key: cord-1011631-v3y2xhjm
authors: Ciatti, Corrado; Gattoni, Serena; Quattrini, Fabrizio; Puma Pagliarello, Calogero; Patane’, Angela Caterina; Capelli, Patrizio; Banchini, Filippo; Rivera, Fabrizio; Sanna, Francesco; Nonne, Daniela; Di Maggio, Bruno; Scaravilli, Gabriele; Maniscalco, Pietro
title: Proximal humerus fractures in covid-19 lockdown: the experience of three orthopedics and traumatology departments in the first ten weeks of the italian epidemic
date: 2021-02-09
journal: Acta Biomed
DOI: 10.23750/abm.v92i1.11231
sha: eea993ba2dd24e62bb3d00d1fdc5d7611b10c573
doc_id: 1011631
cord_uid: v3y2xhjm

INTRODUCTION: Coronavirus disease (CoVID-19) is causing millions of deaths worldwide and the crisis of the global healthcare system. AIM OF THE STUDY: evaluate the preliminary impact of CoVID-19 in three Italian Orthopedics and Traumatology Departments in the first 10 weeks of the national lockdown. We focused on proximal humerus fractures, analyzing data and results in comparison with the same period of 2019. MATERIALS AND METHODS: From February 22(nd) to May 3(rd) 2020, 55 patients were admitted to our departments for promixal humerus fractures. Our cohort of patients is composed by 13 males (23.6%) and 42 females (76.4%), with an average age of 73.8 ± 11.7 years (range 44 - 94). Trauma occurred at home in 43 cases (78.2%), by the roadside in 10 cases (18.2%), in a retirement home in 1 case (1.8%), and at work in 1 case (1.8%). We proposed surgical treatment in 15/55 cases, but 4 patients refused hospitalization, mainly because of the risk of contracting n-CoV19 infection. RESULTS: We noticed a decrease in proximal humerus fractures compared to 2019 (-37.5%). Particularly, we observed a significant drop in traumas occurred on the road and at work respectively 23.9% and 3.4%% in 2019, and 18.2% and 1.8% in 2020, probably due to the consequences of the national lockdown. Sports traumas had a reset during the pandemic (6 cases in 2019, 0 in 2020). As consequence, surgical treatment had a decrease due to the reduction in number of fractures, indications and patient’s consent. CONCLUSION: The incidence of proximal humerus fractures had a significant reduction during CoVID-19 spread. We assume that the reasons of this reduction are to be found in the national lockdown (since March 10th, 2020) and Ministerial Decrees that limited the access to the E.R. only in case of severe traumas in order to avoid CoVID-19 spread.

The new Coronavirus (2019 n-CoV) spread all over the world since the early months of 2020 [1] [2] [3] . It can cause respiratory disorders with flu-like symptoms, anosmia, ageusia and diarrhea. In some case, it might lead to severe acute respiratory distress syndrome (ARDS), multiorgan failure (MOF) or even death [4] [5] [6] [7] . In Italy, the first case of coronavirus disease ( CoVID-19) was diagnosed on February 21st in Codogno (Lodi, Lombardy, Northern Italy) [8] . The Italian epidemic started in here. On February 23 rd 2020, the Italian Government defined a so-called "Red Zone" in Codogno and the neighboring cities, trying to stem the first epidemic outbreaks. On March 11st 2020, the Italian Prime Minister declared the national lockdown for the dramatic number of infected people and deaths, particularly in two cities in the Northern Italy: Piacenza (Emilia-Romagna) and Bergamo (Lombardy). In Piacenza, a survival strategy aimed to avoid the collapse of our healthcare system was developed, as recently reported by Maniscalco et al. [9] .

During the "Phase 1" 210,717 CoVID-19 infections were detected throughout Italy, 81,654 patients were recovered and 28,884 died for ARDS. At the end of this first phase (May, 3rd 2020), 100.179 inhabitants resulted positive to nasopharyngeal swab for 2019-nCOV; among them 18.743 have been hospitalized in CoVID-19 hospitals (1,501 in Intensive Care Unit) and 81.436 have been treated at home ( Table 1) .

