Deep Venous Thrombosis after Conservative Treatment of Clavicular Fracture in COVID-19 Negative Children: Two Case Reports.

A 13-year-old girl suffered fracture of her left clavicle. A figure-of-8 bandage was placed during initial treatment. Six days after trauma her distal arm, elbow and proximal forearm were swollen, pain and tenderness of distal part of brachial vein was recognized during clinical examination. Duplex ultrasonography revealed partial thrombosis of the brachial vein. Bandage was immediately removed and administration of LMWH (enoxaparin) was started. Complete recanalization was achieved after a few days. The fracture was healed without further complication, patient was without sonographic and clinical signs of post-thrombotic syndrome. The second case report describes a 14-year-old boy. Initially, the fixation was a figure-of-8 bandage. 5 days after the injury he had swollen arm and elbow on the injured side, according to duplex ultrasonography deep venous thrombosis of the axillary and the brachial vein was recognized. There was only partial recanalization at the first sonographic follow up, the patient was converted to Warfarin for 3 months after injury after initial LMWH therapy. At the last follow-up, fracture of the left clavicle was healed and there were no DUSG or clinical signs of post-thrombotic syndrome. Key words: clavicle, deep venous thrombosis of the upper extremity, anticoagulant therapy.

National incidence and trends of bicycle injury.

Bicycle utilization continues to increase annually, and this trend was recently accelerated by the coronavirus disease of 2019 pandemic. There is limited epidemiologic data, however, regarding the prevalence and nature of bicycle-related injuries. Therefore, the purpose of this study is to characterize trends in bicycle-related injuries. The National Electronic Injury Surveillance System was queried for bicycle-related injuries from 2012 to 2021. Patient demographic and injury data were collected and analyzed to describe trends in incidence, patient demographics, and injury patterns associated with an emergency department encounter for a bicycle-related injury. There were an estimated 4,666,491 (95% confidence interval: 4,661,472-4,671,510) bicycle-related injuries from 2012 to 2021. The incidence of these injuries has significantly decreased over time (R = -0.983, R2 = 0.967, p < 0.001). However, the rate of injury in elderly patients increased over time. Injuries occurred most often during summer months (36%) and on weekend days (31.9%). Males and younger patients were more commonly injured. Head injuries were the most commonly affected body part among all age groups. Fractures were the most common injury type overall. Upper extremity injuries were more common than the lower extremity. Despite increased public bicycle utilization, there is a significant downtrend in bicycle-related injuries over the last decade. Injuries among elderly patients are becoming more common, who demonstrate a high rate of fracture and head injury. Fractures and head injuries were the most common injuries among all age groups, highlighting the importance of bicycle safety initiatives and helmet-wearing regardless of age.

Reoperation of Maisonneuve fracture with quadricortical syndesmotic screw, zip tight and fibula elongation by autograph: a case report in covid-19 patient.

PURPOSE: . We report a Maisonneuve case of reoperation with proximal fibula fracture, diastasis of syndesmosis and parcel posterior detachment of the third malleolus. PRESENTATION OF CASES: We report a case of 49- year old patient with a Maisonneuve fracture. The first surgery has failed with three-cortical screw rupture.  The second surgery was based on the implantation of quadricortical screw, zip tight and fibula elongation with autograph. The results were excellent despite the patient having contracted Covid-19 virus during rehabilitation. DISCUSSION: Maisonneuve fracture is a misdiagnosed fracture. The diagnosis may be made by RX or TC of lower limb. There are many treatments provides to stabilized and reduced the ankle. We believe the gold standard is the correct realignment of syndesmosis and a strong synthesis. CONCLUSION: The Maisonneuve fracture accounts for 7% of all ankle fractures but misdiagnosed. We emphasize the importance of making good diagnosis of this fracture for an excellent surgical result and avoiding the chronic complications of incorrect treatment. In this case the physical rehabilitation is delayed by covid-19 infection so we suggest to carry out studies on post-operative period in orthopedic patients during this global pandemic.

The Impact of COVID-19 in Bone Metabolism: Basic and Clinical Aspects.

The use of standard procedures for the diagnosis of osteoporosis and assessment of fracture risk significantly decreased during the COVID-19 pandemic, while the incidence of fragility fractures was mostly unaltered. Both COVID-19 per se and its treatments are associated with a negative impact on bone health. Preclinical models show that mice infected with SARS-CoV2 even without symptoms display loss of trabecular bone mass two weeks post infection, due to increased numbers of osteoclasts. Osteoporosis medications do not aggravate the clinical course of COVID-19, while preclinical data suggests possible beneficial effects of some therapies. While vitamin D deficiency is clearly associated with a worse clinical course of COVID-19, evidence of improved patient outcome with vitamin D supplementation is lacking. Osteoporosis treatment should not be generally discontinued, and recommendations for substituting therapies are available. Osteoporosis therapies do not interfere with the efficacy or side-effect profiles of COVID-19 vaccines and should not be stopped or indefinitely delayed because of vaccination.

