury mechanisms of the patients, diagnosis, injured extremity or anatomical region, broken bone, fracture classification, multitrauma rates, trauma-related complications, hospitalization days, and treatment modalities were examined.

Results

In the pre-pandemic period, the mean age of the patients was younger, and the distributions of pediatric/adolescent patients and female patients were higher compared with the pandemic period (p=0.001, p=0.001, and p=0.001; respectively). Fractures and dislocations were more frequent in the pandemic period, whereas soft tissue injuries were more common in the pre-pandemic period (p=0.001). Home accidents increased and occupational accidents decreased during the pandemic period (p=0.001). The rate of surgical treatment statistically increased during the pandemic period (p=0.001).

Conclusion

Considering the epidemiology of orthopedic trauma, estimating the trauma burden and optimizing resource use and allocation are very important for maintaining safe and effective treatment services for patients in extraordinary situations such as the coronavirus disease-2019 pandemic, which can cause serious disruptions in the healthcare system.

INTRODUCTION

Although the coronavirus disease-2019 (COVID-19) pandemic seems to be under control, it continues to be a global problem for all world societies and our health systems because of the new forms (such as Erise variant) that have emerged and the fact that the disease has not yet been fully eradicated (1). Similar to many countries, our government has taken many measures to prevent the spread of the pandemic. Several rigid restrictions were taken to prevent possible blockages in the healthcare system and uncontrolled deaths, especially in the early stages of the pandemic when the vaccine was not yet widespread. Lockdown except for emergencies, closing schools and switching to online education, closing workplaces and developing remote working models, and banning social events and crowded activities were among the main precautions taken to reduce social contact and prevent the rapid spread of the pandemic (2, 3). These precautions significantly affected social mobility. Especially during periods of strict isolation, traffic and human mobility decreased to a minimum level with lockdowns (4, 5).

However, a large number of health institutions were privatized to combat infection, prevent the spread of the pandemic and ensure adequate resource allocation. Despite these regulations, there were serious resource problems in basic health services (6). Outpatient services, except for emergency health services, were either partially or completely stopped depending on the period of the pandemic (2, 7). The precautions and the decrease in social mobility brought about by the precautions led to serious changes in the demand in the healthcare system. The healthcare system reaching saturation due to increasing COVID-19 cases and the filling of intensive care units and inpatient services with COVID-19 cases caused all health services except emergency procedures to be suspended (8). This study was conducted in a level 1 trauma referral center that also provided intensive COVID-19 services throughout the COVID-19 pandemic. The aim of this study was to compare emergency orthopedic trauma admissions between the pre- and pandemic periods and to detect changes in orthopedic trauma epidemiology. We hypothesized that restrictions during the pandemic period would change trauma exposure and injury mechanisms and differentiate orthopedic trauma epidemiology.

METHODS

Study Design and Level of Evidence

This study employed a retrospective cohort study design, classified as level 3 evidence according to established criteria.

This retrospective cross-sectional study was conducted between March 2019 and March 2021 after the approval of the University of Health Sciences Türkiye, Bakırköy Dr. Sadi Konuk Training and Research Hospital Clinical Research Ethics Committee (decision no: 2021-06-44, protocol code: 2021/168, date: 15.03.2021). The study was registered at clinicaltrials.gov (ID: NCT06237023).

The study was conducted with reference to the date of March 10, 2020, when the first case of COVID-19 was observed in our country. Admissions within the same cross-sectional time period were included in the study when creating the groups. A total of 40,700 patients admitted within 1 year between March 2019 and March 2020 constituted the pre-pandemic group and 16,935 patients admitted between March 2020 and March 2021 constituted the pandemic group. In the study, 57,635 patients who were admitted to the emergency department and the emergency orthopedics department within a 2-year period were examined. Demographic characteristics of the patients, such as age and gender, were recorded. In addition, the injury mechanisms of the patients, diagnosis, injured extremity or anatomical region, broken bone, fracture classification, multitrauma rates [injury severity score (ISS) score ≥15], trauma-related complications, hospitalization days, and treatment modalities were examined. The effects of the pandemic on these data were analyzed by comparing them with the pre-pandemic period.

Statistical Analysis

Descriptive statistical methods (mean, standard deviation, median, frequency, ratio, minimum, maximum) were used for data evaluation. The conformity of the quantitative data to the normal distribution was tested using the Shapiro-Wilk test and graphical evaluations. Mann-Whitney U test was used to compare two independent and non-normal distributive variables. The Pearson chi-square test was used to compare qualitative data. Significance was evaluated at the p<0.05 level. NCSS (Number Cruncher Statistical System) 2007 (Kaysville, Utah, USA) program was used for statistical analysis.

RESULTS

The demographic characteristics of the patients are presented in Table 1. Adult patients, male gender, soft tissue injury, extremity trauma, simple fall, and conservative treatment showed proportional dominance. In the pre-pandemic period, the mean age of the patients was younger, and the distributions of pediatric/adolescent patients and female patients were higher compared with the pandemic period (p=0.001, p=0.001, and p=0.001; respectively) (Table 2). Fractures and dislocations were more frequent in the pandemic period, whereas soft tissue injuries were more common in the pre-pandemic period (p=0.001). A statistically significant difference was found between the pre-pandemic and pandemic periods in terms of injury characteristics such as fractured bone, fracture classification, injury location, trauma mechanism, and multitrauma rates (p=0.001). It is noteworthy that accidents at home increased and occupational accidents decreased during the pandemic period (p=0.001). The rate of surgical treatment statistically increased during the pandemic period (p=0.001). However, the surgical technique did not differ (p=0.508). The incidence of trauma-related complications increased by two times compared with the pre-pandemic period (0.2% vs. 0.4%), whereas hospitalization was relatively reduced during the pandemic period (p=0.001 and p=0.023; respectively).