Basing on the observation that fractures of proximal epiphysis of the humerus have a current incidence of 4-5% [10] , we decided to evaluate the impact that COVID-19 had on three main Italian Orthopedics and Traumatology Departments with a different virus spread, comparing data collected during the "COV-ID-19 period" with those of the same period in 2019, the "no-COVID-19 period".

Here, we report the experience of three Italian Orthopedics Departments with a different virus spread: Piacenza (Emilia-Romagna, Northern Italy, very high virus spread), Savigliano (Cuneo, Piemonte, Northern Italy, high virus spread) and Piedimonte Matese ( Caserta, Campania, Southern Italy, low virus spread).

The aim of our study is to evaluate the impact that CoVID-19 had in these centers, focusing the attention on proximal humerus fractures. We analyzed data reported in the first 10 weeks of the Italian outbreak ("Phase 1"), comparing the results obtained with the specular ones of 2019.

We retrospectively analyzed all data relating to patients admitted to the Emergency Department with a diagnosis of proximal humerus fracture (ICD-9-CM Diagnosis Code 812.00) and to the related surgeries performed. The considered period started on February 22 nd and concluded on May 3rd 2020, referring to the first 10 weeks of the Italian CoVID19 epidemic, called "Phase 1". The same period from February 22nd to May 4th 2019 (10 weeks) was used as control group. We ran an analysis confronting three Orthopedic and Trauma centers within areas with different virus spread: Guglielmo da Saliceto Hospital in Piacenza (Emilia Romagna, Northern Italy, very high virus spread), SS Annunziata Hospital in Savigliano (Cuneo, Piemonte, Northern Italy, high virus spread), and Piedimonte Matese Hospital in Caserta (Campania, Southern Italy, low virus spread). Data considered in this study were extrapolated by the qualified office of every participating center and rielaborated using the statistical analysis explained in the related paragraph.

Proximal humerus fractures were studied with anteroposterior, transthoracic, and axillary view (when possible) of the affected shoulder. In all cases, a CT-scan with three-dimensional (3D) reconstruction was obtained. Mechanism of injury was recorded. Indications for surgery were given by one experienced shoulder surgeon (2 years shoulder surgery fellowship and extensive experience on shoulder fractures) based on both x-ray and CT images, in addition to relevant patient characteristics such as age, functional requests (daily and recreational), and comorbidities (including osteoporosis) [11] . The device used for fixation was chosen depending on the surgeon's preference. Fractures were classified using the Neer classification [12] .

Continuous variables were expressed by the mean and standard deviation (SD) and were evaluated by Student T-test or Mann-Whitney U test. Th e categorical data were expressed as number and percentage (%) and were evaluated by chi-square or Fisher's exact test. Th e statistical test level was set as p<0.05. SPSS, version 23.0, was used to perform all the tests (IBM, Armonk, NY, USA).

In Piacenza, one of the most stricken cities (very high virus spread), during the "no-CoVID-19 period", 42 patients were admitted to the Emergency Room for proximal humerus fractures: 8 males (19%) and 34 females (81%), average age 71 ± 13 years (range 29 -97); during the "CoVID-19 period", 24 patients were admitted to the Emergency Room for proximal humerus fractures: 7 males (29%) and 17 females (71%), mean age of 75 ± 12 years (range 44 -92).

In Savigliano (high virus spread), throughout the "no COVID-19 period", 31 patients were admitted to the Emergency Room for proximal humerus fractures: 6 males (19.4%) and 25 females (80.6%), average age of 75 ± 13 years (range 46 -94); during "CoVID-19 period", 22 patients were admitted to the Emergency Room for a proximal humerus fractures: 4 were males (18%) and 18 females (82%), mean age 76 ± 10 years (range 47 -94). In Piedimonte Matese (low virus spread), in the "no COVID-19 period", 15 patients were admitted to the Emergency Room for a proximal humerus fracture: 2 males (13%) and 13 females (87%), mean age of 72 ± 15 years (range 48 -96); in the "COVID-19 period", 9 patients were admitted to the Emergency Room for a proximal humerus fracture: 2 males (22%) and 7 females (78%), with mean age 71 ± 10 years (range 50 -80).

