The Impact of COVID-19 on Hand Trauma

Introduction

The Coronavirus Disease 2019 (COVID-19) was officially declared a pandemic by the World Health Organization ¹ on March 11, 2020. In the following weeks, “lockdown” measures were implemented across Australia on a state-by-state basis. These included restrictions on mass gatherings, social distancing guidelines, domestic and international border closures, quarantine requirements, and the closure of hospitality venues, sporting competitions, and schools. The impact of such restrictions and associated public concern on patterns of disease incidence and presentation has generated significant interest, with early studies demonstrating decreases in total emergency department attendance, ² presentation of major illnesses such as acute stroke, ³ and presentations with negative investigation findings. ⁴

In addition to social distancing measures, significant changes were implemented within hospitals to address the actual and expected surge in patients with COVID-19 and to protect staff and patients. The delivery of surgical services was dramatically altered with the temporary suspension of elective procedures and diversion of staff to areas of increased demand. Perioperative guidelines were adapted to facilitate the safe provision of emergency surgery to potentially infectious patients. Measures included more frequent terminal cleaning of theaters, changes to intubation and extubation protocols, additional personal protective equipment (PPE) for staff, and altered patient flow through the surgical unit. ⁵

Thus, this study aimed to investigate the impact of the COVID-19 pandemic on the presentation and management of hand trauma at a large tertiary referral hand surgery unit in Sydney, New South Wales, Australia.

Methods

Results

During the 5-week study period in 2020, there were a total of 125 presentations to the hand surgery unit; 8 patients were treated nonoperatively with intravenous antibiotics for infection and 3 patients were transferred for surgery in the private system, yielding a total of 114 primary operative presentations. This was a 27.4% decrease from the year earlier, where a total of 176 patients presented for management to the hand surgery unit in the equivalent 5-week period. Of this cohort, 16 were managed nonoperatively and 3 were transferred elsewhere, yielding a total of 157 primary operative presentations.

Patient Characteristics

The mean age of the 2020 cohort was 41.9 years (range 2-99 years), compared with 42.7 years for the year prior. Most patients were men in both years, with a proportion of 64.9% in 2020 and 61.1% in 2019. The right hand was involved in 52.6% of cases in 2020 and in 47.8% of cases in 2019. There were no statistically significant differences between cohorts for age, sex, or affected side (Table 1).

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Table 1.

Patient Characteristics for All Primary Operative Presentations Over a 5-Week Period in March 2019 and 2020.

Variable	2019	2020	P value
Total patients	157	114
Males, %	61.1	64.9	.53
Age
Mean	42.7	41.9	.74
Range	2 - 91	2-99
Side, No. (%)
Right	75 (47.8)	60 (52.6)	.35
Left	82 (52.2)	53 (46.5)
Bilateral	0 (0.0)	1 (0.9)
Urgency, No. (%)
Emergency	116 (73.9)	97 (85.1)	.03
Elective	41 (26.1)	17 (14.9)
Pathology type, No. (%)
Trauma	109 (69.4)	88 (77.2)	.16
Infection	9 (5.7)	10 (8.8)	.33
Neoplasm	9 (5.7)	4 (3.5)	.57
Degenerative	18 (11.5)	6 (5.3)	.08
Foreign body	0 (0.0)	4 (3.5)	.03
Hardware removal	9 (5.7)	0 (0.0)	.01
Revision surgery	1 (0.6)	2 (1.8)	.57
Congenital	2 (1.3)	0 (0.0)	.51

NB: Bold indicates significant difference.

Presentations

There was a significant decrease in the proportion of emergency presentations, comprising 85.1% (n = 97) of the cohort in 2020 and 73.9% (n = 116) a year earlier (P = .03). The remaining 14.9% (n = 17) of presentations in 2020 and 26.1% (n = 41) of presentations in 2019 were elective operations.