DISCUSSION

The most important aspect of the present study is to show the impact of the COVID-19 pandemic on the demographic, diagnosis, and treatment processes in orthopedic trauma admission and daily orthopedic management. Our study showed that all emergency orthopedic admissions decreased by 58.3% during the pandemic period compared with the 1-year period before the pandemic. Previous studies comparing the pandemic period with the pre-pandemic period showed a similar decrease in emergency orthopedic admissions (2, 9-11). The reduced admissions can be explained by a decrease in social mobility caused by strict lockdown precautions taken by governments. It is also a fact that people’s fear of being affected by the pandemic and being infected with COVID-19 is effective in reducing hospital admissions, except for emergencies (12).

In the comparison of the number of child/adolescent and adult admissions, there was a significant decrease in the total number of admissions in both groups during the pandemic period compared with the previous year. On the other hand, an increased rate of adult admission and a decreased rate of child/adolescent admission were noteworthy in this study. Several studies have similarly shown that the average age of fractures was higher during the pandemic period compared with previous periods and that there was a decrease in pediatric trauma admissions (13, 14). The closure of nurseries and schools during the isolation period, the adoption of distance education, and the partial continuation of workplaces with distance rules may explain why child/adolescent emergency admissions decreased more than adults. In addition, the fact that fragility fractures, which concern the adult age group and especially occur at home, are not affected by social mobility may have contributed to the increased emergency admission rates in adults (15). Some authors have reported that the pandemic had no effect on the male-female patient ratio (16, 17) while others have reported an increase in the rate of female admissions compared with males (18). The present study reported a 2.2% decrease in female patients during the pandemic period compared with the pre-pandemic period and an increase in the ratio of male to female patients. Similar to our study, several studies have reported a decrease in the rate of female patient admissions and an increase in the ratio of male to female patients (9, 19-22). Due to the closure of nurseries in our country, official permission was given to women with young children and pregnant women who are sensitive to COVID-19, especially to take care of their children. These precautions explain the decrease in trauma exposure and the number of emergency admissions among females.

Kalem et al. (19) reported that soft tissue traumas decreased and the percentage of fractures increased during the pandemic period. In our study, admissions due to fractures increased by 11.2% and soft tissue lesions decreased during the pandemic period. There was no significant change in the dislocation and fracture-dislocation rates. The decrease in soft tissue trauma rates can be explained by the efforts of patients with simple trauma to cope with their problems themselves and perhaps by applying to private hospitals, which are relatively less busy. Vatsya et al. (23) reported that forearm and wrist fractures were the most common during the pandemic period. The largest proportion of admissions during both the pre-pandemic and pandemic periods were for radius/ulna fractures in this study. Radius/ulna fractures were followed by hand phalanx, tarsal/metatarsal, and foot phalanx fractures. An increase in femur and tibia/fibula fractures was detected in the lower extremities (0.7% and 1.7% respectively). The trauma area and broken bone consisted of upper extremity and radius/ulna fractures in both pre-pandemic and pandemic periods, similar to the literature (19).

In this study, the most common trauma mechanism was simple falls. It was observed that strict isolation measures increased domestic injury rates and flexible working hours reduced work accidents. Our data regarding the mechanism of trauma are similar to the literature (3, 9, 14). Several authors mentioned that traffic accidents and related multitrauma rates have decreased (1, 3, 9, 19, 23).Reduced social mobility will generally ensure a decrease in traffic accidents, multitrauma rates, trauma-related complication rates, and open fracture rates. Interestingly, there was a statistically significant increase in the application rates for pedestrian and motor vehicle accidents in the present study. Similarly, we found a statistically significant increase in trauma-related complication rates, multitrauma (ISS score ≥15), and open fracture rates. Previous studies investigating treatment methods have shown that the tendency toward conservative treatment increased during the pandemic period (24). However, trauma-related complication rates were twice as high as those in the pre-pandemic period, and a significant increase in surgical treatment rates was found in our study. Considering that these parameters (multitrauma, trauma-related complications, open fractures and the need for surgical treatment) are directly related to the severity of trauma, the main reason for the increase in these parameters is that our hospital not only provided COVID-19 healthcare services but also actively accepted trauma. It is noteworthy that similar outcomes have been reported in the literature in such studies conducted in primary trauma referral centers (20, 25-28).In addition, we examined the changes in the length of stay of inpatients and found that our findings were in line with the literature and there was no significant difference (29, 30).

This study has limitations, such as being a single-center and retrospective design. In addition, our study shows the epidemiology of the data, and we did not present any data on patient follow-up or outcomes. Studies in the literature generally investigate the effects of the pandemic on trauma epidemiology by comparing short periods. In our study, comparing the pandemic period with the 1-year period before the pandemic minimized the effect of seasonal changes on trauma admissions. This provides more reliable data on the isolated impact of the pandemic on the etiology of orthopedic trauma. However, because the center where our study was conducted is a primary trauma referral center hospital in the most populous city of the country, the high number of patients included in the study and the high number of trauma admissions make our study strong. However, studies involving more centers and perhaps longer-term analyses are needed to fully understand the impact of the pandemic on orthopedic trauma epidemiology.

CONCLUSION

In conclusion, considering the epidemiology of orthopedic trauma, being able to estimate the trauma burden and optimizing resource use and allocation are essential for maintaining safe and effective treatment services for patients in extraordinary situations such as the COVID-19 pandemic, which can cause serious disruptions in the healthcare system. The present study will guide clinicians to better understand the burden of orthopedic trauma and to be prepared for extraordinary situations such as the COVID-19 pandemic that need to be managed and to optimize resource allocation and use.

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The Impact of the COVID-19 Pandemic on Orthopedic Trauma Management; A Cross-sectional Study