For every case, we collected data about Neer's classifi cation of fracture (Table 2) ; the location of trauma (Table 3) ; orthopedical indication on treatment, eventual type of surgical solution and mean time between trauma and surgical procedure (Table 4 ) ( Figures 1,2) .

In the "no COVID-19 period", the total cohort of patients was composed by 88 patients, 16 male (18%) and 72 females (82%), with an average age of 73 ± 9 years (range 29 -97); in the "COVID-19 period", the total cohort was composed by 55 patients, 13 males (24%) and 42 females (76%), average age of 75 ± 8 years (range 44 -94) ( Table 2 ,3,4).

Comparing the "CoVID-19" and "no COVID-19" periods, a decrease of 37.5% (88 vs 55) was registered in the number of patients admitted for proximal humerus fracture. Th e national Italian lockdown, which imposed traffi c restrictions, the closure of all the schools and universities, of many commercial activities, companies and factories, and stopped all the sports activities, defi nitely reduced people's movements and as consequence, the risk of bone fractures. In the same way, the Government and mass media as early as the end of February warned elderly people, because CoVID-19 seemed to be more aggressive towards this category. Th is is probably due to their immune system, more often weakened by the presence of other pathologies or recent surgical interventions. Our data confi rmed what other studies had previously proposed: Benazzo et al. [13] evaluated the trend in many orthopedic centers during the fi rst weeks of the pandemic, showing a signifi cant decrease of all traumas (compared to the last year, E.R. trauma consultations decreased up to 71%, femoral neck fracture had a stable reduction from 15 to 20% and other trauma surgery decreased up to 50%). Th e orthopedic Center that recorded the most conspicuous drop is Piacenza, with 18 fractures less than the previous year (-42.9%); Caserta had a decrease of 6 fractures (-40.0%), while Savigliano a decrease of 9 fractures (-29.0%).

As far as the mechanism of injury, there was a reset of sports injuries (from 6 to 0) and a signifi cant reduction in fractures occurred in retirement houses (from 9 to 1) and by the roadside (from 21 to 10). Furthermore, other studies [13, 14] underlined an almost complete reset of sports injuries and a signifi cant drop of traumas during work activities and by the roadside. Th ey also showed that domestic traumas got a reduction in numbers of cases, but a raise in percentage, as well as we reported in our cohort of patients: -6 cases, but a percentage increase of +22.5%. Th e drop of sports, work and road traumas is comprehensible, because of the lockdown that forced people to spend more time in their houses. A direct consequence of these limitations is a slight increase in the average age at the time of trauma between the two periods: 73±9 years in 2019 and 75±8 years in 2020.

We expected a similar trend in retirement houses and domestic injuries, but we recorded an important decrease only in the fi rst ones (from 10% to 1.8%). Our hypothesis is that new measures adopted by the Italian Government, that advised people to access the E.R. only for severe situations, forced doctors working in retirement houses to try to manage humerus fractures in their structures and to avoid sending patients to hospitals. Our assumption found confi rm in subsequent months: taking as an example our Piacenza Department, between May 2020 and September 2020, when the fi rst wave of the pandemic was over and a normal lifestyle had slightly returned, 5 patients asked for an outpatient visit. Th ey manifested pain and/or stiff ness to the upper limb, with a positive anamnesis for trauma developed during the pandemic. X-rays and clinical evaluation demonstrated the presence of pseudoarthrosis, due to an incorrect management of these events.

