key: cord-0963931-oedkaf75
authors: Gumina, Stefano; Proietti, Riccardo; Polizzotti, Giuseppi; Carbone, Stefano; Candela, Vittorio
title: The impact of COVID-19 on shoulder and elbow trauma. An Italian survey
date: 2020-05-20
journal: J Shoulder Elbow Surg
DOI: 10.1016/j.jse.2020.05.003
sha: 74eb7ff4e9c1cc1a5265c27ff9a86d4111d2f9e5
doc_id: 963931
cord_uid: oedkaf75

Abstract Background Because of the rapid spreading of COVID-19, on March 8th, Italy became a "protected area": people are told not to leave their homes unless for an essential reason. Aim of this study was to evaluate the activity of our Trauma Centre, relative to shoulder and elbow, in 30 days starting from March 8th, 2020, the first day of restrictions in Italy, and to compare it with the same days of 2019 to weight the impact of Covid-19 on the shoulder and elbow trauma. Materials and methods Patients managed in our Trauma Centre between 8th March 2020 and 8th April 2020 (COVID-19 period) for a shoulder and elbow trauma were retrospectively included and compared to patients admitted in the same period of 2019 (no COVID-19 period).Clinical records of all participants were examined to obtain information regarding age, sex, mechanism of injury, diagnosis. Results During no COVID-19 period, 133 patients were admitted for a shoulder or elbow trauma; in the COVID period, patients were 47(65% less first aid). In the no-COVID and COVID period, patients with shoulder contusion were 60 (14.78% of all) (M:34; F:26) (mean age: 51.8yrs; range: 18-88) and 11 (12.09% of all contusions) (M:7; F:4) (mean age: 43yrs; range: 24-60), respectively. In the no-COVID period, 27 fractures (9.34% of all fractures) involved the shoulder, while 18 fractures (8.69%) were registered in the COVID period. In the no-COVID period,14 elbow fractures were treated (4.8% of all fractures), and 4 in the COVID period. In the no-COVID and COVID periods, 6 (M:5; F:1) (mean age: 42yrs; range 21-64) and 2 (M: 1; F: 1) (mean age: 29.5yrs; range: 24-35 ) patients reported having the feeling of momentary post-traumatic shoulder instability; at the elbow, patients were 0 and 1 (M: 1; F: 0) (age: 56yrs), respectively. Finally, first or recurrent dislocations in the no-COVID period were 10 and 7 in the COVID period.; in the no-COVID period, elbow dislocations were 2, and 3 in the COVID-period. Conclusions During the COVID period, we provided a reduced number of health services, especially for patients with low energy trauma and for those who underwent sports and traffic accidents. However, during the COVID period, elderly subjects remain exposed to shoulder and elbow trauma due to low-energy (domestic) falls. The subsequent hospitalization of these patients has contributed to making more difficult the management of the hospital wards, partly occupied by COVID-19 patients.

accidents. However, during the COVID period, elderly subjects remain exposed to shoulder and 27 elbow trauma due to low-energy (domestic) falls. The subsequent hospitalization of these patients 28 has contributed to making more difficult the management of the hospital wards, partly occupied by 29 COVID-19 patients. On January 29 th , 2020 the Italian Authorities declared the first cases of Coronavirus in Italy: two 38 whole country so that Italy becomes a "protected area". People across Italy are told not to leave 53 their homes unless for an essential reason. Smart working was imposed; movement was strictly 54 limited, and on March 22 nd the Government cracked down further, forbidding unnecessary travel 55 between towns. Travel is only allowed for "urgent, verifiable work situations and emergencies or 56 health reasons". People who have tested positive for COVID-19 must not leave their homes for any 57 reason, while anyone with a fever or respiratory symptoms are strongly encouraged to stay at home 58 and limit social contact, including with their family doctor. People are allowed to go outside for one 59 of the following reasons: 60 • An urgent, demonstrable work-related reason. 61

• Situations of need (for example to buy food). 63

In addition, Italy's latest step in its coronavirus lockdown is to close down all productive activity 64 throughout the territory that is not strictly necessary, crucial, indispensable, to guarantee essential 65 goods and services, starting from March 28 th . All this information can be extracted from the Italian 66 Civil Protection website 22 . 67

The current restrictions have inevitably modified the Orthopedic practice, in particular those of the 68 Trauma Centre. Our aim was to evaluate the activity of the Trauma Centre, relative to shoulder and 69 elbow, of a highly populated suburban area, in a 30-day period starting from the 8 th March 2020, the 70 first day of restrictions in Italy, and to compare it with the same days of 2019 in order to weight the 71 impact of Covid-19 on the shoulder and elbow trauma. 72 73

All the skeletally mature (older than 18 yrs) patients managed in the Emergency Unit of our 75 hospital between March 8 th 2020 and April 8 th 2020 (COVID period) for a shoulder and elbow 76 trauma were retrospectively included and compared to patients admitted in the same period of 2019 (no-COVID period). Our country protects health as a fundamental right of the subject and 78 community and guarantees free care. 79

Clinical records of all participants were examined by two of the authors in order to obtain 80 information regarding age, sex, mechanism of injury, diagnosis. 81

Four categories of diagnosis were distinguished: contusion, fracture, sprain/subluxation, and 82 dislocation. 83

