Trauma and Orthopedics in COVID-19 Pandemic: an Epidemiological Study in a Tertiary Center, South of Iran

Introduction: The novel COVID-19 disease was presented at rst in Wuhan, China, in December 2019. During COVID-19 pandemic, approaching trauma patients, whom could have COVID-19, is a challenging issue required special consideration and healthcare setting. Methods and materials: This retrospective cohort study was conducted at Emtiaz hospital, the main trauma center of the south of Iran, between March 2020 and August 2020 from the beginning of the COVID-19 pandemic. Trauma-related data such as the mechanism of trauma, injury pattern, and surgical intervention procedure of all the suspicious COVID-19 patients were documented. ICU admission and mortality rate were investigated as outcome variables. Results: During six months of the pandemic period, 9248 patients were referred to our referral trauma center, with 222 patients suspicious of having COVID-19 infection. Among sixty-four cases, whom were conrmed to be positive, 33 orthopedic injured patients were observed. The mortality rate of COVID-19 positive cases was 15.6 % (10 patients out of 64) and COVID-19 negative ones was 10.1 % (16 patients out of 158) which was not statistically signicant (p.value:0.25). Multivariate analysis of the effect of the baseline and trauma related factors on mortality rate, showed that older age (p. value: 0.001), COVID-19 infection (p. value: 0.033), and surgical procedure (p.value:0.038) are the poor prognostic factors associated with mortality rate. Conclusion: The mortality rate of trauma patients with COVID-19 positive infection was 15.6 % (10 patients). Older age, COVID-19 infection, and surgical procedure were observed as the statistically signicant prognostic factors leading to more mortality rate.


Introduction
The novel coronavirus, called SARS-COV-2, cause of COVID-19 disease, was presented at rst in Wuhan, China, in December 2019 [1]. Soon after that, it was spread out through more than 190 countries with devastating morbidities and mortalities with over 450,000 infected cases and 20,000 deaths, leading the World Health Organization (WHO) to announce this outbreak as pandemic and public health emergency by March 2020 [2,3,4].
The governors and authorities of the affected countries tried their best to legislate every possible action to reduce caseloads, including lockdown measures, strict tra c laws, city blockade, social distancing, and self-isolation at homes to mitigate viral transmission through the vast number of people [2].
COVID-19 cases could be suspected by obtaining their medical history, exposure to the suspicious or infected cases in the past 14 days and observing clinical symptoms including fever, cough and dyspnea [5,6]. Con rmation of the diagnosis is recommended via performing PCR or lung CT scan, which have approximately 83.3 % and 97.2 % sensitivity, respectively [7].
During the COVID-19 pandemic, elective orthopedic surgeries were canceled or postponed and healthcare potential capacities and resources were reallocated and reorganized to support the large-scale number of infected patients with COVID-19. Urgent and emergent orthopedic situations, including trauma, infection, and malignant tumors were in priority besides the COVID-19 pandemic [8, 9,10].
Iran has a high number of motor vehicle accidents, accounting for approximately 20,590 events, annually.
Despite lockdown measures and quarantine rule in the COVID-19 pandemic, a signi cant number of trauma patients referred to orthopedic centers [11]. Dealing with orthopedic trauma patients, whom could have COVID-19, is a challenging issue that requires special consideration and healthcare setting.
Our study aims to shed light on the characteristics of trauma and orthopedic patients with COVID-19 and eliciting different aspects of managing these cases in a single referral trauma center.

Study design
This retrospective cohort study was performed during six months from the beginning of the COVID-19 pandemic between March 2020 and August 2020. Data were collected from Emtiaz Hospital, the main trauma center of southern Iran, which is located at the Shiraz. Since the report of the novel COVID-19 infection in Iran on March 2020, all the trauma patients who are supposed to be admitted or to be observed for over six hours were considered as "probable" for COVID-19 infection.
Stable trauma patients were examined, and precise history was taken for any signs and symptoms of COVID-19 infection or recent exposure to a suspicious case of COVID-19. According to local protocols, all patients were screened by chest radiography, complete blood cell count, Erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP), besides the mentioned history taking and physical examination. If there was any doubt or they had any ndings in favor of COVID-19 infection, they were transferred to special gray zone ward dedicated to probable COVID-19 infected patients and PCR and lung Highresolution computed tomography (HRCT) scan were requested and screened for any possible signs of COVID-19 infection. All unstable patients were considered probable and transferred to a particular intensive care unit (ICU) and were evaluated for COVID-19 by further con rmatory tests such as PCR or lung HRCT.

