Paediatric orthopaedics in lockdown

Introduction

The World Health Organization (WHO) declared the outbreak of SARS-CoV-2 virus (and the resulting disease, COVID-19) a global pandemic on the 11 March 2020. On 16 March 2020, the UK government implemented measures to reduce the potential spread of the virus and subsequent pressure of resources within the NHS. These included social distancing and advice to avoid busy public venues. A national lockdown was subsequently issued on the 23 March 2020, which lasted until 10 May in England and involved only being allowed to leave the home for four reasons: to shop for essential items, for one form of exercise per day for one hour, for medical or care needs, and for travelling to work if working from home was not possible.

All nonurgent elective surgical procedures were postponed or cancelled on 15 April to mitigate the possible increase in demand for critical care beds and enable increased numbers of staff to contribute to the response. Concurrently, routine outpatient clinical appointments were either deferred or their mode of delivery was changed where possible. Updated guidelines from the British Society for Children’s Orthopaedic Surgery (BSCOS)¹ were used to guide fracture management including the use of removable casts, where safe, to reduce reattendance and footfall within hospitals.

There was a perceived risk to children as lockdown commenced from both accidental and nonaccidental injury (NAI). Known risk factors for NAI include increased social isolation, financial uncertainty, and loss of support networks. All of these were more prevalent due to prolonged school and nursery closures, potential job losses, and enforced isolation.^2,3 The spring of 2020 has been the sunniest across the UK since records began in 1929⁴ and with a significant rise in sales of trampolines and outdoor play equipment, there was a concern that accidental injuries would also rise.⁵

Our children’s hospital is one of only five standalone paediatric major trauma centres (MTC) in the UK and operates a networked service with the surrounding district general hospitals (DGHs) which make up our integrated care system (ICS). This service covers a population of over half a million children. Prior to the pandemic, consultants from the MTC provided outreach paediatric elective clinics. The DGHs would usually manage all paediatric trauma patients presenting to them with the exception of open fractures, complex elective or trauma cases and patients under two years old (for anaesthetic reasons). To help ease pressure on adult services, from 16 April local DGHs transferred paediatric patients requiring operative intervention to the MTC.

The aim of this multicentre study was to further our understanding of the effect of a population-wide lockdown on the rates, mechanisms, and types of injury seen within a paediatric ICS while also examining how the delivery of an outpatient trauma service has changed during this time.

Methods

Data was collected from a paediatric MTC as well as the four networked DGHs which make up our ICS. This was performed retrospectively for both the period of lockdown (24 March 2020 to 10 May 2020 and the corresponding dates in 2019 as a control). For the MTC, data for hospital admissions and new fracture clinic referrals were collected and for the DGHs, data for hospital admission and transfers.

Electronic trauma handover lists, patient records, and theatre lists were used to identify patients in each hospital. Patients transferred for care at the MTC were identified and records were combined to prevent duplication of entries.

All patients attending the MTC emergency department (ED) during the two time periods were identified using the electronic patient records. Digital notes for all patients who were referred to fracture clinic were then reviewed to determine the mechanism of injury and their outcome.

All patients admitted under orthopaedics were included in this study. Patients who were seen and discharged from ED or only discussed verbally with the orthopaedic team were not included unless they subsequently attended a fracture clinic at the MTC. All fracture clinic referrals from ED were identified and reviewed. Exclusion criteria included duplications, ED return clinic episodes, failure to attend fracture clinic, no clinic letter available for review, admissions, referrals to other specialties, and those already known to the orthopaedic service.

Demographic data were collected along with type of injury, mechanism of injury, treatment given, time to theatre (if relevant), and whether there was any concern regarding NAI. For fracture clinic patients, the same data were collected along with mode of fracture clinic, outcome of fracture clinic, and whether self-removable casting techniques (Soft Cast; 3M, Maplewood, Minnesota, USA) were utilized.

