key: cord-0930485-4zrglhjr
authors: Hodhody, Ghazal; Lum, Joann W.Y.; Afzal, Sadia; Mulgrew, Emma V.
title: The COVID CLAVICLE Study: A predictor of future trauma trends
date: 2022-02-01
journal: JSES Int
DOI: 10.1016/j.jseint.2021.12.012
sha: a75bc2a3697927cc31d687fa6b40c3a8564a6f38
doc_id: 930485
cord_uid: 4zrglhjr

BACKGROUND: Clavicle fractures are a common presentation to the Emergency Department following falls and sporting injuries. During 2020, the COVID-19 pandemic brought with it a long period of social isolation resulting in a change of behavior patterns and in return, the presentation of fractures to our local hospitals. The effects of this global pandemic on the presentation and management of clavicles were noted with particular interest to the change in mechanism and its future implications. METHODS: We performed a longitudinal observational study in 10 hospitals in the North West of England, reviewing all patients presenting with a clavicle fracture during six weeks in the first peak of COVID-19 pandemic and compared these with the same time period in 2019. Collection points included the patient demographics, fracture characteristics, mechanism of injury and management. RESULTS: A total of 427 clavicle fractures were assessed with lower numbers of patients presenting with a clavicle fracture during the COVID-2020 period (n=177) compared with 2019 (n=250). Cycling related clavicle fractures increased three fold during the pandemic compared to the 2019 control group. We also noted an overall increase in clavicle fractures resulting from higher energy trauma as opposed to low energy or fragility fracture. We also found a faster time to surgery in the COVID cohort by 2.7 days on average when compared to 2019. CONCLUSIONS: Government restrictions and the encouragement of social distancing led to behavioral changes with a vast increase in cyclists on the road. This created a significant rise in clavicle fractures related to this activity. This is likely to be further driven by the Government pledge to double cyclists on the road by 2025 in the United Kingdom.(5) We forecast that this increase in cyclists, a behavior change accelerated by the pandemic, is a reliable predictor for future trauma trends.

Government restrictions and the encouragement of social distancing led to behavioral changes 28 with a vast increase in cyclists on the road. This created a significant rise in clavicle fractures 29 related to this activity. This is likely to be further driven by the Government pledge to double 30 cyclists on the road by 2025 in the United Kingdom. 5 31

We forecast that this increase in cyclists, a behavior change accelerated by the pandemic, is a 32 reliable predictor for future trauma trends. the world with unique and unprecedented challenges of coping with increased demand. As 53 part of the Government response to COVID-19, the United Kingdom (UK) entered a period of 54 restriction "lockdown" beginning on the 23 rd March 2020 in an effort to slow the spread of 55 disease and lessen the burden on the NHS. 10 As such, restrictions were placed on the British 56 public who were advised to only leave their home for limited purposes. This period of 57 lockdown brought about a long period of social isolation and changed the normal patterns of 58 behavior of the public, and in return, the presentation of fractures to our local hospitals. 59 60 During this initial lockdown there was a significant increase in the number of people cycling. 61

The UK Department for Transport reported an overall increase in cycling from March 2020 62 onwards; reaching a peak increase of 343% in April 2020. 6 63 64

In this study, we compared data collected on clavicle fractures sustained during the peak of the 65 COVID-19 pandemic to that of the same time period during the previous year, in order to 66 review the effects of the global pandemic on the presentation and management of clavicle 67 fractures in the North West of England. We hypothesized that the COVID-19 pandemic had no 68 effect on the presentation and management of clavicle fractures. 69

Our primary outcomes were to assess the change in numbers and the mechanism of injury of 71 clavicle fractures in the North West of England sustained during the peak of the COVID-19 72 pandemic compared to that of the same time period in 2019. Our secondary outcomes were: 1) 73

to ascertain how these fractures were managed i.e. operatively or non-operatively; 2) to assess 74 the difference in demographics between the two cohorts. 

