Management of orthopaedic patients during covid‑19 pandemic

1. Management of Orthopaedic Patients
During COVID-19 Pandemic
in India: A Guide
Moderator : Dr. E.Venkateshulu
Professor and Unit Chief
Dpt. Orthopedics, VIMS, Ballari
Presenter : Dr. Punith Kumar P.C

2. Introduction
Coronaviruses are a group of viruses that mainly affect
human beings through animal transmission. It is the
third time, the emergence of novel coronavirus in last
two decades,
 Severe acute respiratory syndrome (SARS) in 2003
 Middle East respiratory syndrome coronavirus
(MERSCoV) in 2012
 Novel severe acute respiratory syndrome coronavirus
(SARS-CoV-2)-infected pneumonia (COVID-19).

4.  Novel severe acute respiratory syndrome coronavirus
(SARS-CoV-2)-infected pneumonia (COVID-19)
o The novel coronavirus first emerged in Wuhan, China in
December 2019 from the wet seafood market. COVID-19
was regarded as a public health emergency of international
concern in the world by mid-February 2019.
o The epicentre of the pandemic shifted from Europe to USA
from time to time and at present there are around 17.8 lakh
cases of COVID-19 with 109,275 casualties in the world,
amounting to 6.12% mortality rate according to World Health
Organization (WHO) as of now.

5. o India is a developing country with around 1.3 billion population,
2nd largest in the world after China.
o In India, there is one allopathic doctor per 10,926 population ,
which is below WHO’s recommendation of 1:1000, putting
tremendous pressure on the health care system in India due to
COVID-19. The first case of COVID-19 was reported on 30th
January 2020 and the number has reached 8500 as on 12th April
20, with 289 deaths.
o On 25th March 2020, Prime minister of India announced a
nationwide 3-week lockdown to prevent community transmission
in India. This lockdown has been extended further and we have no
idea when this lockdown gets released.

6. o Even after the release of lockdown, the situation will not be
the same as in the past and we have to be more careful in
attending patients. The hospitals are becoming hot zones for
the treatment as well as transmission of COVID-19 due to a
rise in the community transmission from Europe, Asia and the
rest of the world.
o Orthopaedic surgeries including both elective and emergency
procedures (trauma patients) require operation theatres which
are high-risk areas for transmission of COVID-19, risks
health care workers contracting this illness and decreasing the
resources available to the population of India during this
pandemic.

7. o The high prevalence of COVID- 19, limited resources and
staff, increased risks of transmission and the burden on health
systems during this pandemic; keeping all this in mind, the
health system must act immediately and support essential
surgical care while protecting patients and staff and
conserving valuable resources.

8. COVID-19
Coronaviruses are positive-sense RNA viruses having an
extensive and promiscuous range of natural hosts and affect
multiple systems. Coronaviruses can cause clinical diseases in
humans that may extend from the common cold to more
severe respiratory diseases like SARS and MERS.
The recently emerging SARS-CoV-2 has wrought havoc in
China and caused a pandemic situation in the worldwide
population, leading to disease outbreaks that have not been
controlled to date, although extensive efforts are being put in
place to counter this virus.

9. This virus has been proposed to be designated/named severe
acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by
the International Committee on Taxonomy of Viruses (ICTV),
which determined the virus belongs to the Severe acute
respiratory syndrome-related coronavirus category and found
this virus is related to SARS-CoVs. SARS-CoV-2 is a
member of the order Nidovirales, family Coronaviridae,
subfamily Orthocoronavirinae,

10. Naming the coronavirus disease (COVID-19)
and the virus that causes it
Official names have been announced for the virus responsible
for COVID-19 (previously known as “2019 novel
coronavirus”) and the disease it causes. The official names
are:
Disease
coronavirus disease
(COVID-19)
Virus
severe acute respiratory syndrome coronavirus 2
(SARS-CoV-2)

11. Transmission of Virus

14. Orthopaedic Patients Expected During
Lockdown Period
 Trauma.
 History of fall at home, the neck of femur
fracture in elderly.
 History of assault.
 Severe cervical or lumbar pain.
 Post-operative cases for wound dressing or
suture removal.
 Postoperative surgical site infections.
 Elective cases with severe symptoms.

