Expert Consensus on Management Principles of Orthopedic Emergency in COVID – 19

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Expert Consensus on Management Principles of Orthopedic Emergency in the Epidemic of Coronavirus Disease 2019

The COVID-19 pandemic, caused by the novel coronavirus SARS-CoV-2, has necessitated significant adaptations in healthcare delivery, particularly in high-risk specialties such as orthopedics. This consensus, formulated by experts from the Chinese Orthopedic Association and the Chinese Association of Orthopedic Surgeons, provides evidence-based guidelines for managing orthopedic emergencies while mitigating infection risks during the pandemic.

Epidemiological Context and Orthopedic Challenges

COVID-19 emerged in Wuhan, China, in December 2019, with initial cases presenting as severe pneumonia of unknown origin. By January 2020, the disease was classified as a Category B infectious disease under Category A management in China, reflecting its high transmissibility and severe public health impact. Transmission occurs primarily via respiratory droplets and close contact, with aerosol transmission possible in enclosed, poorly ventilated environments. The incubation period ranges from 1 to 14 days, necessitating stringent screening protocols.

During lockdowns, the incidence of high-energy trauma fractures (e.g., traffic accidents) decreased, while low-energy fractures (e.g., falls at home) increased. As restrictions eased and mobility resumed, trauma cases surged, posing dual challenges: managing fractures and preventing nosocomial COVID-19 transmission. Orthopedic departments faced risks from asymptomatic carriers, close contacts, or undiagnosed cases among patients.

Patient Classification and Risk Stratification

Patients are stratified into four categories based on COVID-19 exposure and symptoms:

  1. Type I: No travel to epidemic areas within 14 days; no contact with suspected/confirmed cases.
  2. Type II: Contact with individuals from epidemic areas or residents in neighborhoods with confirmed cases, but asymptomatic and testing negative.
  3. Type III: Suspected COVID-19 cases (e.g., fever, respiratory symptoms, or epidemiological links without confirmatory tests).
  4. Type IV: Laboratory-confirmed COVID-19 cases.

This classification guides protective measures, triage, and treatment pathways to minimize cross-infection.

Infection Control Protocols

1. Admission and Triage

All patients undergo dual assessments: orthopedic evaluation and COVID-19 risk screening. Screening includes travel history, contact with confirmed cases, and symptom checks (fever, cough, dyspnea). Type I and II patients receive prioritized care in designated zones, while Type III and IV patients are isolated and managed in collaboration with infectious disease specialists.

  • Protection Levels:
    • Level 1 (Type I): Standard surgical masks, gloves, and gowns.
    • Level 2 (Type II): Enhanced protection with N95 respirators, goggles, face shields, and disposable gowns. These patients are isolated in single rooms, with dedicated staff and equipment.
    • Level 3 (Type III/IV): Full airborne precautions, including powered air-purifying respirators (PAPRs), double gloves, and negative-pressure isolation rooms.

2. Preoperative Management

For urgent surgeries, rapid nucleic acid testing and chest CT scans are mandated to rule out COVID-19. Type II patients undergo surgery in negative-pressure operating rooms, with strict disinfection protocols post-procedure. Two disinfectants (e.g., chlorine-based and alcohol-based agents) are used sequentially to eliminate residual pathogens.

3. Intraoperative Precautions

Minimally invasive techniques (e.g., closed reduction, external fixation) are prioritized to reduce operative time and aerosol generation. Surgical teams limit personnel to essential staff, all using Level 2 or 3 protection. Airway management during intubation and extubation follows strict aerosol-minimizing protocols.

4. Postoperative Care

Patients recovering in shared wards are monitored for delayed COVID-19 symptoms. Repeat testing is performed if fever or respiratory symptoms emerge. Discharge criteria include fracture stability and negative COVID-19 tests, with telemedicine follow-ups to reduce hospital visits.

Treatment Strategies for Orthopedic Emergencies

The consensus emphasizes conservative management where feasible:

  1. Nonoperative Management:

    • Closed fractures: Manual reduction with casting or bracing.
    • Stable spinal injuries: Rigid collars or braces.
    • Pediatric fractures: Early immobilization to avoid hospitalization.

  2. Surgical Indications:
    Surgery is reserved for:

    • Open fractures with vascular compromise.
    • Unstable pelvic fractures.
    • Spinal cord compression or cauda equina syndrome.
    • Septic arthritis or osteomyelitis.

For confirmed or suspected COVID-19 patients, surgery is delayed unless life- or limb-threatening. When unavoidable, procedures are performed in negative-pressure rooms with Level 3 protection.

Special Considerations

  • Pediatrics: Parental screening is critical, as children may present as asymptomatic carriers.
  • Geriatrics: Higher morbidity necessitates aggressive COVID-19 screening due to overlapping symptoms (e.g., fatigue, confusion).
  • Rehabilitation: Home-based physiotherapy via digital platforms reduces exposure risks.

Logistical and Multidisciplinary Coordination

Hospitals established dedicated orthopedic emergency pathways, segregating COVID-19 suspected/confirmed cases. Multidisciplinary teams (respiratory, ICU, anesthesia) collaborate on high-risk cases. Staff training focused on PPE use, donning/doffing procedures, and infection control audits.

Outcomes and Adaptations

Early implementation of these measures reduced nosocomial outbreaks in orthopedic departments. Key lessons included:

  • Preoperative CT screening identified asymptomatic COVID-19 pneumonia in 5–8% of trauma patients.
  • Tele-triage reduced unnecessary ED visits by 30%.
  • Rapid testing enabled same-day surgery for 85% of Type II patients, minimizing delays.

Conclusion

This consensus provides a structured framework for balancing urgent orthopedic care with COVID-19 containment. Risk stratification, stringent protection protocols, and tailored treatment algorithms ensure patient and staff safety. As the pandemic evolves, continuous adaptation of these guidelines will remain critical to addressing emerging challenges.

doi.org/10.1097/CM9.0000000000000810

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