Data collection
Data of the COVID-19 probable trauma patients were collected from their medical records. Baseline characteristics (including age, sex, comorbidities, history of opium or cigarette smoking) and COVID-19 related data (signs, symptoms and history of exposure to positive or suspicious individuals) were obtained from the registry that belongs to the center of control and prevention of COVID-19 in Fars province, southern of Iran. The trauma-related data including traumatic injuries, need for ICU admission, duration of hospitalization, andoutcome then synced with the mentioned information from their medical records.

Laboratory and radiologic con rmation of COVID-19
Nasopharyngeal and oropharyngeal samples were obtained and checked for SARS-CoV-2 using Real-time reverse transcriptase-polymerase chain reaction (RT-PCR). HRCT was obtained if the chest X-ray was suspicious. HRCTs were reviewed by a trained radiologist. The patients who had a diagnostic pattern of COVID-19 in HRCT or those with positive PCR test were considered as con rmed cases of COVID-19.

Statistical analysis
Data was analyzed by Statistical Package for the Social Sciences version 15.0 (SPSS Inc., Chicago, IL). Descriptive results are presented as mean ± standard for quantitative data and number and percentile for qualitative data. The Chi-square test and T-test were applied to compare different parameters between probable trauma patients with positive and negative paraclinical test results. Univariate and multivariate analyses were used to determine the association of different risk factors, including age, mechanism of trauma, smoking and opium consumption, comorbidities, and COVID-19 infection with outcome factors such as ICU admission and mortality rate.