The distribution of all presentations is shown in Table 1. Notably, there was an increase in the proportion of trauma presentations from 69.4% of cases in 2019 to 77.2% in 2020, though this difference did not reach statistical significance (P = .16). Significant differences were observed for foreign body presentations, which accounted for 0% of cases in 2019 and 3.5% in 2020 (P = .03), and for hardware removal, which accounted for 5.7% of presentations in 2019 and 0% in 2020 (P = .01). Presentations related to infection, neoplasia, degenerative disease, revision surgery, and congenital abnormalities were similar between the cohorts.

The type and mechanism of trauma cases are displayed in Table 2. The greatest differences in the type of trauma were observed for closed fractures, which decreased from 32.1% of trauma cases in 2019 to 23.9% 2020 (P = .20), and for amputation injuries, accounting for 3.7% of trauma in 2019 and 9.1% in 2020 (P = .14). The distribution of other trauma types, including open fractures, lacerations, penetrating injuries, burns, and animal bites, was relatively unchanged between cohorts.

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Table 2.

Trauma Presentation Characteristics Over a 5-Week Period in March 2019 and 2020.

Variable	2019	2020	P value
Total patients	109	88
Trauma type, No. (%)
Closed fracture	35 (32.1)	21 (23.9)	.20
Open fracture	4 (3.7)	4 (4.5)	.76
Laceration	47 (43.1)	41 (46.6)	.63
Penetrating injury	6 (5.5)	3 (3.4)	.48
Burn	0 (0.0)	1 (1.1)	.45
Animal bite	6 (5.5)	4 (4.5)	.76
Amputation	4 (3.7)	8 (9.1)	.14
Other	7 (6.4)	6 (6.8)	.91
Trauma mechanism, No. (%)
Fall from standing	14 (12.8)	11 (12.6)	.87
Fall from height	1 (0.9)	2 (2.3)	.59
Tool/knife accident	32 (29.4)	25 (28.7)	.88
Other accident	17 (15.6)	26 (29.9)	.02
Self-harm	4 (3.7)	1 (1.1)	.38
Violent injury	4 (3.7)	5 (5.7)	.52
Sporting injury	20 (18.3)	8 (9.2)	.06
Motor vehicle accident	11 (10.1)	5 (5.7)	.26
Animal bite	6 (5.5)	4 (4.6)	.76

NB: bold indicates significant difference.

In terms of the trauma mechanism, falls from standing height were relatively constant, accounting for 12.8% of trauma cases in 2019 and 12.6% in 2020 (P = .87). Accidents involving tools or knives were similarly stable, occurring in 29.4% of cases in 2019 and 28.7% in 2020 (P = .88). Differences were observed particularly in the proportion of sporting injuries, which decreased from 18.3% of trauma cases in 2019 to 9.2% in 2020 (P = 0.06), and in motor vehicle accidents (MVAs), which decreased from 10.1% in 2019 to 5.7% in 2020 (P = .26). There was a statistically significant difference in the number of other accidents (those not involving tools or knives, falls, etc.), seen in 15.6% of trauma presentations in 2019 and 29.9% in 2020 (P = .02). One patient in the 2020 cohort did not have sufficient hospital records to determine the mechanism of injury.

Operations

The types of operations performed are shown in Table 3. The proportion of debridement and washouts performed increased significantly, from 31.2% of procedures in 2019 to 43.9% in 2020 (P = .03). There were 9 hardware removal procedures performed in 2019 (5.7% of cases) and none in 2020 (P = .01). There were no other significant differences in the types of operations, and notably the proportion of open reduction internal fixations was relatively constant, accounting for 19.1% of cases in 2019 and 18.4% in 2020 (P = .89).

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Table 3.

All Primary Procedures Performed in a 5-Week Period in March 2019 and 2020.

