Managing Fractures in Patients with COVID-19

As JBJS Editor-in-Chief Marc Swiontkowski, MD observed in a recent editorial, some musculoskeletal health professionals “have been set aside to some degree” during the COVID-19 pandemic. However, Dr. Swiontkowski also emphasized that “emergency/urgent procedures [still] need to be carried out.” Which leads to the question: What are the best medical practices for patients who have both fracture and COVID-19 infection.

To help answer that question, JBJS fast-tracked the publication of an article by Mi et al., which retrospectively reviewed the medical records of 10 patients from 8 hospitals in China who had both a bone fracture and COVID-19 infection.

Presenting Symptoms
All of the fractures were caused by accidents, most of them low-velocity. Flu-like symptoms of patients with a fracture and COVID-19 disease were diverse, as follows:

• 7 patients (70%) reported fever, cough, and fatigue.
• 4 (40%) had a sore throat.
• 5 (50%) presented with dyspnea.
• 3 (30%) reported dizziness.
• 1 patient (10%) reported chest pain, nasal congestion, and headache.
• 1 patient (10%) reported abdominal pain and vomiting.

Imaging and Lab Results
Six of the 10 patients were positive for SARSCoV-2 based on quantitative reverse transcription polymerase chain reaction (qRT-PCR) of throat-swab samples. All patients ultimately showed evidence of viral pneumonia on computed tomography (CT) scans, but on admission 3 patients did not exhibit severe symptoms or have obvious evidence of COVID-19 on CT scans, and they therefore underwent a surgical procedure. Fever and fatigue signs were observed in these 3 patients after the operation.

The overall results of laboratory tests were as follows:

• 6 patients had lymphopenia (<1.0 x 10⁹ cells/L)
• 9 patients had a high level of C-reactive protein.
• 9 patients had D-dimer levels that exceeded upper normal limits. The authors suggest that this finding “could represent the special laboratory characteristics of fractures in patients with COVID-19.”

Management
Three of the 10 patients underwent surgery; the others were managed nonoperatively due to their compromised status.

All patients received antiviral therapy and antibacterial therapy, and 9 patients were managed with supplemental oxygen. None of the patients received invasive mechanical ventilation or extracorporeal membrane oxygenation because of local limitations in medical technology.

Outcomes
Four patients died in the hospital. Among those who died, surgery had been performed on 1. The clinical outcomes for the 6 surviving patients have not yet been determined.

Conclusions
Because 7 of the 10 patients were determined to have developed a nosocomial infection, the authors emphasize the need “to adopt strict infection-control measures…Doctors, nurses, patients, and families should be wearing protective devices such as an N95 respirator and goggles.”

Mi et al. propose the following 3 additional strategies for patients with a fracture and COVID-19 pneumonia:

• Consider nonoperative treatment for older patients with fractures, such as distal radial fractures, in endemic areas.
• Give patients with a fracture and COVID-19 pneumonia more intensive surveillance and treatment.
• Perform surgery on patients with a fracture and COVID-19 pneumonia in a negative-pressure operating room.