Expert consensus on management principles of orthopedic emergency in the epidemic of Corona Virus Disease 2019

Orthopedic Trauma Branch of Chinese Orthopaedic Association; External

Fixation and Limb Reconstruction Branch of Chinese Orthopaedic

Association; Trauma Expert Committee of Chinese Association of

Orthopedic Surgeons; Pei-Fu Tang1, Zhi-Yong Hou2, Xin-Bao Wu3,

Chang-Qing Zhang4, Jun-Wen Wang5, Xin Xing2, Zeng-Wu Shao6, Ai-Xi

Yu 7, Gang Wang8, Bin Chen8, Ping Zhang8, Yan-Jun Hu8, Bo-Wei Wang8,

Xiao-Dong Guo6, Xin Tang9, Dong-Sheng Zhou10, Fan Liu11, Ai-Mi

Chen12, Kun Zhang13, Kai-Nan Li 14, Yan-Bin Zhu2

1Department of Orthopaedics, Department of Orthopaedics, The First

Medical Center, Chinese PLA General Hospital, Beijing 100853, ;

2Emergency Center of Trauma, Third Hospital of Medical

University, Shijiazhuang, Hebei 050051, China;

3Department of Traumatology and Orthopaedics, Beijing 100035, China;

4Department of Orthopaedics, the Sixth People’s Hospital Affiliated to

Shanghai Jiaotong University, 200233, China;

5Department of Orthopaedics, Wuhan Fourth Hospital, Wuhan, Hubei

430034, China; 6Department of Orthopaedics, Union Hospital Tongji Medical College

Huazhong University of Science and Technology, Wuhan, Hubei 430022,

China;

7Department of Trauma Microsurgery, Zhongnan Hospital of Wuhan

University, Wuhan, Hubei 430071, China;

8Department of Orthopaedics and Traumatology, Nanfang Hospital,

Southern Medical University, Guangzhou, Guangdong 510515, China;

9Department of Orthopaedics, The First Affiliated Hospital of Dalian

Medical University, Dalian, Liaoning 116011, China;

10Department of Orthopedics, Shandong Provincial Hospital, Jinan,

Shandong 25002, China;

11Department of Orthopedics, Affiliated Hospital of Nantong University,

Nantong, Jiangsu 226001, China;

12Department of Orthopedics, Changzheng Hospital Affiliated to Naval

Military Medical University, Shanghai 200003, China;

13Department of Orthopaedics, Honghui Hospital Affiliated to Medical college of Xi’an Jiaotong University, Xi’an 710054, , China;

14Department of Orthopaedics, Affiliated Hospital of Chengdu University,

Chengdu, Sichuan 610081, China

Pei-Fu Tang, Zhi-Yong Hou and Xin-Bao Wu were contributed equally to this article

Correspondence to: Prof. Yu Bin, Department of Orthopaedics and

Traumatology, Nanfang Hospital, Southern Medical University,

Guangzhou, Guangdong 510515, China; Email: [email protected]; Prof.

Bao-Guo Jiang, People's Hospital of Peking University, Beijing 100044,

China Email: [email protected]; Prof. Ying-Ze Zhang,

Emergency Center of Trauma, Third Hospital of Hebei Medical

University,Shijiazhuang, Hebei 050051, China; Email: [email protected]

Since December 2019, some hospitals in Wuhan, Hubei province, have admitted many cases of pneumonia with unknown causes with a history of exposure to Huanan seafood market.[1] The patients' symptoms include fever, weakness, dry cough and gradually dyspnea. A part of severe patients developed acute respiratory distress syndrome or septic shock, and even death. On January 7, 2020, Chinese researchers have for the first time detected a new coronavirus from patient’s samples.[2] On

January 20, 2020, the National Health Commission issued Announcement

No. 1 of 2020, which included the new coronavirus pneumonia as a Class

B infectious disease, and conducted epidemic prevention and control according to the Class A infectious disease[3]. The World Health Organization has named the new coronavirus pneumonia “COVID-19”

(Corona Virus Disease 2019). Meanwhile, the Coronavirus Study Group

(CSG) of the International Committee on Taxonomy of Viruses named the new Coronavirus “SARS-COV-2” (Severe Acute Respiratory Syndrome

Coronavirus 2).[4]

By 24:00 on February 18, 2020, China had confirmed a total of 74, 185 cases with new coronavirus pneumonia, 5, 248 suspected cases, 14, 376 cured cases, 2, 004 deaths, and a total of 574, 418 close contacts. [5]

