key: cord-0732632-6ddvqowr authors: Farrell, Sarah; Schaeffer, Emily K.; Mulpuri, Kishore title: Recommendations for the Care of Pediatric Orthopaedic Patients During the COVID Pandemic date: 2020-04-14 journal: J Am Acad Orthop Surg DOI: 10.5435/jaaos-d-20-00391 sha: 350dbb4ac3a9a8633c1a6f5fc31548fabb205177 doc_id: 732632 cord_uid: 6ddvqowr The COVID pandemic has necessitated modifications to pediatric orthopaedic practice to protect patients, families, and healthcare workers and to minimize viral transmission. It is critical to balance the benefits of alterations to current practice to reduce the chances of COVID infection, with the potential long-term impact on patients. Early experiences of the pandemic from orthopaedic surgeons in China, Singapore, and Italy have provided the opportunity to take proactive and preventive measures to protect all involved in pediatric orthopaedic care. These guidelines, based on expert opinion and best available evidence, provide a framework for the management of pediatric orthopaedic patients during the COVID pandemic. General principles include limiting procedures to urgent cases such as traumatic injuries and deferring outpatient visits during the acute phase of the pandemic. Nonsurgical methods should be considered where possible. For patients with developmental or chronic orthopaedic conditions, it may be possible to delay treatment for 2 to 4 months without substantial detrimental long-term impact. S ince the first case of the novel coronavirus (COVID) was reported in Wuhan, China in December 2019, viral infection has spread at an alarming rate. On January 30, 2020, the World Health Organization (WHO) announced COVID as a Public Health Emergency of International Concern, and by March 11, 2020 , it was officially declared a pandemic. 1 As of April 5, 2020, the United States has 330,891 reported cases and 8,910 deaths in total, with 64,966 of those cases and 2,472 deaths attributed to New York City alone. 2, 3 The rapid progression of COVID infection rates has stimulated the international implementation of social distancing practices and temporary cessation of all nonessential businesses. Because COVID is primarily transmitted through respira-tory droplets and close contact, strict adherence to social distancing procedures is critical to limit the spread of infection and mitigate the foreseen impact on healthcare systems. 4 Within the healthcare setting, adaptations to regular clinical procedures are necessary to reduce the risk of infection in patients, families, and healthcare providers alike while balancing the risks and benefits of delaying or altering typical patient care. The COVID pandemic has necessitated substantial changes to the current practice. These guidelines are meant to offer a framework for safe and ethical management of the pediatric orthopaedic patient in these Sarah Farrell, MBChB, FRACS(Ortho), FAOrthoA Emily K. Schaeffer, PhD Kishore Mulpuri, MBBS, MS(Ortho), MHSc(Epi), FRCSC uncertain times. We trust that each surgeon considers whether the benefits of typical treatment protocols before the COVID crisis outweigh the risks in this unusual time. This is likely to require constant reevaluation as the situation evolves and be based on the local healthcare constraints, rather than a "one-sizefits-all" approach. These guidelines are based on an accumulation of expert opinion and evidence-based recommendations where possible, with the aim to reassure surgeons that pediatric patients can be safely and ethically managed with minimal negative long-term consequences. Once some postpandemic normalcy has been restored, it will be imperative to use data obtained at this time to inform future management on the safety of these approaches that were necessitated by the risk of COVID. During the COVID pandemic, there will be an increased emphasis on nonsurgical strategies. Patients who need urgent orthopaedic management, such as serious traumatic injuries or tumors, will be managed according to the typical standard of care. The COVID pandemic will more dramatically affect practice regarding elective procedures and the ensuing follow-up. These changes in clinical practice are guided by following three overarching principles: The Singapore Group identified the need for balance between continuing care and safety for patients, caregivers, and healthcare workers. They concluded that day-case procedures could continue, given their limited impact on healthcare resources, especially allowing for rapid turnover of hospital beds potentially needed for acute admissions. In addition, sameday discharge minimizes the risk to the patient and family of nosocomial exposure to COVID. Here at British Columbia Children's Hospital (BCCH), Vancouver, Canada, we have implemented a rotating team approach in these unusual times. Splitting the department into self-reliant cells allows groups to be physically quarantined and avoids cross-contamination. There is a backup, or "Surge" team available each day, if the primary team is overwhelmed or unable to perform their duties-for instance, if a team member becomes unwell themselves from COVID. The lead surgeon for