The "COVID-19 Approach" to Distal Radius Fracture Management.

Background In response to the coronavirus pandemic the British Orthopaedic Association Standards for Trauma and Orthopaedics (BOAST) guidelines advised treating distal radius fractures (DRFs) non-operatively where possible. Questions/Purpose The aim of this study was to assess whether the coronavirus disease 2019 (COVID-19) pandemic lockdown within the United Kingdom did alter the management of DRFs and whether there was any subsequent change in patient outcome or complication rate. Patients and Methods A retrospective cohort study was performed at a single orthopaedic center within the United Kingdom. The cohort of patients presenting with DRFs during the first lockdown was identified through the virtual fracture clinic database. The cohort of patients from the previous year was also identified for comparison. Data was collected on patient demographics, radiological features of the fractures, management, patient outcome and subsequent complications. Comparisons were then made between the cohorts for each year. Results The pre-COVID cohort had a significantly higher number of patients reviewed in face-to-face clinic appointments ( p = 0.0044) and the mean number of clinic appointments for those patients was significantly higher ( p = 0.0149). There was no significant difference between the cohorts regarding patient complications or any need for return to theater with a minimum 10 month follow-up period. Conclusion Despite comparative numbers and patterns of DRFs as well as no significant difference in the number of injuries requiring orthopaedic intervention, the burden on fracture clinic services was significantly reduced during the COVID pandemic. Encouragingly, this reduction in follow-up has not translated into an increased prevalence of complications or requirement for further surgery. Level of Evidence The level of evidence of the study is level III.

Physical Activity Is Associated with a Lower Risk of Osteoporotic Fractures in Osteoporosis: A Longitudinal Study.

The purpose of our study was to examine the occurrence of osteoporotic fractures (fxs) according to the level of physical activity (PA) among osteoporosis using the Korean National Health Insurance Service (NHIS) customized database. From NHIS data from 2009 to 2017, osteoporosis was selected as requested. PA was classified into 'high PA' (n = 58,620), 'moderate PA' (n = 58,620), and 'low PA' (n = 58,620) and were matched in a 1:1:1 ratio by gender, age, income within the household unit, and region of residence. A stratified Cox proportional hazard model was used to calculate hazard ratios (HRs) for each type of fx comparing PA groups. The 'low PA' group was the reference group. For vertebral fx, the adjusted HR (95% confidence intervals (CIs)) was 0.27 (0.26-0.28) for the 'high PA' group and 0.43 (0.42-0.44) for the 'moderate PA' group. For hip fx, the adjusted HR (95% CIs) was 0.37 (0.34-0.40) for the 'high PA' group and 0.51 (0.47-0.55) for the 'moderate PA' group. For distal radius fx, the adjusted HR (95% CIs) was 0.32 (0.30-0.33) for the 'high PA' group and 0.46 (0.45-0.48) for the 'moderate PA' group. The results of this study suggest that a higher intensity of PA is associated with a lower risk of osteoporotic fxs, including vertebral fx, hip fx, and distal radius fx.

Bilateral distal radius fractures with seven month pregnancy during the peak period of National Lockdown due to COVID 19 pandemic in Nepal: A case report

Introduction Even though distal radius fracture is a common orthopedic problem, bilateral distal radius fracture associated with pregnancy is a very rare injury pattern. A twenty-three old female with seven-month pregnancy came to our hospital with a history of falling from 10 feet height and sustained a fracture on both sides of the wrist joint. On examination, there was a Grade IIIA open fracture on the right wrist, suspected closed fracture on the left wrist, and distended lower abdomen with estimated seven-month pregnancy. X-ray of bilateral wrist and forearm was performed along with ultrasonography of abdomen and pelvis. She was successfully managed through debridement, K wires fixation, and external fixator on the right forearm while fracture on the left side was treated with closed reduction and percutaneous K wires fixation. However, the fetus was evacuated as dead because of concomitant intrauterine fetal injury even though we successfully saved the limb and life during the lockdown period with an extremely worst situation. Conclusion This combination injury in the same individual during the peak period of COVID 19 National Lockdown not only is a challenging condition that needs multidisciplinary management but also requires life and limb saving judicial surgical intervention in one of the worst surrounding environments.

Physical Activity, Sunshine Duration, and Osteoporotic Fractures: A Nested Case-Control Study.

This study examined the associations between the occurrence of osteoporotic fractures in detailed sites and combined physical activity (PA) and sunshine duration (SD). Data from the Korean National Health Insurance Service-National Health Screening Cohort for 7-year periods and from the Korea Meteorological Administration were used. Osteoporotic fractures (n = 12,103), including vertebral fractures, hip fractures, and distal radius fractures, and matched controls (n = 24,206) were selected in 1:2 ratios by age, sex, income, and region of residence. PA was classified as moderate- to high-intensity PA (High PA) and low-intensity PA (Low PA). SD was classified as Short SD (<6.1 h) and Long SD (≥6.1 h). Conditional logistic regression was used to calculate the odds ratios (ORs) with 95%-confidence intervals (CIs) of the combined PA and SD groups for the occurrence of each osteoporotic fracture. Compared to 'Low PA + Short SD', the adjusted ORs (95% CIs) for vertebral fracture in 'High PA + Short SD' and 'High PA + Long SD' were 0.83 (0.76-0.91) and 0.84 (0.77-0.92), respectively. Hip/distal radius fractures were not associated with the combined PA and SD group. We suggest that a higher intensity of PA is inversely associated with the risk of vertebral fracture.

