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      Strategies in reconfiguration of hand injuries management during COVID-19 pandemic

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          Abstract

          During the COVID-19 pandemic there has been a re-organisation of care provided by the Trauma and Orthopaedic services in the United Kingdom. The National Health Service England (NHSE) speciality guide forms the primary responses to this pandemic, whilst British Society for the Surgery of Hand (BSSH) provides sub-specialty guidance on management of hand trauma. The orthopaedic community's responsibility of providing a continuity of care for patients has to be balanced with measures to reduce risk of viral transmission (e.g. reduce face to face consultations) and also protect ion of both the patients and staff.

          We highlight the strategies applied whilst reconfiguration of hand injury management following publication of COVID-19 British Society for the Surgery of Hand and Indian Orthopaedic Association (IOA) guidelines.

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          Wide awake local anaesthesia no tourniquet technique (WALANT)

          Until recently most hand surgeries was performed with a tourniquet to provide better visibility. The discomfort of the tourniquet is very unpleasant and unnecessary for patients. To avoid this, we have traditionally relied on an anesthesiologist to give sedation, brachial plexus or Bier block, or general anesthesia. A good alternative to traditional tourniquet hand surgery is to use only 2 medications; lidocaine for anesthesia and epinephrine for hemostasis. Lidocaine and epinephrine are likely two of the safest and most widely tested drugs known to mankind. Billions of doses of these two medications have been injected into people for simple dental procedures in dental offices since 1950 with no preoperative testing, no monitoring, no intravenous insertion, and very few adverse events. Epinephrine in the finger is now known to be safe (Lalonde DH, Martin A. Epinephrine in local anesthesia in finger and hand surgery: The case for wide-awake anesthesia. J Am Acad Orthop Surg; 2013;21(8):443). Finger necrosis blamed on epinephrine before the1950s when the epinephrine myth was created is now known to have been caused by procaine. Like dental procedures, wide awake hand surgery can be performed with no preoperative testing, no intravenous insertion, and no monitoring. The patient simply gets up and goes home after the procedure. Advantages for the patient • No cost for time out of work (or need for getting a baby sitter) to go get preoperative testing for sedation • Hand surgery under local is not expensive. Many patients could afford it if they did not have to pay the large expenses associated with sedation • No unnecessary preoperative needles for test, EKG, chest Xray, anesthesia consultations, etc • No unnecessary intravenous insertion • Less time at the hospital for the procedure as there is no recovery time. • No need for the patient to have someone be with him the evening of the surgery as is often mandated after sedation • Get to talk to their surgeon during the surgery for post-operative advice on how to look after the hand, time out of work, etc. • Get to see repaired structures working during the surgery after loss of function such as tendon laceration or Dupuytren’s contracture. This visual memory helps motivate the patient in post-operative therapy and recovery. • No need to endure the unnecessary tourniquet, even for 5 minutes. We tell all our trainees that they need to put a tourniquet on their own arm or forearm for 5 minutes before they ever say something like: “Patients tolerate it well” which really means: “They let me do it even though it hurt” • No need to fast or change medication schedules; particularly helpful in diabetics • Patients with sore elbows, shoulders or backs can position themselves comfortably for the hand and elbow surgery (cubital tunnel release) as there is no tourniquet or anesthesiology equipment in the way • They can just sit up and leave right after the surgery without having to recover from sedation or unnecessary opiates. Advantages for the surgeon • Only one nurse required to perform most simple hand operations such as carpal tunnel release. This greatly increases efficiency, reduces costs, and increases productivity for the surgeon. I can do 2 times the number of cases in the same amount of time at ¼ the cost of traditional tourniquet/sedation hand surgery • The surgeon can move simple operations like carpal tunnel and trigger finger out of the operating room and perform them in the clinic or office with field sterility for greatly improved turnover time and patient convenience • Get to educate the patient during the surgery for better outcomes and fewer complications • Get to make adjustments on repaired tendons and bones after seeing active movement in comfortable cooperative patients before the skin is closed to make sure everything is working well to improve results • Do not have to look after in patients who are admitted after hand surgery because of sedation • Patients with multiple medical problems can be looked after safely and easily as their conditions are not affected by sedation. They walk in, have their hand surgery, and then get up and go home just as they do for a dental filling in a dental office. • Get to set proper tension on tendon transfers before closing the skin • Get to see what is happening with active movement during the surgery in complex reconstructive hand surgery cases to improve results. Why no sedation? • Increased safety: The safest sedation is no sedation • No need for sedation: The only medical reasons patients needed sedation in the past for hand surgery were 1) to tolerate the pain of the tourniquet and 2) to tolerate the pain of injection of the local anesthesia). Those reasons no longer exist as there are now ways to inject local anesthesia with minimal pain. • Major decrease in cost. Hand surgery is not expensive. Safe sedation is expensive. Poor patients can afford hand surgery if the sedation component is eliminated. • Patients can receive education from their surgeon and therapist during the surgery as they have no anamnestic drugs to impair their memory and learning ability (see chapter 7 on patient education during surgery) • Pain free unsedated cooperative patients can take reconstructed parts through a full range of active movement during the surgery and remember how well the reconstructed hand functions. The surgeon can make changes during the procedure to improve the outcome. These functions are particularly important in setting the tension in tendon transfer, making sure there is no gapping and that the tendons fit through the pulleys after flexor tendon repair, and see how stable the fixation is with intraoperative active movement after fracture reduction. • Some patients become uninhibited and harder to manage with small amounts of sedation and end up needing general anesthesia with all its risks. • Sedated patients will not remember intraoperative teaching from their surgeon and miss this excellent communication opportunity.
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            Management of Orthopaedic Patients During COVID-19 Pandemic in India: A Guide