each day manages the trauma and delegates tasks to the other team members, aiming to minimize personnel exposure while maintaining quality care. Overall, a pragmatic approach should be taken to treatment decisions and a specific note that the patient was assessed and managed during the coronavirus pandemic will be imperative in the future to assess quality maintenance and the longterm impact of COVID in the pediatric orthopaedic setting. These recommendations should be viewed as guidance and be modified based on locally available resources. Specific reorganization procedures will depend on the practice setting. Considerations to take into account include the num-ber of attending staff surgeons, support staff (clinic/nursing/extended providers/therapy team), and junior staff. Smaller units might have to contact larger centers if staffing becomes an issue. Units should also consider whether they are in the acute phase and perhaps temper their response as the situation improves. Recommendations-General considerations [6] [7] [8] [9] [10] (1) Limit in-person patient review to definitive decision-maker (Attending surgeon) (1) Minimize personnel-excuse medical students and company representatives (2) Avoid laminar flow (3) Use N95 masks and gogglespower tools may be associated with significant droplet and fine particle generation (4) Use additional face shield-can be reusable (5) Do not use pulse lavage (6) Limit team in the operating room during high-risk periods-intubation/extubation (7) Use electrocautery with smoke evacuator (8) Use absorbable sutures as much as possible (9) Use clear dressings (10) Avoid PICO dressings (11) Use splints and removable casts The risk to all healthcare workers is significant, and orthopaedic surgeons can learn from the early experiences of surgeons in Italy and China. In Italy, front-line healthcare workers were disproportionately prone to COVID infection, and often contracted the most severe form of the disease. The risk specifically to surgeons is that the virus is transmitted primarily through aerosolsdroplets containing the virus. This puts anesthesiologists at particular risk during intubation and extubation, but the rest of the team is also susceptible. The risk of aerosolgenerating procedures has led centers to minimize personnel in the operating room. Orthopaedics often requires the use of power tools with aerosolization of material putting the team at further increased risk in comparison to other surgical procedures. Although blood is not the preferred route of the virus, research supports the idea that COVID is an opportunistic invader. Consequently, blood donors in Wuhan are now screened for the virus. Guo et al surveyed orthopaedic surgeons in Wuhan, China, infected with COVID and provided recommendations to safeguard the surgeon according to their experiences as the first province to experience the outbreak. 11, 12 They recommended that healthcare workers have a high level of vigilance and take all necessary precautions to protect themselves from infection with COVID. They should use PPE and consider urging patients to wear masks. Orthopaedic surgeons need to be able to manage often limited resources, particularly PPE, and be flexible in their schedules, such as canceling elective work and being ready to be redeployed as necessary. They should avoid close contact with family members after being in known exposed environments and practice the usual social distancing measures to keep the community safe in all situations. Surgeons should also be careful to monitor their own health regarding both COVID symptoms and also manage fatigue and stress which could compromise their own immunity. During the COVID pandemic, prevention is better than cure. However, traumatic injuries will need to be considered for both surgical and nonsurgical management, regardless of clinic closures. Although social distancing and isolation might serve to limit trauma numbers, there will still be a clinical need to proceed with surgery in many instances. With parks closed, there has been a recent spike in purchase of home play equipment and trampolines. An average of 40% of pediatric injuries requiring hospitalization or emergency department review occur in the home. 13 Consequently, being isolated at home will not prevent all injuries. Minimizing the number of interactions during treatment for traumatic injuries will help protect the patient, caregiver, and healthcare workers. Social and physical distancing preventive measures remain critical to reduce spread. 