Considering the three Orthopedics Departments of the present study, we need to underline that Piacenza is surely the most damaged by CoVID-19 epidemic, because of the high number of infected people. Th e province of Piacenza counts 286,997 inhabitants and the data issued by Italian Civil Protection at the end of lockdown indicated 4,251 infections in this province and 904 deaths; the province of Cuneo has 587,098 inhabitants, 2,535 infections and 255 deaths; the province of Caserta has 922,965 inhabitants, 424 infections and 42 deaths. Consequently, Piacenza registered an infection rate of 1.48% and a death rate of 0.31%; Cuneo an infection rate of 0.43% and a death rate of 0.04%; Caserta an infection rate of 0.05% and a death rate of 0.005%. Th e amount of infections and death in the province of Piacenza is one of the highest in Italy. Th e explanation of this data can be mainly found in two factors. Th e fi rst is the close distance (15 km) between Piacenza and Codogno, the fi rst location of the outbreak, which brought many infected patients to enter our E.R. right after the closure of their hospital [15] . Th e second reason is that Piacenza, where the average age is 46.2 years, is one of the cities with the oldest population in Italy and as reported in literature, elderly people are exposed to many more complications and death when infected by 2019-nCoV [16, 17] . In Cuneo and Caserta, there was not any close outbreak and their population have respectively a mean age of 45.4 and 41.4 years.

Apart from the important decrease of all fractures, during the pandemic all the election surgeries were suspended and only urgent patients where operated. In Piacenza, in 2020, elective surgery was stopped since February 23 rd ; in Savigliano and Piedimonte Matese since March 9 th . As a consequence, having less patients Table 4 .

to operate, we also had a reduction in waiting times to undergo surgery. In fact, in 2019 the average waiting time was 3.7 days compared to 2.2 days in 2020.

If we compare the three cities involved in this study, it is necessary to consider the local scenario. Depending on the spread of the virus both patients and orthopedics reacted differently. Many of the patients who entered the orthopedic E.R. were afraid of CoVID-19 and of the high probability to be infected during the recovery. In some cases, they even refused hospitalization to avoid the contact with other patients. The fear of CoVID-19 was therefore greater than the possibility of ending up with a deficit in the arm [18] . This situation occurred only in Piacenza, where on average 1 patient out of 3 decided to refuse the surgical option because of the fear to being infected by n-2019CoV, while in 2019 all the patients accepted surgery. In Savigliano all "surgical" patients accepted the proposed treatment, both in 2019 and 2020. In Piedimonte Matese the same number of refusals to the surgery has been registered. Inevitably, the novel coronavirus also influenced orthopedist's choices, who were afraid to hospitalize patients for the high-risk of intra-hospital CoVID-19 infection. In particular, in Piacenza, surgical indications was given only when the fracture was clearly surgical and the conservative alternative was not possible: 38.1% in the "non CoVID-19 period" Vs 25.0% in the "CoVID-19" period, with a drop of -13.1%. Since Savigliano and Piedimonte Matese did not face such an impressive number of infections and CoVID-19-related deaths, as counted in Piacenza, these two departments did not register any drop in surgical indications.

In literature, it is well known that CoVID-19 had a devastating effect on the worldwide population, especially on the elderly category, more exposed to complications like ARDS and multi-organ failure. In our experience, we noticed a straight decrease in proximal humerus fractures during the so called "Phase 1" of the Italian epidemic, probably due to the patients' fear of contracting CoVID-19 in hospitals and to the national lockdown imposed by the Italian Government to avoid the spread of the virus and the complete collapse of the healthcare system. Basing on these two observations, elderly people spend less time outside and had a quiet lifestyle at home, reducing the risk of fractures. Our data confirmed the reset of sports traumas and a very significant drop in road and work traumas, but we registered an unexpected reduction of injures in the retirement houses, with no apparent reason.

We are aware that study is preliminary and further investigation will be necessary to confirm our data, but surely it underlines that the different scenario in the three centers of the study modified people's approach to hospitalization. In Piacenza, the hardest stricken city, the fear of becoming infected by CoVID-19 had, without any doubt, a major role in the reduction of hospital admissions, and it often influenced both orthopedics and patients' decisions in the problem solving process.

Each author declares that he or she has no commercial associations (e.g. consultancies, stock ownership, equity interest, patent/licensing arrangement etc.) that might pose a conflict of interest in connection with the submitted article.

Ethics approval: Approval for the study was obtained from our ethics committee prior to study commencement (Prot. n. 2020/0065297, May 29th 2020). Furthermore, all procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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