key: cord-0944475-90as38e2
authors: Lim, Michael Anthonius; Mulyadi Ridia, Ketut Gede; Pranata, Raymond
title: Epidemiological pattern of orthopaedic fracture during the COVID-19 pandemic: A systematic review and meta-analysis
date: 2020-12-30
journal: J Clin Orthop Trauma
DOI: 10.1016/j.jcot.2020.12.028
sha: 1b05ea012e9751acbfbd9f207f71bcd5b3f6f816
doc_id: 944475
cord_uid: 90as38e2

INTRODUCTION: This systematic review and meta-analysis aimed evaluate the 30-day mortality, number and site of fracture, mechanism of injury, and location where injury was sustained during the pandemic compared to pre-pandemic. METHODS: We performed a systematic literature search from PubMed and Embase on original articles, research letters, and short reports which have data about the number of fractures, site of fracture, mechanism of injury, location where injury was sustained, percentage of operative intervention, mortality during the pandemic compared to a specified period of time before the pandemic. The search was finalized in October 14, 2020. RESULTS: A total of 11,936 participants from 16 studies were included in our study. The pooled analysis indicated a higher 30-days mortality associated with fractures during the pandemic (9% vs 4%, OR 1.86 [1.05, 3.27], p = 0.03; I(2): 36%, p = 0.15). The number of fractures presenting to hospitals has declined 43% (35–50%) compared to pre-pandemic. Hand fracture was fewer during the pandemic (18% vs 23%, OR 0.75 [0.58, 0.97], p = 0.03; I(2): 69%, p = 0.002). Work-related traumas, high-energy falls, and domestic accidents were more common during the pandemic, while sports-related traumas were found to be less. Injuries that occurred in the sports area were lower than before the pandemic. CONCLUSION: The present meta-analysis showed that during the COVID-19 pandemic, the number of fractures has decreased, but there is a higher mortality rate associated with fractures.

The rapidly spreading Coronavirus Disease 2019 (COVID-19) continues to burden healthcare providers around the world and stretch their capacity in providing medical services to the limit. The prioritization of COVID-19 cases, avoidance of medical visits and follow-up, and temporary postponement of elective procedures place certain individuals at a higher risk of developing short-term exacerbation or long-term complications 1,2 . People with advanced age, excessive body mass index (BMI), and comorbidities, including diabetes mellitus, hypertension, chronic obstructive pulmonary disease, cerebrovascular disease, heart disease, and chronic kidney disease, are associated with increased severity and mortality if contracting COVID-19 3-12 .

Since the beginning of COVID-19 epidemic, the incidence of orthopaedic trauma admission has declined substantially given the widespread implementation of self-isolation, quarantine, lockdown, and travel restrictions [13] [14] [15] [16] . People are urged to stay at home and only seek medical services if they experience a medical emergency. Reduction on public mobility and outdoor activities contributed to the decrease in motor vehicle accidents, sport-related traumas, and work-related traumas. However, some individuals still suffered injuries while living or wandering around home, ranging from children who knocked, stabbed, or fell while playing to elderly who fell during their daily activities 17, 18 . statistics and Cochran's Q test to evaluate inter-study heterogeneity, which is deemed to be significant if I 2 >50% or p<0.10.

There were a total of 11,936 subjects from 16 studies included in the qualitative and quantitative synthesis. Characteristics of the included studies are presented in Table 1 . The summary of meta-analysis is displayed in Table 2 .

The number of mortality was higher during the pandemic (9% vs 4%, OR 1.86 [1.05, 3 .27], p=0.03; I 2 : 36%, p=0.15) [ Figure 2 ]. The number of fractures and operative management for the injuries during the pandemic did not differ significantly compared to pre-pandemic [ Table 2 , Table 4 ].

The number of fractures declined by 43% (35-50%) during the pandemic compared to prepandemic.

Hand fracture was fewer during the pandemic (18% higher, but only reach a borderline statistical significance. Injuries sustained in public area, school, daycare or residential care were similar during pandemic and pre-pandemic [ Table   2 ].

In this systematic review and meta-analysis, we gathered information regarding the epidemiology and prevalence of orthopaedic trauma cases with an emphasis on fractures occurring during the COVID-19 pandemic and compared them to the pre-pandemic (control) situation. Pooled analysis indicated a higher 30-days mortality associated with fractures during the pandemic. The number of fractures presenting to hospitals has declined compared to pre-pandemic. Hand fractures, work-related traumas, high-energy falls, and domestic accidents were more frequent during the pandemic. Meanwhile, sports-related J o u r n a l P r e -p r o o f injuries decreased during the pandemic. In addition, injuries sustained in sports area were lower during the pandemic.