14 A normal trauma clinic would present many situations capable of facilitating viral transmission. Take the scenario of a child sustaining a both bones forearm fracture that requires reduction in the ED. This child and their family come in contact with ambulance paramedics, the ED booking clerk, nurse, ED physician, radiology booking clerk and technician, orthopaedic staff, and all the staff members required for follow-up. If this same child requires surgery and a short in-patient stay, the potential transmission contact will be exponentially high. Therefore, it is ethically logical to implement changes to minimize these potential transmissions. When considering surgical management, in-patient care should be kept to a minimum and used only when no alternative is available. Every effort should be made to maximize day surgery options. During the COVID pandemic, there will be increased emphasis on managing children with nonsurgical strategies and limiting outpatient visits. The aim is to minimize long-term consequences by prioritizing conditions that have immediate, permanent morbidity, or lack a practical remedial option. Day-case surgery can be an option for many injuries requiring surgical management: 8 (1) Reduction of joint dislocations (2) Fractures with abnormal neurology or soft-tissue compromise that is resolving (3) Periarticular fractures (4) Extra-articular femoral fractures in children aged less than six years Management of non AQ : 6 accidental injury should not change. 8 In many instances of traumatic injury, minimizing postoperative imaging can be done safely. A 2018 systematic review found that immediate postoperative imaging led to an absolute benefit increase in identifying complications of only 0.22%. 15 This can be a valuable application in the current situation, and all imaging that will not change management should be avoided. With open fracture cases, consideration should be given to wash-out and application of a windowed cast. Cases of septic arthritis and osteomyelitis with subperiosteal collection are likely to require operative surgery and ongoing inpatient management. Aim to minimize procedures as much as possible, and use a PICC line at time of surgery. Keep imaging to a minimum, choosing the single, most useful imaging modality to limit contacts and transmissions between patients and healthcare workers. Where possible, consider the use of at-home intravenous antibiotic treatment. Dislocations should be reduced in emergency wherever possible and managed as day surgery if admission is required. These treatment protocols should serve as a framework for the management of common fractures in this time. At our center, trauma referrals are reviewed by the day's attending surgeon. As much as reasonably possible, required follow-ups are done using video or teleconferencing, and conditions which can wait are postponed during this period. Much of the clinical assessment can be done via videoconference or teleconference with the family. Imaging is only performed if it is likely to change the treatment plan. When not in-person, follow-up needs to be carefully organized to ensure patients are not lost to follow up, and parents have appropriate support for the extra tasks with which they are being entrusted. Most upper limb fractures can be managed conservatively. As an overarching principle, aim to maximize the use of removable casts and splints. Accept that there will be more initial deformity than what might previously have been tolerated; the high remodeling potential in pediatric patients mitigates the risk of residual deformity, and there are options for highly successful corrective procedures at a later date if needed. 16 Please refer to ½T1 Table 1 for a summary of recommendations for pediatric orthopaedic trauma management. Many orthopaedic units in hospitals across the globe have begun to take preventive measures by reducing or closing clinics to most outpatients. Taking lessons learned from early experiences with the COVID pandemic in Singapore and China, the BCCH Orthopedic Surgery department has scaled back clinics as much as possible for a 3-month period. Key decisions have been made to limit or postpone treating children with developmental, congenital, or chronic orthopaedic conditions, such as developmental dysplasia of the hip (DDH), Legg-Calvé-Perthes dis-ease (LCPD), clubfoot, scoliosis, and orthopaedic conditions secondary to cerebral palsy. The decision to defer clinic visits for up to three months may be fraught with concern over the long-term impact of delayed treatment. This is particularly true in conditions, such as DDH, where early detection and treatment are widely regarded to optimize outcomes. However, the risks of deferring treatment must be weighed against the risks of continuing treatment as usual during the COVID crisis. A unique feature of pediatric care is the number of caregivers and/or family members who typically accompany an infant or child to a clinic appointment. It is common to see two or three caregivers in clinic along with the child. In addition, there are typically a minimum of four healthcare workers in contact with the family during the visit. Each family member present could potentially be an asymptomatic or presymptomatic vector for viral transmission, increasing the chance of spreading infection to healthcare workers or other patients and families. Eliminating as many of these visits as possible during the peak of the pandemic can greatly reduce the chances of viral spread. Another primary concern is for the safety of the child. Although initial impressions of COVID have been that children are not as susceptible to infection, a recent retrospective review of the epidemiology of pediatric cases in China suggested that infants