Data was collected from ten different hospital trusts in the North West of England, which 77 included three Major Trauma Centers and four Trauma Units. The study was approved by each 78 individual trust via registration through the relevant audit and research departments. All patient 79

information remained anonymous at all times. All collaborators were recruited via the regional 80 research committee (the North West Orthopaedic Research Collaborative) and were orthopedic 81 trainees in the region. 82

Participants: 83 Table I shows the inclusion and exclusion criteria for this study. 84

This is a longitudinal retrospective observational study, comparing the data from two different 86 years during the same 6-week period. Data was analyzed from 1st April 2020 -14th May 2020 87 and compared to the exact same time period in 2019. The data from 2019 acted as our control 88 group. 89

Data collected per patient included the following; patient age, gender, date of injury, side of 91 We used the Allman classification system for clavicle fractures (I, II & III) to determine the 104 position of the fracture. 1 Injury mechanism data was analyzed and grouped into seven separate 105 categories: Bicycle injuries, low energy injuries (such as fall from standing height), team 106 sports, major trauma, trampoline injuries, equine related and unwitnessed/unknown 107 mechanism. 108

Data was collected on a pre-populated Microsoft Excel sheet. 15 All data collection points were 110 inputted into a premade template. Simple statistical methods were used to calculate 111 significance via P Values. A P value of <0.05 was deemed significant. Chi-Squared was used 112 to compare the data between two discrete variables. Means were used to present continuous 113 variables with standard deviations and range. Mann-Whitney U test was used to calculate the 114 significance of non-normally distributed continuous variables. Any categorical data was also 115 shown in terms of percentage of number. 116

Epidemiology 118

In total, 427 patients met our eligibility criteria. Between the two years of data, three patients 119 were excluded from the initial search due pathological fracture (n=1) or birthing injury (n=2). 120

During the COVID pandemic in 2020, 62% of patients (n=108) were male as opposed to 121 female (n=69). This is in contrast to 2019, where the percentage of male patients was 68% 122 (n=174) . The ratio of men to women fell from 2.3:1 in 2019 to 1.6:1 in 2020. 123

The mean age of a patient presenting with a clavicle fracture during the pandemic was slightly 125 higher at 35.6 years, compared to 2019 where mean age was 29.8 years. This increase was not 126 statistically significant where p=0.18. Further breakdown of the age between the sexes revealed 127 an overall higher age presentation in females in both cohorts. The mean age in men changed 128 significantly between 2019 and COVID 2020 (from 28.9 years to 35.0 years respectively , 129 p=0.0168). In contrast, the mean female age changed less from 41.1 in 2019 and 37.9 in 2020 130 

The fracture positions are documented in Table II Our study looked at a total of 427 patients between the 6 week study period in both years. An 212 epidemiological study of clavicle fractures from the Swedish fracture registry in 2017 by 213

Kihlstrom et al 12 looked at 2,422 patients and found that 68% occurred in males as did another 214 study by Postachiini et al. 19 This was mirrored by our study that showed nearly 70% of patients 215 to be male in the 2019 cohort with a small reduction to 62% in 2020. Previous government 216 figures in the UK have shown that men are twice as likely as women to cycle in the UK, 11 217 whereas women are more likely to partake in swimming and gym activities, which are less 218 likely to result in clavicle fractures. The same government research also confirmed that men 219 are more likely to participate in team sports in the UK, an activity that was restricted during 220 the lockdown period. 11 This can explain the shift in change of male to female ratios. Local 221 studies in England showed an increase in female cyclists during the lockdown period, all 222 contributing to a more even distribution of the sexes presenting with clavicle fractures between 223 2019 and the COVID-2020 period. 14 224

The mechanism of injury was one of the most significant findings during our study. The 2019 225 control data shows low energy injuries such as those from a standing height represented the 226 J o u r n a l P r e -p r o o f majority of injuries. This is reflected in other studies, 17,19,22 often followed by cycling injuries 227 in the young. 17 In 2020, cycling injuries dramatically increased three-fold to be a causative 228 factor for 36% of all clavicle fractures during the first peak. This can be explained by a rise in 229 cycling use for transport during lockdown, driven further by the advice to socially distance and 230 avoid public transport. Government data published by the Department for Transport reported 231 a peak increase of 343% in cyclists at the end of April 2020 compared to March 2020. 5 This is 232 a clear representation of how the COVID-19 pandemic affected social behavior and in return, 233 the presentation of fractures to our Emergency Departments. Equally, the number of fragility 234 fractures caused from standing height fell from n=101 to n=61 in 2020. This evidences that the 235 government advice given to the elderly, the comorbid and frail patients to remain indoors as 236 much as possible to avoid exposure to the virus, was effective resulting in a reduction in the 237 risk of falls outdoors and in uneven terrain. 7 Another clear decrease in numbers was that of 238 team sports related clavicle fractures in 2020. Trampoline injuries increased during the 239 COVID-2020 period as expected and mainly in our younger patients as was noted in other 240 studies during this period and will continue to be a concern for the safety of our pediatric 241 population. 3 Our total pediatric population did however almost half in numbers in the COVID-242 2020 period (n=55 from n=104) from the previous year, a consequence of school and group 243 play restrictions. 244