Upscaling Virtual Fracture Clinic Use Is a Safe, Effective Measure in the Delivery of Trauma Care.

The Virtual Fracture Clinic (VFC) has proved beneficial in reducing footfall within the hospital setting, improving the cost of running a trauma service, while satisfying the majority of referred patients. The mandatory upscaling of telemedicine use, specifically the enhancement of the VFC, amidst the COVID-19 pandemic, was analyzed. The remit of the VFC within our hospital was expanded so as to include all referred ambulatory trauma. Outcomes of our VFC review over the 6-week period following the introduction of the national Irish COVID-19-related restrictions were gathered. These outcomes were analyzed and compared with the corresponding 6-week period from 2019. A 77.2% increase in the VFC referral volume was observed throughout the COVID-19-related period. Patients were directly discharged in 55.2% of cases in 2020, as opposed to 47.8% in 2019 (P = 0.044); referred directly for physiotherapy in 32.9% of cases in 2020, as opposed to 28.9% in 2019 (P = 0.173); and referred to a fracture clinic in 11.9% of cases in 2020, as opposed to 23.7% in 2019 (P < 0.001). Also, 3.0% of patients returned to the clinic after discharge in 2020, compared with 4.4% in 2019 (P = 0.237); 4.5% of patients were referred for surgery in 2020, as opposed to 2.2% in 2019 (P = 0.105). The VFC proved to be an efficient tool in managing ambulatory trauma throughout the pandemic. Upscaling the VFC to include all ambulatory trauma is a safe, effective method in reducing clinic attendances and hospital footfall, whilst ensuring that high care standards are maintained. LEVEL OF EVIDENCE:: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Early Orthopaedic Trauma Outcomes in COVID-19 Infected Patients: A Case Series.

Orthopaedic trauma presents a unique and complex challenge in the initial phase of the coronavirus 2019 (COVID-19) global crisis. Little is currently known about the surgical practices in orthopaedic emergencies in the early days of the COVID-19 outbreak (1). This is a retrospective case series of 10 orthopaedic trauma patients who underwent fracture fixation in March 2020. Of the 10 patients testing COVID-19 positive, there were a total of 16 long bone fractures, 5 pelvic ring fractures, and 1 lumbar burst fracture. There were 7 (70%) males in this cohort. Two (20%) of the COVID-positive patients did not develop fever, leukocytosis, respiratory insufficiency, or positive imaging findings and were younger (average age 25.5 years) with fewer comorbidities (average 0.5) compared with the 8 symptomatic COVID-19-positive patients (56.6 years with 1.88 comorbidities). Advancement of COVID-19 pathogenesis with lung opacities and prolonged intubation occurred in all 5 patients who remained on ventilation postoperatively (range 9 hours-11 days). At the time of most recent follow-up, all patients survived, 1 continues to require ventilation support, 1 remains admitted without ventilation support, and 8 (80%) were discharged to home. LEVEL OF EVIDENCE:: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Effect of COVID-19 pandemic on the fracture demographics: Data from a tertiary care hospital in Turkey.

OBJECTIVE: The purpose of this study was to evaluate the types and the frequency of fractures, both in the pediatric and adult population during the COVID-19 pandemic and to find out the differences in comparison to the non-pandemic period. METHODS: Patients who were admitted to the hospital with a new fracture during pandemic period (March 16 to May 22, 2020) were evaluated. Control group consisted of patients with new fractures admitted to the hospital in the same date range in 2018 and 2019. The patients were divided into two groups as ≤16 years old (group 1) and >16 years old (group 2). The evaluation was based on the age and gender of the patients and localization of the fractures. Hospitalized and surgically treated patients were evaluated as well. RESULTS: A total of 1794, 1747, and 670 fractures were observed in 2018, 2019, and 2020, respectively. Mean age of the patients in group 1 was found to have decreased in the pandemic period (p<0.001). The most common fracture sites in the pediatric population were the distal forearm and distal arm, whereas hand, distal forearm, and foot were most common fracture sites in adults, in both pandemic and non-pandemic periods. The proportional increase in femoral and tibial shaft fractures in group 1, and toe, tibial shaft, and metacarpal fractures in group 2 was found to be statistically significantly (p<0.05). In group 1; 6.8%, 7.7%, and 14.6% of the fractures were treated surgically in 2018, 2019, and 2020, respectively (p<0.001). For group 2, these rates were 20.1%, 18.6%, and 18.1%, respectively (p=0.67). There were 48, 29, and 26 open fractures in 2018, 2019 and 2020, respectively (p=0.066). In pandemic period, duration of the hospital stay was significantly shorter for distal humerus and proximal femur fractures (p values= 0.001 and 0.017, respectively). CONCLUSION: We observed that the frequency of fractures decreased by approximately one-third during the pandemic period compared with that in the non-pandemic period. The mean age of the patients with a fracture in the pediatric group was found to have decreased also. Finger fractures in pediatric patients and metatarsal fractures in adult patients were found to have significantly decreased during the pandemic. LEVEL OF EVIDENCE: Level III, Diagnostic study.

