Fractures in the Times of Corona in Elderly: Challenges

Being an elderly in itself is a huge risk factor for various medical conditions such as diabetes and hypertension and as well for fractures. With the world finding itself in the clutches of the Corona virus, it has become ever more difficult to stand up to the challenges in treating an elderly with a fracture, suffering from various comorbidities with topping of COVID-19.

With no dearth of information about Corona virus, most of us have come to understand that it is the elderlies in our population who are most susceptible not only to contract infection and suffer most complications but they are also the most common to succumb to the novel Corona virus.

Fractures of the hip are one of the most common orthopedic injuries in elderly. Hip fractures were considered a death sentence in elderlies before the era of internal fixation started. Hip fracture patients were treated with traction on a complete bed rest. An elderly already suffering from multiple age related comorbidities would soon develop bed sores, chest complications with decrease in lung capacity and oxygen diffusion.

An orthopedic surgeon has to not only fix the fracture in a grossly osteopenic bone but also to manage comorbidities and prevent complications. With the general population increasingly getting infected with COVID-19, an orthopedic surgeon has to face new challenges.

We also have to deal with the fear of the Corona virus not only among the healthcare staff but also the attendants and relatives. All of us are reluctant to see a corona patient let alone handle and provide healthcare.

Here we will exemplify the above mentioned situation with such a similar case we had in our hospital. We received an 83 year old frail, old gentleman in our emergency room with the history of fall at home. One look at the patient and no one would bet his money on him. Patient was managed well and examined, diagnosed with fracture of right femur at the trochanteric level and admitted to the orthopedic unit. All routine investigations and COVID-19 investigations were sent for. All routine investigations were in normal limits for the age and as the patient was being optimised for surgery next day waiting for COVID-19 report which came out positive. 

This report threw everything out of gear, the patient was shifted to quarantine, nursing staff were removed and sent for quarantine, patient was transferred and treated under pulmonologist, attendants and relatives self quarantined themselves in their homes. The priorities changed. 

That frail eldery 83 year old looking gentleman who had a right hip fracture,was bed ridden now had a bigger enemy to fight. Soon with the proper care and treatment he turned COVID-19 negative in a few days and was tested twice to confirm it. Patient successfully underwent hip surgery and was so positive with energy that when he was discharged a few days after surgery, he went home walking with the help of support.

A recent article published in COVIDSurg collaborative under the heading 

Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

revealed 

“Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery.”

Though we must avoid or delay surgery in a COVID-19 positive patient, at times it is imperative to undertake the surgery as not doing so poses a bigger risk to the life of the patient.