The overall proportion of high energy injuries increased from 53.2% of all clavicle fractures in 245 the 2019 period to 62.7% in the COVID-2020. This is a significant upsurge of high energy 246 trauma between the two years caused by behavioral changes in lockdown. less commuters. This study indicates there will continue to be more cyclists on the roads, a 278 prediction supported by cycling superstore, Halfords', research report, named "The great bike 279 boom continues".² 5 Which looks at how attitudes and behaviors have changed amongst the UK 280 population throughout the pandemic leading to the increasing popularity of cycling. The report 281 findings conclude these behavior changes to be sustained post pandemic, particularly as cycling 282

forms both a mode of transport and exercise, increasing it's potential participants. 283

Our evidence shows that further measures need to be taken nationally to improve cycling safety 284 through education and infrastructure. Health services need capacity planning to contend with 285 the rise in cycling-related trauma as well as injury management strategies and protocols. 286

To our knowledge, this is the only study to date which assesses the effect that lockdown has 288 had on the presentation, classification and management of clavicle fractures during the peak of 289 the COVID-19 pandemic. Furthermore, due to the multicenter nature, our study has a large 290 demographic population of the North West of England. The total cohort or 427 patients is one 291 of the largest clavicle databases studied in these circumstances. 292

This was a small snapshot observational study, looking at only one area in England during a 294 short period of time. The retrospective nature of this study leaves it to inherent compromises 295 in data accuracy. Data was collected through the PACS imaging systems and some fractures 296 may have been missed due to either coding errors or fractures picked up on alternative X-rays 297 such as chest X-rays, which in turn may have underestimated the number of clavicle fractures 298 in both data sets. Fracture data collection was also usually only performed by one individual 299 assessor per trust. The brief data collection period was also insufficient to capture post management 301 complications in such a vast dataset. 302

This study reflects a large increase in clavicle fractures following a threefold upsurge in 304

cycling. The sudden escalation in cycling induced trauma will have important implications for 305 trauma services and more broadly, intensify the strain placed on an already struggling National 306

Health Service. There may be greater scope for studies on the management of high energy 307 clavicle fractures and their outcomes following the increase in cyclists, subsequent to the 308 government drive. Further consideration of the management of heightened trauma numbers 309 created by this ideology may be prudent in order to prevent trauma centers from being 310 overwhelmed post pandemic. This study also showed a greater efficiency in the time to theatre 311 for our surgically managed patients and further follow-up of long-term outcomes for this group 312 in comparison to the 2019 cohort may be beneficial in highlighting the importance of early 313 intervention of high clavicle fractures. 314

The 'Covid Clavicle study' collated one of the largest databases of clavicle fractures from 10 316 hospitals in the North West of England throughout the first lockdown period. Our study found 317 an overall lower number of clavicle fractures and trauma cases presented during the first peak 318 of the COVID-19 pandemic. Illustrating the effectiveness of the public message delivery by 319 the government. 320

Due to the restrictions in place and encouragement of social distancing, this led to behavioral 321 changes in the population. We noted a threefold increase of cycling related clavicle fractures 322 when compared to our control group. We believe our study is a predictor of future trauma 323 trends, evidencing that the popularity of cycling in the UK has soared because of the pandemic 324 restrictions. 6 We forecast this trend to continue underpinned by the government drive to 325 increase cyclists by 2025 alongside the preexisting 'bike to work' scheme. 4,5 326

Consequently, further preventative and management resources will need to be made available 327 to tackle this predicted increase in demand on our trauma services in the UK. 

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The great bike boom continues

J o u r n a l P r e -p r o o f