            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 [1], Middle East respiratory syndrome coronavirus (MERS-CoV) in 2012 [2] and novel severe acute respiratory syndrome coronavirus (SARS-CoV-2)-infected pneumonia (COVID-19). The novel coronavirus first emerged in Wuhan, China in December 2019 from the wet seafood market [3]. COVID-19 was regarded as a public health emergency of international concern in the world by mid-February 2019 [4]. The epicentre of the pandemic shifted from Europe to USA from time to time and at present there are around 17.8 lakhs 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. The number of cases and deaths are increasing day by day and the infection is spreading to almost every corner of this world. India is a developing country with around 1.3 billion population, 2nd largest in the world after China. In India, there is one allopathic doctor per 10,926 population [5], which is below WHO’s recommendation of 1:1000 [6], 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. 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. 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. 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. 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. 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. Follow These Steps to Create a Safe Working Environment 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. 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. 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 in-patient 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. 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. 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 guidelines [7, 8]. 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. We depicted these management protocols in our flowchart below. We have postulated guidelines for management of non COVID patients (standard protocol) and COVID positive patients (COVID protocol). Standard Protocol Resuscitate patient, rule out all other injuries (Primary survey). High chances of missed injuries in light of COVID suspicion (Secondary survey). Manage conservatively whenever possible. 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. Maintain a follow up OPD in a separate area for dressing, suture removal and Plaster removal. Covid Protocol Manage conservatively whenever possible. From the triage area patients (separate allocated area for COVID) should be shifted to the operating room. Strict regulations must be maintained while shifting the patients. Sterilize all things that used while shifting, viz. trolley, lift etc. Maintain a dedicated COVID operating room with trained staff. Preventive measures must be followed at every level. Every effort should be made to minimize the duration of surgery. Decrease blood spilling. Proper disposal of surgical waste. Maintain negative pressure ventilation. Patients have to be shifted to dedicated COVID isolation wards postoperatively and discharged only after COVID results are negative. Care must be taken during the hospital stay to physiotherapy, bedsores and DVT prevention. 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. 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. 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. 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. 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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              The use of the mini C-arm in the outpatient setting: evolving practice.

              The mini C-arm image intensifier (mini C-arm) has now become an established diagnostic tool in the hand surgery outpatient department. This study reviews the use of the mini C-arm and formal radiographs (X-rays) in the outpatient hand surgery setting. X-rays provide a standard image whereas the mini C-arm can obtain non-standard images to aid diagnosis and treatment. The mini C-arm enables the clinician to obtain dynamic images and perform interventions such as manipulations or injections. The mini C-arm results in a significantly lower radiation exposure for the patients than a formal X-ray. Use of the mini C-arm may be cheaper, and can lead to a shorter outpatient visit with less travel between hospital departments.
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                Author and article information

                Contributors
                Journal
                J Clin Orthop Trauma
                J Clin Orthop Trauma
                Journal of Clinical Orthopaedics and Trauma
                Delhi Orthopedic Association.
                0976-5662
                2213-3445
                29 May 2020
                29 May 2020
                Affiliations
                [a ]Clinical Fellow in Trauma and Orthopaedics, University Hospital Llandough, Cardiff and Vale University Health Board, Cardiff, Wales, CF64 2XX, UK
                [b ]Trauma and Orthopaedic Surgeon, Southport and Ormskirk NHS Trust, Southport, PR8 6PN, UK
                [c ]Consultant Hand, Wrist and Orthopaedic Surgeon, Southport and Ormskirk NHS Trust, Southport, PR8 6PN, UK
                Author notes
                []Corresponding author. kartikp31@ 123456hotmail.com
                Article
                S0976-5662(20)30207-1
                10.1016/j.jcot.2020.05.020
                7258809
                5b489810-2070-4afe-a788-071799078ef7
                © 2020 Delhi Orthopedic Association. All rights reserved.

                Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

                History
                : 16 May 2020
                : 19 May 2020
                : 19 May 2020
                Categories
                Article

                covid-19,coronavirus,hand injuries,orthopaedics,radiology
                covid-19, coronavirus, hand injuries, orthopaedics, radiology

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