Types, management and complications in paediatric distal radial fractures sustained during COVID-19 lockdown.

In response to the coronavirus pandemic the British Orthopaedic Association Standards for Trauma and Orthopaedics (BOAST) guidelines advised treating distal radial fractures non-operatively where possible. A cohort was studied retrospectively to assess whether the COVID pandemic lockdown within the UK altered types, the management and complications of paediatric distal radial fractures. The cohort studied comprised of 194 paediatric distal radial fractures in the pre-COVID cohort and 101 fractures in the COVID cohort. There was no significant differences in the type of fractures in the two cohorts. Significantly more high energy injuries were sustained among the COVID cohort than the pre-COVID (p < 0.001). The COVID cohort had significantly more patients managed in cast (p < 0.001) and significantly more managed with K-wire fixation (p = 0.049). The COVID cohort had significantly more complications (p = 0.016) at minimum 10-month follow-up. The results suggest that treatment of paediatric distal radial fractures during lockdown was too conservative and subsequent complications may put additional strain on orthopaedic services.Level of evidence: IV.

Changing to Removable Casts During the Coronavirus Pandemic-Has It Affected Outcomes for Distal Radius Fractures?

BOAST (British Orthopaedic Association Standards for Trauma & Orthopaedics) guidelines recommended that during the coronavirus pandemic most upper limb fractures should be treated conservatively, and removable casts should be used, where possible. As a result, our district general hospital started using a new soft combination (soft-combi) casting technique for conservative management of distal radius fractures (DRFs) in an attempt to reduce follow-up attendances. To assess if radiological outcomes of soft-combi casts are better or worse than previously used rigid casts for DRFs. Twenty DRFs treated with soft-combi casts were compared with 20 DRFs treated with the old rigid cast types. Radiological parameters were measured pre-manipulation, post-manipulation, at 2-week follow-up, and at final follow-up. Statistical analysis was performed to assess for significant differences seen at follow-up between the groups. The mean loss of volar angulation seen at 2-week follow-up was 4.9° for the rigid casts vs. 1.5° for the soft-combi casts (p = 0.158; 95% CI, - 8.17 to 1.38). The mean loss of radial height after 2 weeks was 0.2 mm vs 0.5 mm (p = 0.675; 95% CI, - 1.09 to 1.66), and the mean loss of radial inclination was 2.0° vs 1.0° (p = 0.349; 95% CI, - 2.96 to 1.07), respectively. The soft-combi casts appeared to be equally effective at maintaining the reduction of DRFs compared to their rigid counterparts, as no statistically significant difference was seen in our study. We can be reassured that continued use of these removable casts in the current climate is unlikely to have a detrimental effect on outcomes for DRFs.

Displaced distal radius fracture: reduction, follow-up, and clinical outcomes : learning from a pragmatic approach during the 2020 COVID-19 lockdown transition.

AIMS: Displaced distal radius fractures were investigated at a level 1 major trauma centre during the COVID-19 2020 lockdown due to the implementation of temporary changes in practice. The primary aim was to establish if follow-up at one week in place of the 72-hour British Orthopaedic Association Standards for Trauma & Orthopaedics (BOAST) guidance was safe following manipulation under anaesthetic. A parallel adaptation during lockdown was the non-expectation of Bier's block. The secondary aim was to compare clinical outcomes with respect to block type. METHODS: Overall, 90 patients were assessed in a cross-sectional cohort study using a mixed, retrospective-prospective approach. Consecutive sampling of 30 patients pre-lockdown (P1), 30 during lockdown (P2), and 30 during post-lockdown (P3) was applied. Type of block, operative status, follow-up, and complications were extracted. Primary endpoints were early complications (≤ one week). Secondary endpoints were later complications including malunion, delayed union or osteotomy. RESULTS: In P1, 86.6% of patients were seen between days one to three, 26.7% in P2, and 56.7% in P3. There were no documented complications from days one to three. Operative rate was 35.5%, which did not vary significantly (p= 0.712). Primary endpoints occurred between day four to seven, and included one patient each period treated for plaster cast pain. Secondary endpoints in P1 included delayed union (one patient). During P2, this included malunion (one patient), a pressure sore (one patient) and ulnar cutaneous nerve symptoms (two patients). In P3, malunion was identified in one patient. Mean follow-up was six months (4 to 9) with union rate 96%. Change in block practice varied significantly (p =＜0.05). The risk ratio of complications using regional block (Bier's) over haematoma block was 0.65. CONCLUSION: Follow-up adaptations during lockdown did not adversely affect patient outcomes. Regional anaesthesia is gold standard for manipulation of displaced distal radial fractures. Cite this article: Bone Jt Open 2021;2(5):338-343.

