ABSTRACT
Background The widespread societal effects of the COVID-19 pandemic connote public health and epidemiological changes for orthopedic injuries. The epidemiology of upper extremity injuries and the effects of the pandemic on these nationwide trends is poorly defined. Methods This cross-sectional, descriptive epidemiological study compares epidemiological trends among upper extremity (UE) orthopedic injuries presenting to emergency departments (EDs) prior to and during the COVID-19 pandemic. Upper extremity fracture and dislocation data was sourced from the National Electronic Injury Surveillance System (NEISS) database in years prior to (2015-2019) and during the pandemic (2020-2021). Data on incidence, patient demographics, injury patterns, mechanisms of injury, incident locale, and patient disposition were collected and compared between years. Results The pre-COVID-19 incidence rate (IR) of UE fractures at 2.03 per 1,000 persons (n=3038930 from 2015-2019) decreased to 1.84 per 1,000 in 2020 (n=474805) and 1.82 per 1,000 in 2021 (n=471793). Dislocation rates were largely unchanged at 0.34 per 1,000 people (n=476740) prior to the pandemic and with incidence rates of 0.33 per 1,000 (n=85582) and 0.34 per 1,000 (n=89386) in 2020 and 2021, respectively. Female patients over 65 had the highest injury IR at 4.85 per 1,000 (n=976948). Finger fractures (IR=0.38 per 1000, n=96009) overtook hand fractures (IR=0.51 per 1000, n=310710) as more common during COVID-19 in males, while wrist (IR=0.55 per 1000, n=350650) fractures remained most common in females. Injuries from individual sports, such as skateboarding and bicycling, increased during the pandemic, while injuries from team sports decreased. Hospital admission and observation increased in 2020, while discharge and transfer rates decreased. Admission, observation, and discharge rates moved closer to pre-pandemic levels in 2021. Conclusions The COVID-19 pandemic was associated with epidemiological and activity changes regarding UE fractures and dislocations presenting to EDs. The present study demonstrates notable decreases in rates of upper extremity fractures and dislocations, increases in rates of injuries related to outdoor and individual sports such as skateboarding with corresponding decreases in rates of injuries related to organized sports such as basketball, increases in the rates of injuries occurring in homes and in association with pet supplies, and decreases in rates of injuries occurring in schools and places of recreation observed during the pandemic. Additionally, trends observed among patient disposition specific to the pandemic, such as increasing rates of patient admission, observation, and against medical advice (AMA) departure with decreasing rates of discharge and transfer, offer insight into the burden of upper extremity injuries on the healthcare system during this critical time. While upper extremity orthopedic injuries remained common through the pandemic, the early pandemic was associated with higher rates of hospital admission that normalized closer to pre-pandemic levels by 2021, which may herald a shift and return to pre-pandemic trends. Future research will determine the long-term downstream effects of COVID-19 on activity-related orthopedic injuries and bone health.
ABSTRACT
BACKGROUND: Recent spread of severe acute respiratory coronavirus syndrome-2 (SARS-CoV-2) has led to the coronavirus disease (COVID-19) pandemic, resulting in new challenges across all medical specialties. Limb and digit ischemia have been associated with COVID-19 infection. This systematic review includes primary studies of COVID-19 limb ischemia to identify risk factors, comorbidities, case characteristics, and treatment strategies to better understand the nature of this disease and its effects on the extremities. METHODS: A literature search for studies detailing COVID-19 infected patients with limb or digit ischemia was performed, identifying 157 articles, 12 of which met inclusion criteria, accounting for 47 patients. Inclusion criteria were (1) primary studies, (2) positive disease diagnosis (3) limb ischemia, (4) reported treatment. Demographic data, case characteristics, treatments, outcomes and mortality were collected and pooled. RESULTS: The average patient age was 67.6 years, predominantly male (79.6%). Of the 44 cases discussing treatment, 13 (30%) patients underwent medical treatment alone, while 23 (52.3%) patients underwent medical plus surgical treatment. Four patients (9.1%) were treated with observation. In 10 of the 12 studies, lab findings, thrombosis, or conclusions supporting a hypercoagulable state as a cause of limb/digit ischemia were cited. Five patients (10.6%) were on vasopressors and 8 patients (17.0%) were on a ventilator. Of those treated with observation alone, there was 100% resolution of symptoms. Of those treated medically without surgical intervention (17 patients), 6 patients (35.3%) were reported to have revascularization, 6 patients (35.3%) died, and the remaining outcomes were not reported. Medical and surgical treatment resulted in one limb amputation (4.4%) and altogether 74% of patients achieved revascularization of the affected limb/digit. Mortality rate was 45%. CONCLUSIONS: COVID-19 infection may be associated with increased risk of limb or digital ischemia, although the quality of evidence supporting this theory is limited. Evidence of inflammatory-mediated thrombosis and endothelial injury are possible explanations which would support the use of immunotherapy in addition to anticoagulation for treatment or prevention of thromboembolic events. Current outcomes and treatment strategies are variable. LEVEL OF EVIDENCE: IV.