During the epidemic, many provinces and cities implemented strict control measures to limit the flow of personnel, effectively preventing the further spread of the epidemic, reducing the risk of fracture caused by high energy trauma, and subsequently reducing significantly the number of fracture patients. However, the fractures caused by low energy accidental falls at home occur frequently, especially for the elderly who are unable to move easily. Academician Zhong Nanshan points out that the incubation period of the new coronavirus pneumonia is 1-14 days, and the longest is 24 days[6]. Therefore, there may be virus carriers or asymptomatic infected cases among these fracture patients. Medical institutions at all levels should pay enough attention to prevent the occurrence of hospital cluster transmitted events. According to the current situation of epidemic prevention in China and the principles of emergency surgery of orthopedic traumatology, the expert group formulated the Expert Consensus on emergency orthopedic surgery during the epidemic of new coronavirus pneumonia.

Reception of orthopedic emergency cases

Orthopedic emergency patients often sustain injuries to the extremities, pelvis and spine, etc. These patients cannot move independently. If patients have serious injuries such as open fractures and multiple trauma, a more comprehensive and detailed physical examination is required.

However, during the special duration of epidemic, the doctors’ contact examination with low-grade protection will greatly increase the risk of infection between doctors and patients. Therefore, in the course of diagnosis and treatment, doctors should strictly prevent themselves and patients from affected by virus. Firstly, correctly wear surgical masks, work caps, overalls, isolation clothes, latex inspection gloves and goggles.

Secondly, the stethoscope, thermometer, percussion hammer, protractor and other tools should be strictly sterilized following the standard of "one person, one disinfection". Thirdly, the consultation room should be disinfected at least twice a day. When suturing small wounds in the daytime operating room, doctors should wear goggles and double gloves in addition to their usual operating clothes and isolation clothes. Patients are also required to wear surgical masks and goggles during diagnosis and treatment. If medical supplies are insufficient, plastic masks or plastic films can also be used instead of goggles.

All patients should be divided into four categories according to the following criteria. Type I, the patients had not traveled in the epidemic area within 14 days, had no history of direct or indirect contact with people from the epidemic area, and lived in the neighborhoods without suspected or confirmed new coronavirus pneumonia patients. The patients had no clinical symptoms, and all laboratory tests, imaging examination and new coronavirus nucleic acid tests of nasopharyngeal swabs were negative. Type II, the patients had a history of direct or indirect contact with people from the epidemic area within 14 days, or patients live in the neighborhoods where there were suspected or confirmed COVID-19 patients. The patients had no clinical symptoms related to COVID-19, and all examinations were negative. In the past 2 weeks, none of the close contacts with the patients had clinical symptoms related to COVID-19. Type III, the patient is diagnosed as a suspected case of COVID-19 according to the diagnostic criteria of the sixth edition of "Diagnosis and treatment plan of pneumonia infected by new coronavirus" issued by the National Health Commission. Type IV, the patient is diagnosed as a confirmed case of COVID-19 according to the diagnostic criteria of the sixth edition of "diagnosis and treatment plan of pneumonia infected by new coronavirus".

Perioperative prevention and control measures for patients in orthopedic emergency conditions

During the epidemic period of new coronavirus pneumonia, orthopedic emergency patients should be assessed by both the orthopedic surgeons and the specialist to assess the risk of new coronavirus pneumonia infection. The prevention measured should be adopted in strict accordance with the risk level of infection prevention and control. For type I patients in the above-mentioned classification, medical staff adopt first-level protection measures. For type II patients, they adopt second-level protection measured. For type III and IV patients, they should be transferred to designated hospitals for new coronavirus pneumonia treatment. When the patients are considered unable to be referred, the medical staff shall adopt the third-level protection.

The first-level protection measures include strict adherence to the standard prevention principles, strictly abiding by the rules and regulations of disinfection and isolation. Medical staff wear work caps, surgical masks, overalls and isolation clothes. Wear disposable gloves during physical examination. Wear latex gloves and goggles or protective screen during dressing change.

The second-level protection measures are established on the basis of the first-level protection. Healthcare workers must wear medical protective masks, double-layered gloves and shoe covers. Perioperative patient management: 1. The single ward would be preferred for this type of patients, who should be treated and cared by specially-designated medical staff. The medical staffs in the operating room and anesthesia department should be informed that the patient without manifestations of coronavirus disease has a history of close contact with those exposure to virus. During hospital stay, the relevant tests and examinations should be performed regularly for patients. If fever or respiratory symptoms occur in the patient, relevant tests and examinations should be performed without delay. Once confirmed as patients infected by new coronavirus, the patient should be immediately transferred to the designated hospital. 2.