15. Steps to Create a Safe Working
Environment
1. Ensure Safe Working Environment
The examination area in the emergency especially door handles,
working stations and frequently used items should be cleaned
regularly at least four times a day with 1% hypochlorite/lysol.
Ensure that the healthcare staff including the doctor, nurses and
paramedical staff have no signs and symptoms related to COVID-19
infection or any contact with COVID patients in the past 14 days
and it is better to screen the health care staff, if feasible.
All health care staff should wear a personal protective equipment
(PPE) in the emergency, if not at least wear an N-95 mask, a
surgical gown and examination gloves and shoe covers. Education
of health care staff, patients and their attendants should be of utmost
priority.

16. 2. How to Attend Patients?
A three-layer surgical mask, hand sanitizer and a disposable
glove box should be available at the entry point of the
emergency area for patients and their attendants. In case of
trauma, it might be not possible to wear a mask for the patient
in all cases, at least ensure that attendants are provided with
one.
History of COVID-19 like symptoms and any history of
contact should be obtained both from patient and attendant
and a separate perform should be attached to record all
information.

17. If there is any positive history then isolate both patient and attendant
and treat as COVID positive unless proved otherwise. It is better to
keep every patient in isolation and convert every ward to isolation
rooms as there will be a limited number of patients in inpatient
departments (IPD). Maintain a separate dressing room and plaster
room for patients and waste like dressing material, gauges etc. of
suspected patients should be disposed of carefully.

18. 3. Avoid Negligence Towards Elective Patients
with Severe Symptoms
Every symptom should be recorded carefully and one should not be
negligent towards elective patients. Patients with tumour or
pathological fracture, or cauda equina or any infection should be
investigated properly and surgical intervention should be deferred
unless it is required on an urgent basis.
We may also have cases like avascular necrosis/ ankylosing hips or
rheumatoid knee where patients present with severe pain, adequate
analgesia should be given to get rid of acute symptoms.

19. 4. How to Manage a Trauma Patient with COVID-19-Like Symptoms?
(Having Signs or History of Contact)
Inform hospital administration authority, CMO or SMO. A specialized
COVID area in the triage should be ready for COVID-19 patients with
trauma. Resuscitate the patient with a primary survey along with
splintage of fracture limb. All necessary pre-operative investigations
along with COVID- 19 testing should be done.
If possible, get portable X-rays and ultrasound to avoid contamination
of the radiology area and it also helps in decreasing movement of
COVID patients. For investigations like CT scan or MRI, we have to
sterilize the respective area after investigating every patient as per
centres for disease control and prevention.

20. Patients with closed fractures should wait for surgical interventions
until the COVID-19 results are out. All cases which need urgent
management like an open fracture, vascular injuries, compartment
syndrome or mangled limb; we cannot wait until COVID results.
These patients should be managed as COVID positive patients and
strict precautions should be taken to avoid transmission to
caregivers or to other patients.
If the results are positive keep the patient in the COVID isolation
ward until the results are negative and take the help of the COVID
response team of the hospital. If the results are negative shift the
patient to the orthopaedic ward and then discharge as early as
possible.

21. Guidelines for management of non COVID patients
(standard protocol) and COVID positive patients
(COVID protocol).

23. Continued..

24. Standard Protocol
1. Resuscitate patient, rule out all other injuries (Primary
survey).
2. High chances of missed injuries in light of COVID suspicion
(Secondary survey).
3. Manage conservatively whenever possible.
4. Keep patients in isolation wards. Provide patients and
attendants with masks. Minimize patient and attendants’
movements. Expedite the process of operation and discharge
to lessen the load over the health system. These
patients should be attended by separate team surgeons.
5. Maintain a follow up OPD in a separate area for dressing,
suture removal and Plaster removal.

25. COVID Protocol
1. Manage conservatively whenever possible.
2. From the triage area patients (separate allocated area
for COVID) should be shifted to the operating room.
3. Strict regulations must be maintained while shifting the
patients. Sterilize all things that used while shifting,
viz. trolley, lift etc.
4. Maintain a dedicated COVID operating room with
trained staff.
5. Preventive measures must be followed at every level.

26. 6. Every effort should be made to minimize the duration of
surgery.
7. Decrease blood spilling.
8. Proper disposal of surgical waste.
9. Maintain negative pressure ventilation.
10.Patients have to be shifted to dedicated COVID isolation
wards postoperatively and discharged only after COVID
results are negative.
11.Care must be taken during the hospital stay to physiotherapy,
bedsores and DVT prevention.