Lessons from a lumbar burst fracture patient infected with SARS-CoV-2.

In December 2019, the 2019 novel coronavirus (SARS-CoV-2) began spreading in China. At present, there are no special protocols for treating lumbar burst fracture (LBF) patients infected with SARS-CoV-2. Here, we present our lessons and experiences with a patient presenting with a severe LBF complicated by an occult SARS-CoV-2 infection. The clinical data for a 52-year-old male LBF patient were collected during the incubation period of COVID-19. The patient exhibited no obvious COVID-19-related symptoms prior to his surgery, and his vital signs were stable on the first day after the operation. By postoperative day 3, however, the patient was exhibiting chills and high fever. A chest CT showed a patchy high-density shadow surrounded by ground-glass opacity in the lower portion of his right lung. A nucleic acid test for SARS-CoV-2 was positive, and the patient was then transferred to the Department of Infectious Disease for further special treatment. This case taught that when treating patients with severe trauma within an epicenter of this pandemic, it is crucial for healthcare workers to be vigilant so as to avoid potential widespread outbreaks of COVID-19 within hospitals.

COVID-19 Orthopaedic Safe Care Toolset: Guidelines for the Diagnosis and Management of Patients with Fracture and COVID-19.

The SARS-CoV-2 (severe acute respiratory syndrome-coronavirus 2) was reported in Wuhan, Hubei Province, People's Republic of China, and, subsequently, in other provinces and regions across the People's Republic of China and >212 countries. COVID-19, the disease caused by this coronavirus, was declared a worldwide pandemic by the World Health Organization (WHO). The incidence of patients with fracture who are also positive for COVID-19 is on the rise. The diagnosis and management of such patients can be complicated as their clinical characteristics are heterogeneous. Furthermore, a surgical procedure can be particularly challenging given that the use of high-speed devices results in aerosol generation. In this study, we develop and propose globally applicable guidelines to fill this knowledge gap and we identify and propose the necessary protective strategies for medical personnel in an orthopaedic emergency department and in the inpatient wards. We also introduce diagnostic criteria, surgical complication management, and follow-up strategies for infected patients. These guidelines may be helpful to decrease the infection rate of orthopaedic trauma personnel and to provide diagnosis and treatment therapy for patients with fracture and COVID-19.

Characteristics and Early Prognosis of COVID-19 Infection in Fracture Patients.

BACKGROUND: Studies of the novel coronavirus-induced disease COVID-19 in Wuhan, China, have elucidated the epidemiological and clinical characteristics of this disease in the general population. The present investigation summarizes the clinical characteristics and early prognosis of COVID-19 infection in a cohort of patients with fractures. METHODS: Data on 10 patients with a fracture and COVID-19 were collected from 8 different hospitals located in the Hubei province from January 1, 2020, to February 27, 2020. Analyses of early prognosis were based on clinical outcomes and trends in laboratory results during treatment. RESULTS: All 10 patients presented with limited activity related to the fracture. The most common signs were fever, cough, and fatigue at the time of presentation (7 patients each). Other, less common signs included sore throat (4 patients), dyspnea (5 patients), chest pain (1 patient), nasal congestion (1 patient), headache (1 patient), dizziness (3 patients), abdominal pain (1 patient), and vomiting (1 patient). Lymphopenia (<1.0 × 10 cells/L) was identified in 6 of 10 patients, 9 of 9 patients had a high serum level of D-dimer, and 9 of 9 patients had a high level of C-reactive protein. Three patients underwent surgery, whereas the others were managed nonoperatively because of their compromised status. Four patients died on day 8 (3 patients) or day 14 (1 patient) after admission. The clinical outcomes for the surviving patients are not yet determined. CONCLUSIONS: The clinical characteristics and early prognosis of COVID-19 in patients with fracture tended to be more severe than those reported for adult patients with COVID-19 without fracture. This finding may be related to the duration between the development of symptoms and presentation. Surgical treatment should be carried out cautiously or nonoperative care should be chosen for patients with fracture in COVID-19-affected areas, especially older individuals with intertrochanteric fractures. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.