Epidemiology of distal radius fractures in children and adults during the COVID-19 pandemic - a two-center study.

BACKGROUND: Distal radius fractures (DRFs) constitute 15-21% of all fractures. There are no detailed data on the possible changes in the epidemiology and treatment of DRFs in children and adults during the Covid pandemic. The purpose of our study was a comprehensive assessment of the impact of the COVID-19 pandemic on distal radius fractures (DRF) epidemiology, including both children and adults and various fracture fixation methods in two large trauma centers in Poland. METHODS: This study compared the medical data on the treatment of distal radius fractures in Poland in two periods: the period of the COVID-19 pandemic (from March 15 to October 15, 2020) and the corresponding period prior to the pandemic (from March 15 to October 15, 2019). We assessed detailed data from two trauma centers for pediatric and adult patients. Outpatients seeking medical attention at emergency departments and inpatients undergoing surgery at trauma-orthopedic wards were evaluated. We compared epidemiological data, demographic data, treatment type, and hospital stay duration. RESULTS: The total number of patients hospitalized due to DRF during the pandemic was 180, it was 15.1% lower than that from the pre-COVID-19 pandemic period (212). In the case of adult patients, the total number of those hospitalized during the pandemic decreased significantly (by 22%) from 132 to 103 patients. Analysis of the individual treatment methods revealed that the number of adults who underwent conservative treatment was considerably (by 30.3%) significantly lower in the period of the COVID-19 pandemic, from 119 to 83 patients. Compared to 13 patients from the pre-pandemic period, the number of surgically treated adults statistically increased to 20 patients (by 53.8%). Our analyses showed hospitalizations of surgically treated adults to be shorter by 12.7% during the pandemic, with the corresponding hospitalizations of surgically treated pediatric patients to be shorter by11.5%. CONCLUSIONS: Our study showed a significant impact of the COVID-19 pandemic on the epidemiology and treatment of DRFs in children and adults. We found decreased numbers of pediatric and adult patients with DRFs during the COVID-19 pandemic. The pandemic caused an increase in the number of children and significantly increase adults undergoing surgical treatment for DRFs, a decrease in mean patient age, shorter significantly length of hospital stay, and an increased number of men with DRFs.

The theoretical impact on corrective upper limb elective services following analysis of distal radius fractures managed nonoperatively during COVID-19 pandemic.

AIMS: To assess the proportion of patients with distal radius fractures (DRFs) who were managed nonoperatively during the COVID-19 pandemic in accordance with the British Orthopaedic Association BOAST COVID-19 guidelines, who would have otherwise been considered for an operative intervention. METHODS: We retrospectively reviewed the radiographs and clinical notes of all patients with DRFs managed nonoperatively, following the publication of the BOAST COVID-19 guidelines on the management of urgent trauma between 26 March and 18 May 2020. Radiological parameters including radial height, radial inclination, intra-articular step-off, and volar tilt from post-reduction or post-application of cast radiographs were measured. The assumption was that if one radiological parameter exceeds the acceptable criteria, the patient would have been considered for an operative intervention in pre-COVID times. RESULTS: Overall, 92 patients formed the cohort of this study with a mean age of 66 years (21 to 96); 84% (n = 77) were female and 16% (n = 15) were male. In total, 54% (n = 50) of patients met at least one radiological indication for operative intervention with a mean age of 68 years (21 to 96). Of these, 42% (n = 21) were aged < 65 years and 58% (29) were aged ≥ 65 years. CONCLUSION: More than half of all DRFs managed nonoperatively during the COVID-19 pandemic had at least one radiological indication to be considered for operative management pre-COVID. We anticipate a proportion of these cases will require corrective surgery in the future, which increases the load on corrective upper limb elective services. This should be accounted for when planning an exit strategy and the restart of elective surgery services.Cite this article: Bone Joint Open 2020;1-10:612-616.

Approaching "Elective" Surgery in the Era of COVID-19.

The coronavirus disease 2019 pandemic created unprecedented challenges for the health care system. To meet capacity demands, hospitals around the world suspended surgeries deemed to be elective. In hand surgery, numerous pathologies are treated on an elective basis, but a delay or absence of care may result in poorer outcomes. Here, we present an ethical framework for prioritizing elective surgery during a period of resource scarcity. Instead of using the term "elective," we define procedures that can be safely delayed on the basis of 3 considerations. First, a safe delay is possible only if deferral will not result in permanent injury. Second, a delay in care will come with tolerable costs and impositions that can be appropriately managed in the future. Third, a safe delay will preserve the bioethical principle of patient autonomy. In considering these criteria, 3 case examples are discussed considering individual patient characteristics and the pathophysiology of the condition. This framework design is applicable to ambulatory surgery in any period of crisis that may strain resources, but further considerations may be important if an operation requires hospital admission.