The patient must be transferred with the use of specialized lcheelstretoher, disposable protective cover, specialized channel and specialized elevator.

Operating room management: A separate negative-pressure operating room is arranged for the patient and thoroughly disinfected with two methods of disinfection after surgery.

The third-level protection measures are established on the basis of the second-level protection. Healthcare workers must wear protective clothing, whole-face masks, waterproof boots and shoes covers. Patient management: 1. During the procedure of patient transport, the patient must wear disposable sleeves and socks in order to avoid direct contact with any lcheelstretoher, elevator or other goods. 2. If a doctor is responsible for many patients, he/she should change the isolation clothing, outer gloves and shoe covers after examining one patient to prevent the occurrence of cross-infection. The principle for disposing clinical waste:

All disposable medical supplies used for patients during the whole perioperative periods should be disposed after surgery according to the standard of "one patient, one bag". And the clinical waste should be disposed in accordance with the national requirements.

The surgeon in charge of the patients should report the patients’ condition to the medical affairs department and nursing department in time. At the same time, the surgeon must inform the director of the surgical department and the anesthesiologist by phone. The words " Corona Virus Disease suspected case" should be clearly marked on the surgical notice.

Discuss with the anesthesiologist the method of anesthesia. If nerves-block anesthesia is appropriate for the surgery, do not perform general anesthesia with tracheal intubation. The anesthesiologist should comply with the rules of the third-level protection.

The operation should be performed in a specialized negative-pressure operating room. The laminar flow and air-conditioner must be turned off to avoid cross-infection with other operating rooms. In principle, the surgeries performed on Corona Virus Disease suspected cases are better to be arranged in one specialized operating room and do not use other rooms. The air conditioner units in the operating room need to be dealed with daily cleaning and disinfection. In addition, the filter screen of air inlet and outlet also need daily disinfection. In the surgical intervals or after a day of surgeries, spray the air inlet with chlorine-containing liquid disinfectant (1000 mg/L) and start the purification units to clear the air of the operating room for more than 1 hour. Wipe the floor and object’s surface with chlorine-containing liquid disinfectant (1000 mg/L). The devices unable to tolerate chlorine disinfectants can be wiped with 75% alcohol. Use ultraviolet radiation to make air sterilization.

In each operating room, skilled OR nurses are arranged according to the operations’ type in order to facilitate the operation and shorten operative time. During the operation, it is better not to use electrotome devices which will create the smoke. Because the smoke may form into aerosol that will increase the infection risk of medical staff. Surgeons and nurses should avoid sharp instrument injuries during the surgery. Surgical mask is usually replaced every 4 hours and must be replaced immediately when contaminated or wet. If protective clothing, isolation clothing, gloves or goggles are spilled on or contaminated with patients' body fluids or blood, they should be replaced immediately according to the standard procedures.

Report the condition of type IV patients, who are diagnosed with Corona

Virus Disease, to superior departments in time. The patients who are not life-threatened in a short time should be quarantined under specialized supervision and transferred to the designated hospital for further treatment. The patients in danger of life should be rescued in the isolated area following strict third-level measures and transferred to designated hospital after vital signs are stable. All medical staff participating in the treatment process must receive medical observation for at least 14 days on the basis of the third-level protection.

Treatment options

For orthopedic emergency patients, who are suspected or confirmed cases to be infected with the new coronavirus, multidisciplinary collaboration from respiratory department, intensive care unit, and anesthesia department are required to evaluate the patient's general condition and perioperative risks. Manual reduction and brace or plaster fixation can be tried for the majority of traumatic fractures of four extremities. Minimally invasive techniques are also recommended for fracture fixation in a fast fashion, such as closed reduction and external fixation or homeopathic bi-direction traction reduction technique. While restoring the length of the limbs and correcting the deformity, the third purpose is to reduce the pain of patients. There are three key points. Firstly, the reduction and alignment of the fractured limbs should be maintained after fracture deformity corrected. Secondly, reduce the patient's pain as much as possible without obvious psychological discomfort. Thirdly, ensure that the fracture is fixed stably. For patients with active bleeding at the site of the fracture, those over 65 years old and in poor physical condition, as well as those with pelvic fracture, spine fracture, or complex fractures of the limb, nutritional support such as blood or albumin transfusion should be given if necessary. If the patient has an open fracture, debridement should be done carefully during the operation. To prevent the occurrence of local soft tissue secondary damage caused by the shearing force at the fracture end, an external fixation can be used for stable fixation. It is at high risk for patients with active bleeding receiving anticoagulant drugs.