According to the mechanism of injury we arbitrarily distinguished 6 subgroups: 1) Accidental fall; 84 2) Sports trauma; 3) High energy trauma occurred by car, motorcycle, public transport, pedestrian 85 investment; 4) Accident at work; 5) Trauma due to assault, beatings; 6) Gunshot and stab wounds. 86

According to the law of our country, this study did not need any Ethical Committee Approval. 87

Continuous variables were expressed by the mean and standard deviation (SD) and were evaluated 89 by Student t-test or Mann-Whitney U test. The categorical data were expressed as number and 90 percentage (%) and were evaluated by chi-square or Fisher's exact test. The statistical test level was 91 set as p<0.05. SPSS23.0 was used to perform all the tests (IBM, Armonk, NY, USA). 92 93

In March-April 2019 (no-COVID period), in our Trauma Center, there were 1349 accesses; in the 95 same month of the following year (COVID period) the accesses were 474: two thirds less (p<0.05). 96

During the no-COVID time, 133 patients turned to our Trauma Center for a shoulder and/or elbow 97 trauma; instead, patients treated during the COVID period for the same reasons were 47 (p<0.05). 98 Therefore, we performed 65% less first aid shoulder/elbow services. Six and 1 patients, during the 99 no-COVID and COVID period, respectively, underwent multiple-fractures. Of them, no patients 100 had shoulder and/or elbow fractures. No patients underwent to shoulder/elbow trauma following 101 gunshot and stab wounds (subgroup 6), therefore this subgroup is not mentioned in the Tables.

In the no-COVID and COVID period, patients to whom a diagnosis of shoulder contusion was 103 formulated were 60 (14.78% of the 406 contusions occurred on the whole body) (M:34; F:26) 104 (mean age: 51.8yrs; range: 18-88) and 11 (12.09% of 91 contusions) (M:7; F:4) (mean age: 43yrs; 105 range: 24-60), respectively. Elbow contusions were 14 (3.4% of 406 contusions) (M: 9; F: 5) (mean 106 age: 50.2yrs; range: 18-80) in the no-COVID period and 1 (1.1% of 91 contusions) (M: 1; F: 0) 107 (age: 29) in the COVID period. Table I shows the traumatic mechanism responsible for shoulder 108 and elbow contusion in the two examined periods. 109

In the no-COVID time we treated 289 fractures; 27 of them (9.34%) involved the shoulder girdle. (M:2) (mean age 60yrs; range 39-81) and no fractures involved the scapula (0%). Fig.1 shows the 116 humeral, clavicle and scapular type fracture according to Hertel 3 , Allman 1 and Ideberg 10 117 classification, respectively, in the two examined periods, instead, Table II sensation, but at the elbow, were 0 and 1 (M:1) (age: 56yrs), respectively. Table IV shows The adopted measures taken to deal with the COVID-19 global pandemic have led to a profound 145 change in our daily habits. In Europe, ours was the first country to adopt restrictive measures that 146 prevented citizens from leaving their homes, except for proven health reasons and for carrying out 147 useful to the community functions. This made our streets free of traffic, our sports facilities unused 148 and public parks closed. Therefore, we wanted to verify the impact that these restrictions have had 149 on the traumatic shoulder and elbow pathology. We, therefore, compared the epidemiological data 150 relating to the first aid services inherent in these two anatomical districts, and that occurred in Since in the last two weeks, our Government has granted some job categories the opportunity to 154 resume work, although, with the necessary precautions aimed at preventing the transmission of the 155 virus, we have deemed it unnecessary to extend the study period. 156

The reduction in services (less 65%) provided in our Trauma Center during the pandemic period is 157 the most striking data of our investigation. The most evident decrease was observed in the 158 percentage concerning the number of contusions (low energy injuries) compared to all the health 159 services provided. In the no-COVID time, this percentage was 30%; in the COVID period, it fell to 160

We believe that 4 causes have led to a drastic reduction in health services. In an epidemiological study 11 , 178 elbow dislocations, occurred during the studied twelve years, 220 have been prevalently attributed to sports injury. We managed two elbow dislocations in the no-221 COVID period and three in the COVID period. Surprisingly, in all cases, the dislocations had 222 occurred following an accidental fall, therefore regardless of the new lifestyle imposed by the 223 quarantine. 224 225

During the COVID period, in our Trauma Center, we provided a reduced number of health 227 services, compared to the same time of the previous year, especially for those patients with low 228 energy trauma (contusions) and for those who underwent sports injuries and traffic accidents government restrictions imposed to limit COVID-19 spread. However, during the COVID period, 231 elderly subjects remain exposed to shoulder and elbow trauma due to low energy ( 

Fractures and ligamentous injuries of the clavicle and its articulation

Basic 238 epidemiology of fractures of the upper and lower limb among Americans over 65 years of 239 age

Initial post-fracture humeral head ischemia does not predict 242 development of necrosis

Fracture patterns

Fractures of the radial head

The Elbow and 251 its disorders

Epidemiology ofscapular fractures. Incidence and 265 classification of 338 fractures

Incidence of elbow dislocation

The epidemiology of radial head fractures

Epidemiology 274 of shoulder dislocations in high school and collegiate athletics in the United States: 275

Closed treatment of fractures of the proximal humerus

Surgical outcomes in the frequency, etiology, direction, and severity 283 (FEDS) classification system for shoulder instability

Some observations on fractures of the head of the radius with a review of one 287 hundred cases