covid 19 impact on ortho services

1. Dr.Dinesh Dhar,SeniorSpecialist Orthopedics,
Nizwa Hospital
dinesh612015@gmail.com
Impact of COVID- 19
On Orthopedic Services

2. Coronavirus
Structural
Protein
Functional Protein
Nucleocapsid
Protein (N)
• Bound to RNA
genome to make up
nucleocapsid
Spike Protein (S) • Critical for binding of
host cell receptors to
facilitate entry of
host cell
Envelop Protein
(E)
• Interacts with M to
form viral envelop
Membrane
Protein (M)
• Central organizer of
CoV assembly
• Determines shape of
viral envelop
NOTE: Some CoV’s do not need to have the full
ensemble of structural proteins to make virions,
highlighting that certain proteins may be dispensable or
compensated by the function of non-structural proteins.

3. Emergence of COVID-19
• The COVID-19 outbreak has
presented a significant challenge to
the HS, the scale of which is
unprecedented since its creation.
• There were well-founded concerns the
HS was unprepared and under-
resourced for a pandemic.
• In the absence of clear national advice
and guidance, individual trusts and
departments were forced to be
reactive and develop their own
systems of response..

4. 4
Immediate and long‐term impact of the COVID‐19 pandemic on delivery of surgical services
BJS (British Journal of Surgery), First published: 30 April 2020, DOI: (10.1002/bjs.11670)

5. 05/7/2020

6. The way forward : “Prepare now “
• Protocol development in your hospital / Institution
• Re evaluate the backlog of your surgical wait list and prioritize it .
• Existing patient care optimization :Non surgical wherever possible
• Prioritize pt urgency based on known prognostic factors
• Assess patient readiness for surgery
• Resume pre op evaluation of priority delayed or surgical waitlist pts.
• Ensure covid status is confirmed , appropriate precautions taken in
lead upto surgery.
• General readiness of equipment /PPE .
• Work collaboratively with all stake holders .

7. Impact COVID-19
• As an Orthopaedic department in a
regional hospital, our role in the
management of this crisis at first was
uncertain
• Wider aspects of hospital-based care have
had to change and adapt.
• My talk discusses the impact of this
pandemic on the orthopaedic service and
our response to the crisis in the early
days.

8. Impact COVID-19
• Povide support and reassurance to
clinicians
• Best marshall a limited physical resource
• Keep the key resource of personnel
operational
• Triage and contract the service as physical
and personnel resources diminish

9. Service Changes
• Department changes in
anticipation of potentially large
numbers of infected patients
being admitted to the hospital.
• These changes included acute
(trauma) work; elective
theatre/clinic; workforce
planning, and infection control
measures.

10. Trauma meetings
• First change implemented was social distancing advise .
• Restrict attendance in person to just the on-call and
theatre teams.
• The trauma meeting was run as usual, discussing new
admissions and planning the trauma list.
• A further virtual meeting for the whole department was
introduced via social media to discuss issues, xrays
raise concerns and answer questions at the end of day.

11. Work Force Planning
• Early in the outbreak department took the decision that
only staff members with necessary clinical commitments
should be at work with all other work being done
remotely.
• This was done to achieve social distancing, reduce
exposure to higher viral load, and promote resilience on
the workforce in the event of staff sickness.
• Regional and national guidelines were incorporated into
the departmental guidance.
• The on-call structure remained more or less unchanged.

12. Outpatient clinics
*Consultant delivered, definitive decision-making at
first attendance
•segregated facilities to provide safely-spaced
waiting areas,
•follow-up should be the default, with booked
appointments
•Follow-up appointments should be delivered by
telephone .
• Existing appointments should be cancelled,
postponed or conducted remotely
•Follow-up imaging to spaced
•Use of removable casts or splints
• multiple imaging modalities to be avoided
•CT scanning should be minimised ,
•Triaging in (ED) to reduce Outpatient cases.

13. Inpatient Management
Is important to stop the spread of the virus
• Patients should only be admitted to hospital if there is
no alternative.
• Major Trauma and other networks should develop
solutions for communication and distribution of
workload.
• Surgery involving high-speed devices is considered
to be an (AGP).
• Appropriate (PPE) should be used by all staff in line
with most recent Public Health guidance.

14. Surgery Prioritizing Policy
Emergent surgery :Warranted for life and limb
threatning injuries
Urgent Surgery : definition broadly includes closed
fractures that lead to loss of function or permanent
disablity if left untreated for >30 days.
Categorization as per timing includes those within :
24-72 hrs (Emergent/urgent)
2 weeks (Expedited semi urgent)
06 -12 weeks (Semi urgent)
Beyond 12 weeks (Non urgent)

15. 05/7/2020
Ortho
Sub-
specialty
< 24h (Emergent) < 48-72hs
(Urgent)
< 2 weeks
(Expedited
semi-urgent)
< 3-months
(semi-
urgent)
>3-months (non- urgent)





16. General orthopaedic trauma
• Complex fractures surgery planned. If a staged
approach is used, aim to discharge and readmit
the patient if possible.
• UL fractures that require surgery (e.g. forearm
fractures) should be managed as day cases.
• Use absorbable sutures to be encouraged
• Non-operative management and bracing of
patients with uncomplicated spinal fractures
.
•

17. Emergent surgery:Life and limb threatening injuries
• Multiple injuries, pelvic & acetabular fractures with major
hge, open fractures, compartment syndrome and
exsanguinating injuries,Spinal injuries with neual
compromise , septic arthritis .
. Early amputation for whom limb salvage has an uncertain
outcome and is likely to require multiple operations and a
prolonged inpatient stay
. Hip and femoral fractures remains urgent and a surgical
priority within 24 hrs
. Fragility fractures should be discharged early to avoid
exposure to virus.