Injury patterns were analyzed by zone of injury: shoulder and humeral shaft, supracondylar fracture, other elbow injuries, forearm, wrist, spine, pelvic and hip, femur/thigh, knee, tibia/leg, ankle, and foot.

Mechanism of injury was recorded in detail and then subcategorised into one of the following: fall from standing height, fall from play equipment/height, fall from furniture, trampoline related, non-traumatic/infection, sports, fall from bike/scooter/rollerblades/skateboard, road traffic collision (RTC), laceration, kick/punch, or unknown.

Treatment given was subcategorised into type of surgery performed, application of cast in plaster room or nonoperative management.

Referral data for potential safeguarding concern was collected separately and was obtained from the regional safeguarding department.

Results

Discussion

As the worldwide impact of COVID-19 developed, it was clear that our usual way of working had to change. Although children were not being affected in the same numbers or degree as the adult population, the risk of disease spread among staff and patient families remained a concern. NHS England issued a guideline stating “the elective component of our work may be curtailed, and resources diverted to areas of greater need. However, non-elective patients will continue to need high quality care and we need to ensure that they receive the care that is appropriate. We should seek the best local solutions to continue the proper management of unwell neonates and children while protecting resources for the response to coronavirus.”⁶ This led to the cancellation of nonurgent elective work, clinics were completely restructured and visitors to the hospital were restricted to a single accompanying adult.

Demand was felt likely to be far higher in adult services⁶ and a plan was formulated to assist with this response as a dedicated children’s hospital. Specific additional measures were required to manage paediatric patients who still required surgery for orthopaedic trauma. The British Orthopaedic Association published updated Standards for Trauma, alongside paediatric specific trauma guidance release by BSCOS and Alder Hey Children’s Hospital.¹ Although we implemented elements of these guidelines and regularly reviewed our practice, certain aspects of patient management did not change. These guidelines advocated the increased use of conservative measures and manipulation of fractures in ED. However, we did not experience a reduction in rate of operative management overall. In our region there has been limited uptake of manipulation in the ED and with a corresponding increase in the capacity of available emergency theatre lists, we continued to perform the majority of our manipulations in theatre.

There has, however, been a significant reduction in the number of both MUA + cast and MUA + K-wires performed across the region and a significant increase in the use of a manipulation in the plaster room. These figures are partially skewed by the uptake of plaster room manipulations in one DGH in the majority, although adoption of the BSCOS/Alder Hey guidelines is likely to have affected decision making to some degree to avoid theatre and in particular avoid aerosol generating procedures (AGPs) where possible.⁷ These guidelines accepted that corrective surgery may be required for these patients and were written when the full effect of the pandemic on NHS services was unknown. Longer term follow-up and review is required to assess whether patients who would have ordinarily had surgical management require corrective surgery as a result of a change in practice.

Globally, paediatric cases of COVID-19 have made up a minority of cases, contributing to between 1% and 5% of total numbers.⁸ There have been no positive tests for COVID-19 within our paediatric orthopaedic patients and low rates of positive tests were seen across Sheffield Children’s NHS Foundation Trust, with only seven children testing positive as of 12 June 2020. Transmission rates of child to child and child to adults are low⁸ and as a result, we have not had the same bed pressures that our DGHs have encountered. This has allowed us to transfer all regional paediatric trauma cases requiring surgery to our care, enabling us to provide the same high standard of surgical treatment where required, without any delay to theatre.

There was a 33% decrease in admission rates during the lockdown period, compared to 56% in the adult population.⁹ This may represent a lack of paediatric comprehension of the lockdown rules, continued high numbers of fractures sustained following a fall from a standing height and the fact the children have continued to use high-risk play equipment. Indeed, there was a significant increase in bicycle/scooter/roller-skate/skateboard injuries attending fracture clinic but many of these injuries were minor and did not require admission or surgical management.

There was a significant decrease in the age of patients admitted across the region between the two time periods. This is likely due to the ban on team sports and the limiting of outdoor activity. We know from previous epidemiological studies that sporting injuries are usually sustained by older children¹⁰ and this corresponds with the reduction seen in our data.