Overall, the number of fractures decreased sharply in all 13,17,27-31,19-26 but one 32 of the included studies. Although the total number of fractures was reduced by 43% (35-50%) during the pandemic, we found that the proportion hand fractures was lower (significant), the proportion of femur fractures was higher (borderline significance), whereas the proportion of fractures at other locations was relatively constant. The proportion of femoral fractures reported during the pandemic was 32% greater than in the pre-pandemic period.

Injuries that occur in the home, residential care, or hospital setting contribute to the incidence of proximal femur (hip) fractures regardless of the period 25 . Even though the number of major trauma reduced during the epidemic, the rate of fragility hip fracture remained stable 33 . It has been found that individuals with hip fracture and concomitant COVID-19 are associated with increased risk of mortality 34 . During the current outbreak, this high-risk population remains a clinical priority who requires immediate surgical intervention. Post-operatively, the incidence of inpatients falls was reported to be higher during the pandemic, which concerns their recovery and sometimes necessitates reoperation 20 . The proportion of fractures in the hand during the pandemic was only 75% of those in the pre-pandemic period. Traffic accidents contributed greatly to hand traumatic injuries during the pre-pandemic pandemic, followed by work-related trauma, sportsrelated trauma, and other causes. However, the majority of hand and wrist injuries during the pandemic were due to domestic accidents that occurred in the home or surrounding environment rather than in public places 19 . The proportion of open fractures was lower during the pandemic but not significantly different from the pre-pandemic period. The increase in domestic accidents during the epidemic period plays a role in this finding. The proportion of operative management also reduced during the pandemic, but this decline was not significant compared to the prepandemic period. Depending on the location, severity, and complexity of fracture, most fractures require surgical management but some cases can be managed conservatively.

However, we found that proportion of mortality during the pandemic was up to 2 times J o u r n a l P r e -p r o o f higher than that reported during the pre-pandemic period. A positive COVID-19 infection can worsen the prognosis of certain groups of patients, such as elderly with traumatic fractures, thereby increasing the morbidity and mortality. The prevalence of comorbidities, physical deterioration, and possible psychological problems put the elderly at a greater risk of accidental events 18 .

Relating to the mechanism of injury, the proportion of sports-related trauma was significantly lower during the pandemic compared to the control period, whereas the proportion of work-related trauma was significantly higher in the pandemic than in the prepandemic period. The suspension of sports events, school activities, and work from office contributed to the change in proportion in both timeframes. Prior to the COVID-19 epidemic, motor vehicle accidents accounted the largest percentage of all trauma cases, but this figure has fallen dramatically due to restrictions of mobility and travel, although the decline in proportion is not statistically significant. In the pandemic period, the proportion of low-energy fall was borderline significant, while high-energy fall and domestic accidents was significantly higher than in the control period. Low-energy fall is equivalent to a fall from a standing height or a height <1 m (e.g. bed, chair, stool, standing, walking, slipping), while high-energy fall is equivalent to a fall from a height >1m (e.g. roof, tree, trampoline, playground) 18 . During the outbreak, low-energy fall is most commonly seen in elderly and resulted in fragility fractures 17, 18, 24 . Low-energy fall is also a major cause of humeral fracture 23 , which most frequently affect the proximal part (head), followed by the middle (shaft) and distal part. Even though humerus is not the most frequent site of fractures during this pandemic, some cases such as complex and displaced fractures require surgical management. Post-operatively, the majority of patients had good outcomes with respect to COVID-19-associated respiratory complications 37 .In contrary, high-energy is frequently J o u r n a l P r e -p r o o f reported in children while playing 17, 21, 28 . Domestic accidents are events that are not related to sport, traffic, or vehicles, which have implications for those occur at home or its surrounding 38 .

In terms of location where the injury was sustained, the proportion of that occurring in public (community, street), school, daycare, or residential care, and sports area were lower during the pandemic than in the control period, even though the result were only significant in sports area 21,22,24,25 . Restrictions on outdoor activities and encouragement to stay at home contributed to the reduction of proportion between the two periods. However, this advice also prolongs the duration that people are at home and doing their new normal activities. Therefore, this condition played a part to a rise in the proportion of injury that occur at home (almost 4 times higher) during the pandemic, and this finding is borderline significant 21,24,25 .

We should pay more attention to the prevention of home injuries during the outbreak. 

During the COVID-19 pandemic, the number of fractures admitted to hospitals has decreased compared to the pre-pandemic, but the proportion of hand fractures was found to be higher. The 30-day mortality associated with fractures was higher during the pandemic. In terms of the mechanism of injury, work-related traumas, high-energy falls, and domestic accidents were more common during the pandemic, while sports-related traumas were found to be less. Regarding the location where the injuries sustained, those that occurred in the sports area were lower than before the pandemic. 

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