key: cord-0949898-55nwfwp8
authors: Iyengar, Karthikeyan; Vaish, Abhishek; Vaishya, Raju
title: Revisiting conservative orthopaedic management of fractures during COVID-19 pandemic
date: 2020-05-16
journal: J Clin Orthop Trauma
DOI: 10.1016/j.jcot.2020.05.010
sha: 282279d9e81c329c3a71565817803075f6a33fe2
doc_id: 949898
cord_uid: 55nwfwp8

COVID-19 pandemic has brought the need to revisit the conservative management of orthopaedic injuries back into sharp focus. On the advent of COVID-19 pandemic, it has been acknowledged by the British Orthopaedic Association (BOA) emergency COVID-19 and the National Health Service England (NHSE) guidelines to manage urgent orthopaedic and trauma conditions pragmatically balancing optimum treatment of patients against clinical safety with resource utilization .The current Coronavirus outbreak has refocussed orthopaedic minds on managing many injuries conservatively, which would have otherwise been managed with operative fixations. We revisit the role of conservative orthopaedic management of fractures in the context of COVID-19 and current guidelines.

pandemic Keywords: COVID-19; Coronavirus; pandemics; bone fracture; conservative treatment.

COVID-19 pandemic has brought the need to revisit the conservative management of orthopaedic injuries back into sharp focus. Over the years as trauma and orthopaedics have evolved, operatives techniques have been developed, along with refinement of implants and instruments with an aim of transforming contemporary treatment of fractures to provide anatomical or near anatomical alignment of the fractures, stable fixation, with early pain free range of motion and rehabilitation [1] . In the last five decades or so, the management of most fractures of the extremities has revolved around the operative management.

On the advent of COVID-19 pandemic, it has been acknowledged by the British Orthopaedic Association (BOA) emergency COVID-19 and the National Health Service England (NHSE) guidelines to manage urgent orthopaedic and trauma conditions pragmatically balancing optimum treatment of patients against clinical safety with resource utilization [2, 3] . The current Coronavirus outbreak has refocussed orthopaedic minds on managing many injuries conservatively, which would have otherwise been managed with operative fixations. It is mainly because of the restraints put on by this viral infection, limited availability of resources including personnel and operating theatre slots (whilst they were redirected to manage urgent clinical priorities including respiratory emergencies due to COVID-19 infections on the frontline) and due to reluctance of undertaking operative intervention in an atmosphere of increased risk of viral transmission, responsibility of protecting staff and 'social distancing' guidelines [4] .

The fracture healing involves a combination of inflammatory, vascular, anabolic and catabolic events to allow eventual return of function [5] . Traditional conservative treatment of fractures is based on three basic principles of fracture management; namely, reduction of fracture, holding the fracture reduced and keeping it reduced in a supported environment (such as a cast or splint) till the fracture heals. "Closed treatment of fractures" was very elaborately and scientifically described by Sir John Charnley is his monograph in 1950 [6] .

Earliest example of non-operative active treatment of fractures in humans was discovered by G. Elliot Smith during his Egyptian expedition in 1903. [8, 9] . Decision becomes more pragmatic in managing lower limb 'obligatory' fractures such as hip injuries where weight bearing mobilization is essential to avoid problems of recumbence and immobility.

Operative treatment of fractures was heralded by the development of three major inventions of anaesthesia (1846), antisepsis (1865) and Roentgen discovery of X-rays in1895 [10] . As such advances in operative management of fractures coupled with asepsis have been the key in the modern orthopaedic principles of managing injuries. In late 1960s, the AO group of surgeons from Switzerland popularized the principles and techniques of various fracture fixation by several metallic implants. Since, then the operative management of the fractures have evolved significantly across the globe, to the extent that it has now become a panacea.

However, the current pandemic situation has exposed us to the situation faced by Sir R Jones Table 1 ]. It is obvious from this table that a majority of paediatric injuries can be adequately managed with conservative treatment.

Articular and peri-articular fractures may provide a challenge, since principles of fracture fixation (anatomical reduction, rigid fixation, early range of joint motion) and avoidance of post-traumatic arthritis are not possible with conservative management in most of these injuries [ Table 2 ] and hence operative management may be required, at a later stage.

Meanwhile, complementary traditional techniques of skeletal traction, splintage, with an aim to best manage fracture to restore function and availability of future reconstruction surgery in such injuries with the current restraints may be therefore deemed necessary [1] . However, there are certain absolute indication for the surgery of fractures and dislocation, even in the pandemic times (table 2) , which are also the contraindications for conservative management.

The aim should be to minimise risk of viral transmission by avoiding Aerosol Generating Procedures (AGP) and minimising risk of infection with appropriate use of Personal Protective Equipment (PPE). These principles are critically engrained in our current orthopaedic response to the pandemic.

Conservative, non-operative therapeutic approach may thus provide an alternative in nonobligatory fractures in the current COVID-19 pandemic (and perhaps later on as well). It may serve as a route for us to manage orthopaedic injuries till we tide over the peak of the pandemic and resume conventional surgery. Perhaps the Coronavirus crisis has given us this unique opportunity to rethink and revisit traditional methods of treating fractures and the tolerance to operate every limb fracture must be risen. We must realize that all the fractures do not always need operations and the conservative management still has a certain place in our armamentarium of fracture management, in an evolving world!

No funding granted or received.

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