Supracondylar fractures made up a significantly greater proportion of the injuries seen in fracture clinic during lockdown. This may be partly due to uptake of the BSCOS/Alder Hey guidelines for these injuries during COVID-19, with the recommendation for Gartland 2 injuries to be managed nonoperatively.¹ There is also established evidence to show that the rates of supracondylar fractures increase during school holidays and the most common mechanism is a fall from play equipment.¹¹

There was no increase in trampoline related injuries that required orthopaedic input. This is despite the four-fold increase in the value of trampoline sales compared with 2019,⁵ and the 42% increase in the sale of outdoor play equipment since last year. This conflicts with the data from Broomhill Hospital, where there was a 500% increase in trampoline-related injuries when they examined the injury rates during early lockdown.¹²

Rates of patients admitted with infection remained constant. This is reassuring as early during lockdown there was a concern that parents were delaying seeking medical assistance with non-COVID-19 related problems, resulting in increased morbidity.¹³

Despite the concerns at the start of lockdown, this region has seen a reduction in referrals to safeguarding. The authors acknowledge that the reasons for this could be multifactorial. There may be fewer incidences occurring due to all members of the family being at home during lockdown resulting in fewer occasions where an offending adult is left with a child alone. It may be that the incidence of abuse has remained constant or indeed increased as per the initial concerns at the start of lockdown and these children have not been able to be identified due to not being seen in school, nursery, or by other family or friends. Whichever of these it is, it remains vitally important that we as orthopaedic surgeons remain vigilant over this as a potential cause of injury and refer on to safeguarding where needed.

Fracture clinic has undergone significant changes during lockdown. The use of reinforced soft casting techniques has enabled parents to safely remove casts at home, avoiding unnecessary journeys to hospital where possible. The accompanying adult was shown how to do this at time of cast application as well as given the link to the BSCOS online video,¹⁴ and written instructions for removal of soft cast. This meant that a significant proportion of follow-up could take place over the phone while maintaining the option for the patient to attend in person if there were any concerns. Ongoing review of these patients is required to ensure no deleterious effect of these methods, but such treatment is well established as being safe and cost effective¹⁵ and these changes in practice may drive an improvement in patient care and experience for the future.

This study does have limitations. The study includes a relatively small numbers of patients but by performing a multicentre study to include all hospitals within the ICS we believe adequate numbers have been included to achieve our aim of demonstrating the effects the UK lockdown has had on the paediatric orthopaedic trauma workload. The retrospective nature of the study leads to potential difficulties in the data collection, however, given hospital records are stored electronically in each unit we believe this possibility to be small and our dataset to be complete. This multicentre study examines the changes in trauma workload throughout a single region within the UK. However, we anticipate similar trends will have been experienced in paediatric orthopaedic departments throughout the country.

We reviewed the practice and management of paediatric orthopaedic trauma during the lockdown period of the SARS-CoV-2 pandemic. Low levels of COVID-19 were documented within the entire paediatric hospital population. The low levels of COVID-19 in paediatric inpatients, measures taken to reduce footfall and keep necessary patient contact to a minimum, and utilization of paediatric MTC theatre space to relieve DGHs of paediatric trauma have reduced the pressure on local hospitals treating adults.

We identified changes in mechanisms of injury, anatomical regions and median age of affected patients with an increase in the proportion of tibial fractures and a reduction in knee injuries. Increased trampoline sales have not caused significant changes to our workload and while we remain vigilant, the early concerns over increased incidences of NAI have not transpired.

Significant changes to standard practice were required in order to maintain appropriate trauma management. The guidelines for paediatric trauma management generated by BSCOS and Alder Hey hospital were adopted resulting in a significant decrease in both the number of MUAs and MUA+ K-wire procedures performed and a significant increase in the proportion of supracondylar fractures treated non-operatively through fracture clinic.

Ongoing review is required to assess the impact of any changes in practice as a result of COVID-19.