27. Flowchart for dealing with orthopaedic and Trauma
cases during the period of the COVID-19 Pandemic.

29. Examples for Recommendations for Orthopaedic Paediatric Trauma
Management during COVID-19 pandemic
Injury What to do immediately Follow up
Gartland 1 Supracondylar
fracture
Collar and cuff, removed
by family at 3 weeks.
None required.
Fibular Fracture Apply walking boot
Weight bear as tolerated
Family to remove boot at
week 4
Teleconference week 6

30. Example Management Rationale Follow-up
New case of a
club foot
Do not start a
Ponseti
casting
Ponseti method
requires frequent
reviews,
risk of
transmission
Ponsetti casting
can be
commenced later
Review after
COVID
pandemic (3
months)
Consider
teleconferencing
Anterior Cruciate
Ligament
Postpone Excellent results
can be still
obtained
with a period of
delay
Follow-up after
the pandemic.
Offer prehab
program.

31. Peri-operative precautions when
operating on a COVID-19 positive or
suspected case
This should be incorporated into hospital plans and rules to
face the pandemic, and can be subdivided into measures
involving
 The operating room,
 Personnel,
 Anaesthesia,
 The procedure,
 Postoperative precautions.

32. Operating room measures
o Separate operating rooms (OR) should be designated for COVID-19
positive patients, isolated from other operating rooms. The
operating room is preferred to have a separate ventilation system
with negative pressure, which if not available, it is recommended to
add High-Efficiency Particulate Air (HEPA) filters to positive
pressure rooms.
o Moreover, Air conditioning should be turned off. Only the materials
necessary for the case should be brought into the OR. All equipment
and screens should be covered with plastic sheets to facilitate
decontamination. Consider attenuation of residual environmental
contamination through cleaning with surface disinfectants and
ultraviolet light (UV-C).

33. o All traffic in and out of the OR should be minimized. All doors
should be closed once the patient is transferred in and during the
whole operation. The path of the patient to and from the OR should
be kept clear and better to be separate from other operating rooms.
Patients should cover their face with a surgical mask.
o The patient should recover in the operating room and transferred
directly to the isolation ward . The number of personnel inside the
OR should be kept to the minimum. Services personnel should not
enter the room until enough time has elapsed for air changers to
reduce the risk of contamination. Sales representatives, residents,
and fellows should be discarded from OR unless essential.

34. Operating personnel
o The fewest number of personnel possible is the main goal, with the
highest skilled surgeon performing the procedure to avoid
prolongation of the surgery.
o All personnel in the operating room should wear the PPE which
include Association of Advancement of Medical Instrumentation
(AAMI) level III surgical gowns, surgical hood (for head and neck
covering), double gloves, facemasks and either N95, Filtering Face
Piece 2 (FFP2) respirators with a face shield/googles or Powered
Air-Purifying Respirator (PARP), fluid-resistant shoes or booties.

35. o Donning and doffing of PPE should be done in an anteroom if
available, with hand hygiene prior and after donning/doffing PPE.
o Avoid self-contamination during PPE doffing. Disinfect the first
pair of gloves with an alcohol solution, before removing the surgical
mask with the shield and the hair cap. Consider placing a simple
surgical mask on top of the N-95 to prevent gross contamination.
Each time N95 respirator is taken off, it must be double-checked for
not being soiled or damaged before reuse. Full face shield is
preferred to protective eye goggles.

36. Consideration of PPE for
Orthopaedic surgeon
Confirmed Non-COVID-
19
COVID_19( Status Unknown) COVOD-19
Positive
Minimum
Standard PPE (surgical
masks, eye protection and
gown)
Minimum
Standard PPE
Additional PPE Considerations for
possible aerosolizing orthopaedic
procedures
N95 respirator with full-face shield
or surgical hood
N95 respirator
with full face
shield or surgical
hood

37. Anaesthesia
o Dedicated anaesthesia machines should be exclusively designated
for COVID-19 positive cases. The most experienced
anaesthesiologist should intubate the patient in the shortest possible
time with minimal airway manipulation, avoiding face mask
ventilation and open-air way suction as possible.
o Keep the minimum number of personnel inside the anaesthesia
room which should be separate from the operating room, which
should not be entered for 15–20 min after intubation. Use deep
anaesthesia and neuromuscular blockage.
o Preoxygenation should be performed via well-fitting face mask to
avoid hypoxia in critically ill COVID-19 patients with respiratory
failure. It is preferred to avoid general anaesthesia and use of
regional/spinal anaesthesia is recommended whenever possible.

