The Merriam-Webster dictionary defines “lockdown” as “security measure taken during an emergency to prevent people from leaving or entering a location” [3]. The Indian government was sufficiently proactive to initiate this “security measure” against the spread of Coronavirus from 24th March 2020. This led to a fear of overflow of the hospitals with patients, and shortage of healthcare facilities. Most hospitals, including ours, had plans in place where even orthopaedic surgeons would have to work in areas needing intensive care. As the lockdown continued, production and distribution of essential commodities had slowed down drastically and using up resources would deplete them further. The Government felt the economic pinch, and was left with the difficult task of fine-tuning the balance between a slowing down of the economy and dealing with the pandemic health crisis. Subsequently, following the pattern all over the world, there were various conditional relaxations in the application of lockdowns from 4th May 2020 onwards.
The purpose of this study was to evaluate any changes in the epidemiological profile of the trauma patients presenting to orthopaedic trauma center during various stages of the lockdown. We could discern almost a doubling of trauma patients once the strict phase of the first lockdown was over, with road accidents becoming more than three times the number as compared to lockdown 1. This could not be compared statistically, as the number of days of the two periods was different. However, the number of cases was still lower than the corresponding periods of the previous year, which implied that the restraints put in place by the government were sufficient to reduce mishaps initially, as is evident by the significant reduction of road accident cases seen. In the subsequent phase of lockdown, although reduced as compared to the previous year, RTA remained a major cause of trauma admissions; this implied that sufficient traffic was plying despite government guidelines in both phases of the lockdown. One fact of note, which may not be evidenced by statistics, was the reduction in actual numbers of open injuries in lockdown phase 1 (0.9/day as compared to 3.7/day in 2019), reflecting again on population mobility and effectiveness of restrictions in the initial phase.
On specifically evaluating the change in incidence of trauma due to fall, a reduction in overall cases was noted, although as a percentage of cases presenting it was higher in both phases especially in phase 1 (p < 0.05). Paediatric trauma also followed similar trend as trauma due to fall but it was not statistically significant. For the elderly, the pattern was the same, but in both the age groups, this was not statistically significant, implying that falls of children and elderly continued to occur, despite people not venturing out of their homes.
One fact of note was that the insignificant reduction in percentage of cases with open fractures and complex injuries, implying that whatever complex cases that presented to other centres during this period, were still being referred to our hospital.
As per the guidelines of various orthopaedic societies [4], an effort was made to reduce operative intervention where possible. Our data showed that although operative interventions were reduced to some extent, the change was not statistically significant, reflecting again upon the complex nature of injuries, which our institute deals with, which mostly require operative interventions.
A survey of international surgeons [5] revealed significant changes in trauma management and orthopaedic practice worldwide; 63 orthopaedic centres from 28 countries informed that 91% centres had a reduced workload and only 17% of these were doing elective surgeries. 30% of these had needed to deploy orthopaedic personnel to help in non-orthopaedic areas prior to May 15, 2020. This is similar to our experience, as our functioning has also drastically changed, and our personnel have been made ready since 1st June 2020 to be used in high intensity areas if needed.
Lockdowns of varying degree were imposed in various countries worldwide, and our understanding is that these were not as strict as they were in India. We compared our preliminary observational data to studies evaluating orthopaedic patients in Spain [6] and New Zealand [7]. Although the studies were different from ours, data from Spain [6] noted a similar reduction in traffic and workplace accidents, with reductions in hospital admissions, but the number of geriatric hip fractures remained almost the same; this was somewhat different from our experience. Since our hospital also had a block designated as a COVID hospital, it is our impression that many elderly cases who would have come to our centre with hip fractures etc. were diverted to private hospitals due to the fear of acquiring the disease in our centre.
The New Zealand study [7] looked at variations of volume and pattern in a level 1 trauma centre over two 14-day periods; they noted a 43% reduction in injury related admissions, and 48% reduction in paediatric admissions, and documented a predominance of injury at home, specifically falls in all age groups. We also found overall reduction in number of paediatric and elderly patients but there was no significant difference in terms of percentage.
Under pandemic conditions, where resource utilisation needs to be optimal, it becomes important for orthopaedic surgeons to understand the epidemiological pattern of the patients who present to the trauma centres; this allows them to be better prepared and use the available resources wisely. Non-operative management protocols maybe used in some cases as per the recommendation of national bodies [8], but with care as we do not want trauma patients to come back with problems like malunion and non-union at a later date.
In Italy [7], hospital reorganisation was done in some areas, where patients not requiring multi-specialty care were shifted to two specific hubs created for orthopaedic injuries alone. All elective surgeries were stopped, as were routine outpatient services, and only emergency OPD services were functional; all patients in emergency were subjected to oropharyngeal swabs and kept in a separate room till tests determined their status. Subsequent segregation was done according to the reports. By the second phase of the lockdown, this was also the protocol being followed in our hospital.
One fear prevalent in the medical community was contact with COVID-19 patients and adaptations of interventions and protocols. In the total period analysed, we had only one case of bilateral lower limb amputation who subsequently became COVID positive; this lead to the patient being shifted to the COVID isolation centre for subsequent care; the team identified to have dealt with the case was put into isolation, and the whole area including operation room used for surgery were sterilised. Luckily, none of them tested positive, and our changed protocols in place are preventing this episode from being repeated.
Joob and Wiwanitkit [9] have documented a case of wrist fracture they operated in Thailand after he returned from Japan; this was in the early period of the pandemic and awareness levels were low. Hence, it becomes important for all trauma cases to be tested prior to interventions, unless these are life or limb threatening. Even in these cases, immediate tests should be sent, and surgery should proceed with all COVID precautions and that too in specified isolation areas with designated operation rooms. This has also been documented by Mi et al. [10] who came in contact with the initial cases in China, and this can serve as an eye-opener for all of us.
Our study has a few limitations, first its a retrospective study and data was collected from hospital records. Second, being based on hospital admissions, it might not be representative of the overall pattern of orthopaedic trauma; being a designated COVID hospital some people might have opted to visit other hospitals for treatment for cases that were not so severe, thus altering our data. The Government of India is currently allowing more freedoms, and the government has further eased the restrictions. The increase in the number of trauma cases continues, and it is expected to rise further owing to increased human interactions and traffic. The pandemic scenario is expected to stay with us for quite some time, and our experience with trauma admissions and alteration of standard management protocols that we have followed, may provide administrators and surgeons information about what to expect in a crisis like this, so that we are better prepared for future circumstances. However due to limitations of our data, and the fact that we had an evolving learning experience as the pandemic also evolved, does not allow us to give more specific recommendations beyond sharing our experiences.