	2019, No. (%)	2020, No. (%)	P value
ORIF	30 (19.1)	21 (18.4)	.89
Closed reduction	9 (5.7)	3 (2.6)	.25
External fixation	0 (0.0)	1 (0.9)	.42
Debridement and washout	49 (31.2)	50 (43.9)	.03
Tendon/Neurovascular structure repair	26 (16.6)	21 (18.4)	.69
Excision of lesion	8 (5.1)	2 (1.8)	.15
Nailbed repair	5 (3.2)	8 (7.0)	.15
Terminalization	3 (1.9)	2 (1.8)	.93
Carpal tunnel release	9 (5.7)	4 (3.5)	.40
Removal of hardware	9 (5.7)	0 (0.0)	.01
Other elective procedure	9 (5.7)	2 (1.8)	.13

Note. ORIF = open reduction internal fixation.

NB: bold indicates significant difference.

The operative details and times are displayed in Table 4. There were no significant differences in the proportion of consultant-led cases or cases performed out-of-hours. The mean number of staff members scrubbed during the operation was 1.96 and 1.79 in 2019 and 2020, respectively, a difference which was statistically significant (P = .03). There was also a statistically significant decrease in the mean anesthetic time, which was 1.85 hours in 2020 compared with 2.08 hours in 2019 (P = .01); in the mean surgical time, which was 1.09 hours in 2020 and 1.23 hours in 2019 (P = .01); and in the mean triage to theater time, which was 12.81 hours in 2020 and 17.02 hours in 2019 (P = .03). Differences in the mean operating room time and mean length of hospital stay were not statistically significant.

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Table 4.

Operative Staff and Time Metrics for All Primary Procedures in a 5-Week Period in March 2019 and 2020.

	2019	2020	P value
Consultant primary surgeon, %	67.50	68.10	.91
Cases done after hours, %	21.90	25.90	.45
Mean number of staff members scrubbed	1.96	1.79	.03
Mean anesthetic time, h	2.08	1.85	.01
Mean surgical time, h	1.23	1.09	.01
Mean total time in room, h	1.65	1.50	.40
Mean triage to theater time, h	17.02	12.81	.03
Length of stay, d	1.94	1.60	.43

NB: bold indicates significant difference.

Discussion

The impact of COVID-19 on the health care system in Australia has been markedly different from that in regions of the United States and Europe, where the extent of severe pulmonary illness has stretched the critical care capacities. In Australia, where the general population has been fortunate to avoid the direct impact of widespread disease transmission, the implementation of strict social policies has influenced distribution of injuries and the etiology of hospital presentations, with resultant changes to the running of the hospital system at all levels.

The primary and most visible consequence of social restrictions is the reduction in activity across almost all planes of society. For example, during March 2020, the CityMapper Mobility Index ⁷ reported an 84% reduction in population mobility in Sydney compared with baseline. This trend drives an expectation of a decreased number of presentations alongside a specific reduction in MVAs, sporting injuries, and workplace injuries as participation in these activities is restricted. This was reflected in this study, with a decrease of 27.4% in overall presentations between 2019 and 2020. This consisted of a statistically significant reduction of 11.2% in the proportion of elective procedures (P = .03), including a reduction in elective removal of hardware procedures—no such procedures were performed in the 2020 period of interest, despite comprising 5.7% of all procedures the year prior (P = .01)—and is explained in large part by the suspension of nonessential elective surgeries from March 25 to April 27. ⁸ A nonsignificant reduction in MVAs (4.4%) and sporting injuries (9.1%) was also noted. However, other low-energy injuries such as falls in the elderly, which typically occur within home and are due to intrinsic patient factors, were shown to be largely unchanged, with a reduction in incidence of 0.2%. In line with this relative shift away from elective procedures is the significant increase of 12.7% in the proportion of procedures requiring exploration, debridement, and lavage, typically associated with emergency presentations.