38. Surgical procedure
o Consider the use of minimally invasive approaches to decrease
operating staff exposure and shorten case duration. Use disposable
medical supplies/instruments whenever possible, and absorbable
sutures for wound closure to avoid a postoperative unnecessary
visit.
o The use of electrocautery should be reduced to minimize the
surgical smoke and should be used in conjunction with a smoke
evacuator. Care should be taken when using sharp objects to avoid
sharp injury or damage of PPE. The use of power tools like bone
saws, reamers, and drills should be reduced to the minimum and the
power settings should be as low as possible, as they release
aerosols, increasing the risk of virus spread. Suction devices to
remove smoke and aerosols should be used during their use.

39. o All body fluids as blood, secretions, urine, or pathological
specimens should be collected in double sealed bags for inspection
or destruction. All contaminated instruments and devices should be
disinfected separately followed by proper labelling.

40. Postoperative precautions
o The transfer to isolation wards should be through dedicated corridors and
elevators which should be carefully sterilized after transport. During the
transfer, transport personnel should wear PPE which should not be the
same as worn during the procedure and patients should be wearing N-
95/FFP2 masks and covered with disposable operating sheets.
o Surgeons must be aware of common postoperative complications from
COVID-19 infections. In the presence of fever and one of the symptoms of
a respiratory infection (dry cough, etc.), laboratory tests for COVID-19
diagnosis must be ordered. Suspected cases should be reported
immediately together with transfer of the patient to an isolation ward.

41. o Patients should receive adequate nutrition, fluid hydration, and
electrolyte balance to promote immune recovery and rapid
rehabilitation. Frequent monitoring of temperature, laboratory
Complete Blood Count (CBC), C-reactive protein, and Ferritin level
should be done.
o Severe COVID-19 infection might cause a “cytokine storm
syndrome”, which is characterized by a fulminant and fatal hyper-
cytokinemia with multiorgan failure. An increased level of ferretin
occurs in approximately 50% of patients. All patients with severe
COVID-19 should be screened for hyper-inflammation markers.

42. DISCUSSION
 Patients presented to the emergency triage with an
orthopaedic emergency such as joint dislocations,
compartment syndrome, open fractures, mangled extremity,
polytrauma with FESS should be managed according to a
specific guideline during global health emergencies like a
pandemic of COVID-19.
 These orthopaedic emergencies require effective outpatient,
inpatient and surgical care besides avoiding transmission of
infection to fellow patients and health care givers.

43.  Low- and middle-income countries in Southeast Asia require
a standard protocol that can be followed throughout the
country with minimum resources available to ease burden
over the health care system.
 There are no guidelines published in the past. Hence, this
article can be valuable for the development of a standard
universal guidelines for management these emergencies.

44.  The patient attendees should also be screened for the risk
factors and number of visitors to be restricted. Contact tracing
can also be done with the help of these visitors. The
department of Preventive and Social Medicine and COVID
response team should be involved in this regard.
 To prevent cross-contamination among fellow residents and
faculty, it’s imperative to have a dedicated orthopaedic team
to manage these suspected or diagnosed COVID-19 patients.
This team should comprise of a junior resident, registrar and
consultant.

45.  This team has to manage and follow these patients throughout their
hospital stay including the pre-operative, intra-operative and post-
operative care.
 They are not allowed to attend other patients and remain segregated
from the other department colleagues. We need to have 2–3 such
teams who work according to shifts.
 They should be advised to wear a triple layer surgical mask
(preferably N-95) and hand hygiene to be maintained with the use of
hand sanitizers and frequent hand washing. They must wear full
PPE and should be taught how to wear and remove PPE effectively.

46.  The lesson learned worldwide by orthopaedic surgeons can
benefit India, to stay on top as we plan our approach to
orthopaedic surgery during this pandemic of COVID-19.
 One should always remember that we are a doctor before an
Orthopaedician. We should collectively work with other
departments to face this pandemic.

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49. THANK YOU