were more susceptible to the severe infection than older children, with 10.6% of cases severe or critical in infants younger than one year of age. 20 For a condition such as DDH, most children coming to the orthopaedic clinic for DDH are younger than one year of age; therefore, these patients represent a potentially vulnerable cohort during this time. Children with cerebral palsy also represent a particularly at-risk and open reduction even in older infants seen within IHDR can allay some of these concerns. At present, the main priority is reducing the spread of COVID-19. After careful consideration of the risk/benefit ratio of delaying treatment to reduce odds of infection, BCCH is choosing to postpone assessment and treatment of DDH for the next 2 to 4 months. There is evidence to suggest that good outcomes for DDH can still be achieved, by either conservative or surgical approaches, beyond 4 months of age. Even when treated by conservative methods, infants require frequent hospital visits throughout their treatment course. Given the emerging evidence showing infants may be vulnerable to COVID-19 infection, this would put them at increased risk. Consideration should be given to provide extensive educational tools and guidance to parents on hip healthy swaddling techniques and hip healthy baby carriers. Once the COVID pandemic has settled, it will be important for surgeons to look back on the results of the way trauma and elective care have been managed during this period. Research will be needed to look at what the negative consequences of these interventions have been. We expect there to be more residual deformity to correct, conditions that might have been addressed more simply sooner might require more extensive procedures, and all surgeons will have to manage their own surgical backlog as best they can according to their available resources. COVID-necessitated practice changes provide the potential for positives lessons that can result in meaningful long-term improvements in care. With a greater emphasis on video-conferencing and teleconferencing, it might be possible to see more routine patient reviews in this manner, freeing up personnel and resources for more involved or complicated new patients. Managing without such frequent imaging might highlight which conditions truly require the routine follow-up radiograph and which do not, ultimately reducing unnecessary exposure to radiation and unnecessary clinic visits. Teams may also gain unexpected new experience in the management of limited resources. They will likely learn to be more adaptable and resilient, having worked in todays' constantly changing environment. These are valuable skills which are ultimately learned best through experience. Adapting to perform clinical practice during this unusual time of COVID could galvanize the pediatric orthopaedic community both locally and worldwide. World Health Organization: Rolling Updates on Coronavirus Disease (COVID-19) COVID-19: Data. Available at SARS-CoV-2 and COVID-19: The most important research questions Novel coronavirus and orthopaedic surgery Australian and New Zealand Association of Paediatric Surgeons Inc: Guidelines in the management of paediatric patients in the COVID-19 era Royal College of Surgeons in Ireland: Clinical guidance for surgeons British Orthopaedic Association: BOAST-Management of Patients With Urgent Orthopaedic Conditions and Trauma During the Coronavirus Pandemic American College of Surgeons: COVID-19 guidelines for triage of orthopaedic patients COVID-19: Member Resources The Orthopaedic Forum Survey of COVID-19 disease among orthopaedic surgeons in Wuhan, People's Republic of China Bloomberg Opinion: Why Surgeons Don't Want to Operate Right Now Adjusting to a New Pace of Life During the COVID-19 Pandemic Centers for Disease Control and Prevention: Coronavirus Disease 2019 in Children-United States Do immediate postoperative radiographs change patient management after fracture fixation? A systematic review Closed treatment of overriding distal radial fractures without reduction in children Alder Hey Orthopaedics: COVID 19 Resources Outcomes of operative and non-operative treatment of adolescent mid-diaphyseal clavicle fractures Assessing the reliability of the modified Gartland classification system for extension-type supracondylar humerus fractures Epidemiological characteristics of 2143 pediatric patients with 2019 coronavirus disease in China Evaluation of brace treatment for infant hip dislocation in a prospective cohort International Hip Dysplasia Institute: Closed reduction for developmental dysplasia of the hip Optimal timing for containment surgery for Perthes disease Management of Legg-Calvé-Perthes disease using an A-frame orthosis and hip range of motion: A 25-year experience North American Spine Society: COVID-19 Resources and Updates The authors would like to thank Caitlyn Siu for her invaluable contributions to manuscript preparation. The authors would also like to thank Wendy Krishnaswamy, RN, for providing her valued perspective from a nursing standpoint on orthopaedic patient management and consideration of patient families.