Despite limitations on workplace attendance and social gatherings, there was only a negligible reduction in tool and knife accidents (0.7%), and in fact a statistically significant increase of 3.5% in foreign body injuries (P = .03). These were typically wooden splinters and were split between injuries in the home and on the work site, reflecting both the continuation of construction as an essential service and an increase in the uptake of Do-It-Yourself projects at home. A minor increase in the incidence of violence-related injury was also noted, despite the decrease in social functions and previous corollaries between violent injuries and alcohol consumption in a social setting, with data suggesting that almost half of violent injuries occur under the influence of recreational alcohol or drugs.^9,10 Although this study found only 1 case of reported domestic violence, which occurred in the 2019 cohort, other early data have suggested a concerning increase in the rate of domestic violence during the COVID-19 pandemic related to social factors such as home isolation and reduced support network contact in conjunction with social, financial, and health stressors.^11-13

These factors together have not only shifted the volume of emergency hand presentations, but also generated a unique change in injury distribution, with implications for how resources can best be allocated in times of reduced societal interaction. Most notably, in 2020 there was a reduction in the incidence of closed fractures, likely reflecting decreased sporting and MVA injuries, whereas lacerations were relatively constant in number and accounted for a greater proportion of injuries during 2020. The differing requirements for these injuries, including regarding intraoperative equipment, postoperative ward care, and long-term follow-up, may inform decisions surrounding staff and resource allocation. It is also important to note the inelastic components of emergency presentations, which are not influenced by society at large, namely the rate of closed fractures following falls in the elderly, which has remained stable in the face of the pandemic. Any redistribution of resources from hand trauma services to areas of increased demand, such as respiratory medicine or intensive care unit during the COVID-19 pandemic, must account for this relatively fixed level of injury.

A major concern during the pandemic has been the impact of a prolonged period of social isolation, uncertainty, and fear on the mental health of the general population—a consideration that holds such importance in guiding lockdown policy that exercise is protected as an essential activity even under stage 4 lockdown. ¹⁴ Mental health support hotlines experienced a spike of up to 20% over this period, with 39% of calls to the suicide prevention service Lifeline directly related to COVID-19. ¹⁵ However, as a representation of its most severe manifestation, this study noted a reduction in deliberate self-harm presentations from 3.7% to 1.1% (P = .38). This may be indicative of the effectiveness of a number of social and welfare policies, including the implementation of Jobseeker/Jobkeeper stipends and the expansion of free and subsidized mental health services delivered remotely via telehealth. ¹⁶ It must be noted that hand trauma presentations are an indirect measure of self-harm incidence, and dedicated data from psychiatric and mental health services are required to better address this important question.

An outbreak of this scale has had an unprecedented impact on the internal policies and proceedings of practice within the hospital. In the surgical context, operating procedures were dramatically altered by changes, including staff redistribution, PPE requirements, theater terminal cleaning protocols, and altered anesthetic practices particularly during aerosolizing procedures such as intubation. Although the implementation of new policies and requirements could ostensibly be expected to increase surgical times, this study, alongside another study performed at our institute, ¹⁷ noted a decrease in surgical times in the 2020 cohort. This may reflect an increased proportion of relatively simple and expedient procedures, such as washout and debridement, and a decrease in the proportion of more time-consuming elective procedures. Other contributing factors may include the slight increase in consultant-led procedures and the decrease in the number of staff members scrubbed in, from a mean of 1.96 in 2019 to a mean of 1.79 in 2020 (P = .03), which may reflect a reduction in the presence of junior staff and medical students, with less time spent teaching. The reduction in anesthetic time is likely a result of altered anesthetic protocols, which allowed early extubation in the operating room rather than in recovery to minimize the exposure of staff members to potentially infectious aerosolized droplets. As for the reduction in triage to theater time observed in 2020, it is likely that the suspension of elective surgeries and decreased overall surgical load allowed for more efficient and timely operating theater scheduling. Although beyond the scope of this study, further research is required to explore the impact of these changes on long-term patient outcomes and on trainee education and performance.

Conclusions

The COVID-19 pandemic has had a profound impact on all aspects of society and of medical practice, and the patterns of disease presentation and management during this unique period provide useful insights. There was a decrease in the overall number of presentations and a decrease particularly in elective cases, as well as alterations in the patterns of injury type and mechanism, at our tertiary-level hand and peripheral nerve referral center. Anesthetic and operating times were reduced, as was the time from presentation to surgery. Future research examining the relative impact of the diverse approaches taken by other hospitals, states, and countries may provide further insight.