18. Management of specific injuries
• Dislocations to be reduced in ED if stable
after reduction, the patient should be
discharged
• UL # clavicle, humeral and wrist fractures,
have high rates of union and may be
managed non-operatively
• Ligamentous injuries of the knee may be
managed with bracing
• Penetrating injuries of limbs not
contaminated without NV deficit may be
sutured in the ED.

19. Pediatric orthopaedic trauma
• Always consider the possibility of non-
accidental injury
• Xrays can be avoided in
– Soft tissue injuries.
– Wrist, forearm, clavicle and proximal
humeral fractures.
– Long bone fractures with clinical deformity.
– Foot fractures without significant clinical
deformity and swelling.
• Single follow-up appoint at 4 to 12 weeks,
depending on the limb or bone fractured, is
acceptable for the majority of injuries

20. Pediatric orthopaedic trauma
Majority of Fractures can be managed non operatively
Operative management :
.Open fractures
.Septic arthritis and osteomyelitis with subperiosteal collection.
.Femoral fractures in children aged over six years (operative
stabilisation).
.Displaced articular or peri-articular fractures, including
Gartland type 3 supracondylar fractures and acute SCFE
Time-dependent conditions DDH/CTEV require surgery
within 03 MONTHS

21. 05/7/2020

22. 05/7/2020

24. 05/7/2020
3

25. Personal protection equipment (PPE)
• Discussing all potential COVID-19 cases in the team brief, including
the use of standard and enhanced PPE on a case-by-case basis
• Classifying high speed drilling, pulsed lavage and cutting diathermy
as aerosol generating procedures (AGPs),
• Avoiding AGPs, specifically no use of pulsed lavage; diathermy used
sparingly in coagulation mode;
• Use of tourniquets; operate in a dry field and cover the operative field
when using drills or saws.
• Use waterproof surgical face masks and eye protection for
suspected or confirmed COVID-19 cases, with FFP3 masks used for
AGPs.
• Surgical hoods not to be used as it increase viral load into the suit.

30. Can wearing a medical face mask protect
against new corona virus?
Block liquid
droplets only
Don’t offer full
protection
against airborne
viruses
Don’t fully seal
off nose and
mouth
Wearer’s eye
remain exposed
Regular
Surgical Mask:
NO

31. What about N95 and N99 P95 Mask?
N95 Face Mask N99 Face Mask
Designed to prevent 95% of small
particles from entering nose and
mouth area 2.5 cm from air
Can filter up to 99% of particulate
matter from 2.5 cm from air
A valve or two – dedicated to exhaled air, to ensure there is no moisture near
nose bridge or eye
Thicker than surgical mask

32. Coping with stress during the
COVID-19 can be stressful, the effects can be both
physical and emotional.
Things you can do to reduce stress:
• Take breaks from listening to, watching
or reading about COVID-19 frequently,
including social media.
• Focus on the facts of COVID-19 and
understand the risk to yourself and
those you care about.
• Separate facts from rumours. Gather
information from reliable sources.
• If stress continues to hamper your daily
activities, talk to a doctor, or someone
you can trust.
Keep yourself in the
best possible health.
Sleep well, eat healthy
and be physically
active.

33. 05/7/2020

34. 05/7/2020

36. References :
1. Royal college of surgeons of england guidance for surgeons working during the
COVID-19 pandemic. https://www.rcseng.ac.uk/coronavirus/joint-guidance-for-
surgeons
2. British Orthopaedic Association BOAST-Management of patients with urgent
orthopaedic conditions and trauma during the coronavirus
pandemic. https://www.boa.ac.uk/resources/covid-19-boasts-combined.html
3.. Health Education England Coronavirus (Covid-19) information for
trainees. https://www.hee.nhs.uk/coronavirus-information-trainees
4.COVID-19 outbreak: The early response of a UK orthopaedic department
Tadros, Black, and Dhinsa J Clin Orthop Trauma. 2020 May; 11(Suppl 3): S301–
S303.
5. Out Patient Department Practices in Orthopaedics Amidst COVID-19: The
Evolving Model Hitesh Lal 1, Deepak Kumar Sharma 2, Mohit Kumar
Patralekh 2, Vijay Kumar Jain 3, Lalit Maini . J Clin Orthop Trauma 2020 May 18. doi:
10.1016/j.jcot.2020.05.009
6.Best Practice for surgeons COVID-19 Evidence –Based Scoping Review
Orthoevidence Version 3 May30 , 2020

38. 05/7/2020