Instruct patients to strengthen passive or active activities of both lower limbs to prevent deep vein thrombosis.

Summary

During the current epidemic of COVID-19, the treatment of orthopedic emergencies should fully consider the epidemic situation, and the rules and regulatory regime for the prevention and control of new coronavirus pneumonia. Orthopedic emergency should be managed following the infectious disease prevention and control procedures. Simple and effective treatment should be applied to complete bone and soft tissue repair.

Members for consensus formulating (sorted by last name):

Wei-Jun An, Zheng-Gang BI, Shan-Bao Cai, Xian-Hua Cai, Xue-Cheng Cao, Bing-Fang Cao, Yi-Min Chai, Ai-Min Chen, Hua Chen, Wei-Gao

Chen, Yan-Xi Chen, Yun-Zhen Chen, Zhong Chen, Bin Chen, Peng Chen,

Lei-Ting Chi, Xiao-Qian Dang, Zhen-Qi Ding, Jing-Ming Dong,

Guo-Feng Fan, Shi-Yuan Fang, Gao-Peng Fu, Li-Qiang Gu, Rong-Guang

Guo, Xiao-Shan Guo, Yang Guo, Xiao-Dong Guo, Zhi-Yong Hou,

Fu-Guo Huang, Lei Huang, Yan-Jun Hu, Ji-Hong Ji, Ji-Fang Quan,

Shi-Kong Jia, Yan-Fei Jia, Bao-Guo Jiang, Xie-Yuan Jiang, Yu-Hua Jing,

Qing-Lin Kang, Rong Kong, Jun Li, Kai-Nan Li, Lin-Qi Li, Wei-Xu Li,

Jia-Li Liang, Qi-Lin Liao, Fei Feng, Peng Lin, Sheng-Yuan Lin, Ye Liu,

Guang-Yao Liu, Guo-Hui Liu, Li-Min Liu, Yong Liu, Zhi-Luo Liu,

Cong-Feng Luo, De-Cheng Lyu, Gang Lyu, Xin Lyu, Zhi Lyu, Bao-Tong

Ma, Xian-Zhong Ma, Xin-Long Ma, Jiang-Dong Ni, Wei-Dong Ni,

Zhi-Jun Pan, Guo-Xian Pei, A-Qin Peng, Jian Qi, Hong-Bo Qian,

Yong-Jun Rui, Xi-Guang Sang, Jian Shang, Lin Shao, Zeng-Wu Shao,

Qing-Xuan Shi, Heng-Sheng Shu, Zhao-Hui Song, Da-Hui ,

Yu-Qiang Sun, Yue-Hua Sun, Xin Tang, Jian Tang, Pei-Fu Tang, Ran Tao,

Yu-Liang Wang, Ai-Guo Wang, Bao-Jun Wang, Dong Wang, Gang Wang,

Guang-Lin Wang, Guo-Xuan Wang, Lei Wang, Li-Min Wang, Man-Yi

Wang, Peng-Cheng Wang, Qiu-Gen Wang, Yue Wang, Jun-Wen Wang,

Bo-Wei Wang, Liang-Yuan Wen, Bo Wu, Dan-Kai Wu, Duo-Qing Wu,

Ke-Jian Wu, Xin-Bao Wu, De-Ming Xiao, Zeng-Ru Xie, Zhao Xie, Ming-Guo Xu, Wei-Guo Xu, Yong-Qing Xu, Xin Xing, Hua-Qing Yang,

Jun Yang, Lei Yang, Ming-Hui Yang, Sheng-Song Yang, Qi Yao, Fa-Gang

Ye, Jun-Jian Ye, Bin Yu, Bao-Qing Yu, Ai-Xi Yu, Zhi Yuan, Ying-Chao

Yin, Bao-Zhong Zhang, Dian-Ying Zhang, Jian-Ning Zhang, Jian-Zheng

Zhang, Jin-Li Zhang, Kun Zhang, Li-Hai Zhang, Qun Zhang, Shu-Ming

Zhang, Wei Zhang, Ya-Kui Zhang, Yi Zhang, Ying-Ze Zhang,

Chang-Qing Zhang, Ping Zhang, Jin-Min Zhao, Wen Zhao, Long-Po

Zheng, Dong-Sheng Zhou, Fang Zhou, Jun-Lin Zhou, Shi-Wen Zhu,

Yong Zhu, Yan-Bin Zhu, Yan Zhuang, Yun-Qiang Zhuang

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