Results
During six months from the emerging COVID-19 pandemic, 9248 patients were visited in our referral trauma center. As shown in Figure-1, from 222 patients who were suspicious for COVID-19 infection, 64 trauma patients were con rmed by either a HRCT scan or PCR test. Thirty-three patients of the con rmed cases had an orthopedic injury that 23 needed surgical treatment.
Baseline characteristics of the trauma patients with suspicious COVID-19 infection, categorized into COVID-19 negative or positive groups based on their con rmatory tests, are shown in Table.1. The age and sex distribution were similar between the two groups. The most prevalent comorbidities were hypertension, cardiovascular disease, and diabetes mellitus in both groups. The baseline characteristics were similar between positive and negative cases.
Clinical and outcome characteristics of the two groups were presented in Table.2. Among all only history of exposure to a suspicious COVID-19 infectious case was signi cantly higher among the positive cases compared to the negative ones (8 (12.5 %) versus 5 (3.2 %); p.value = 0.012)). The most prevalent signs and symptoms among the patients in both groups were fever, cough, and weakness. One hundred eleven (48.1%) patients had been admitted to ICU and 26 (11.3%) were deceased.
Univariate analysis of the association of the baseline and prognostic factors, including, age, sex, mechanism of trauma, cigarette smoking, opium consumption, COVID-19 infection, and comorbidities with ICU admission was performed which revealed cigarette smoking is the only statistically signi cant factor associated with more ICU admission of the patients. After adjusting for the effect of all the mentioned variables, multivariate analysis showed no signi cant association of any of the parameters with ICU admission. (Table. 3) Univariate analysis of the association of the baseline and prognostic factors, including age, sex, mechanism of trauma, cigarette smoking, opium consumption, COVID-19 infection, comorbidities and surgical procedure with mortality rate was performed which revealed older age and asthma as the only statistically signi cant factors associated with more mortality rate of the trauma patients. After adjusting for the effect of all the aforementioned variables, multivariate analysis showed a signi cant association of older age (p.value: 0.001), COVID-19 positive (0.03), and surgical procedure (0.03) with more mortality rate. (Table. 4) Table.5 illustrates the characteristics of the trauma patients who needed orthopedic intervention. Twentyfour (72.7%) cases had tra c accidents while the remaining 9 (27.3%) ones happened by falling. The most prevalent sites of injury were pelvic and acetabulum (10 cases), femur (11 cases), and clavicle (7 cases). Twenty-three patients were treated surgically with a mean admission to surgery duration of 8.2 ± 6.8 days. The mean operation duration time was 3.1 ± 2.0 hours.
Sixty-four con rmed cases showed a history of exposure to suspicious and symptomatic people at a higher rate compared to the 158 COVID-19-negative cases, which was statistically signi cant. (12.5 % to 3.2 %. p.Value = 0.012). This could lead us to be more cautious about approaching a patient with a history of exposure by not only providing more personal protective equipment for medical staff, but also taking immediate actions toward the isolation of these patients from other unsuspicious ones.
The most prevalent comorbidities among our studied patients were hypertension, diabetes mellitus and cardiovascular disease, similar to the previous reports [13,15,16].
We observed different age and injury patterns compared to the other studies in COVID-19 pandemic reporting the mean age of 67 years or older [10,15,16], and demonstrating low energy trauma as the most common mechanism of trauma [12,17,18]. Mean age of the patients in our study was 42.5 and 80 % of them were men, most were the victims of motor vehicle accidents (MVA) (72.7%). Besides, One study from Iran showed the mean age of the studied patients was 38.6, and high energy trauma was the main cause (8 patients out of 13) [11]. Noteworthy, it could be concluded that despite government legislation of lockdown measures, strict tra c laws, and self-isolation at home, the MVA still has a devastating impact and the utmost role, giving rise to traumatic injury to the patients in Iran during the COVID-19 pandemic.
Among 64 con rmed cases, 33 showed orthopedic injuries, mostly comprised of the pelvis and acetabulum, clavicle, and pertrochanteric fractures (10, 7, and 6 patients, respectively). Among the patients with orthopedic injuries, 24 (72.7%) ones were the victim of MVA and 9 patients were injured due COVID-19 negative patients with concomitant hip fracture showed 9.8 % (8 patients) ICU admission in COVID-19 positive case compared to 0.9 % (3 patients) in COVID-19 negative ones, not presenting poor prognostic factors associated with more ICU admission [10]. We observed no signi cant association with any baseline and prognostic factors with more ICU admission. While, a study of 34 COVID-19 patients, who had been operated, with an ICU admission proportion similar to our study (44%), stated that patients with comorbidities such as HTN and CVD, older age and the more complicated surgery have increased risk for admitting to the ICU [13]. Of note, the ICU admission rate among COVID-19 patients without surgery is documented at 26 % in the literature [19]. While the proposed reason for the mentioned results of previous reports could be that any surgical procedure brings about immune system compromise and jeopardize multi-organ functions resulting in the need for more ICU care, it should be taken into account that our surgical procedures were performed after ICU admission of the trauma patients. One explanation for the observed nonsigni cant effect of associated comorbidities on the rate of ICU admission among our patients, may be rooted in the lower mean of their age compared with the aforementioned studies. 11.7 % (26 patients) of 222 patients were expired during hospitalization. The hospital-associated mortality rate of the COVID-19 positive cases with concomitant orthopedic trauma was 15.6 % (10 patients) which was in contrast to previous reports by Jain (36.3 %), Kayani (30.5 %), and Maniscalco (43 %) [10,16,20]. The most logical explanation could be the younger population of our study (mean age: 42) comparing to the mentioned studies. One study on 34 COVID-19 patients who underwent surgery with closer age distribution (median age: 55) to ours, showed a 20.5 % mortality rate [13]. Meanwhile, it should be mentioned that case fatality rate of COVID-19 patients without surgery is 2.3 % [21]. After a multivariate analysis of risk factors association with the mortality rate in the suspicious COVID-19 patients with trauma, it was determined that older age, COVID-19 infection, and surgical procedure are poor prognostic factors. However, Kayani et al. showed cigarette smoking and multiple comorbidities, and Lei et al. proposed more complicated surgeries and medical comorbidities as detrimental factors associated with more mortality rate in their study population [10,13]. One of the most important ndings of our study was that the presence of COVID-19 showed signi cant association with more mortality rate among trauma patients, which was similar to Kayani's report [10].

Strengths and limitations
We conducted a retrospective cohort study with a medium-sized sample of suspicious COVID-19 and trauma patients in a center with a high volume of incoming trauma patients from south of Iran, which evaluated 9248 trauma cases in a six months pandemic period. This large-scale referred patients to our hospital is an e cient representative of the Iranian people's pro le regarding COVID-19 status during the pandemic. The other strength of our study could be using two con rming tests (HRCT and PCR) to increase more diagnostic accuracy and sensitivity.
One of the limitations was that asymptomatic carriers of COVID-19 disease were not investigated due to the lack of enough available PCR kits. Meanwhile, the incubation period of COVID-19 infection is stated to be 14 days, and trauma patients need to be managed urgently and any delay in surgical treatment may accelerate or exacerbate their current condition and leading to the poor functional outcomes [14,22]. The other limitation was that any developing signs and symptoms in suspicious cases after their hospital course were not assessed. The study has not any source of funding.      Figure 1 Diagram of orthopedic trauma patients during six months from COVID-19 pandemia in our referral trauma center. N: Number