Patterns of Adult and Paediatric Hand Trauma During the COVID-19 Lockdown.

Dear Sir,

The first reported cases of the novel Coronavirus SARS-CoV-2 (COVID-19) emerged from Wuhan, the capital of Hubei province (China) in December 2019. At the time of writing, there have been 201,101 laboratory confirmed cases in the United Kingdom (UK), with 30,076 associated deaths. The UK response on the 23rd March 2020 was to impose a nationwide lockdown to prevent the transmission and spread of the virus. This involved the closure of all non-essential businesses, schools and nurseries, strict limitations on non-essential travel, one-hour limit on outdoor exercise, and the concept of social distancing.

We performed a single tertiary trauma centre comparative cohort study to examine referral patterns of hand injuries, and whether enforced changes would result in a change in the aetiology of presenting hand trauma.

Two cohorts of patients were identified; a prospective cohort (Cohort-P) during the COVID-19 lockdown period from 23rd March 2020 to 26th April 2020, and a retrospective cohort (Cohort-R) as a comparison from 18th March 2019 to 21st April 2019 (this time last year). All patients (adults

and paediatric) with upper limb injuries referred for surgery were identified. Patients that were subsequently managed non-operatively on the day of surgery were still included. We collected demographic data for each patient, the mechanism and aetiology of their injury, and where the injury occurred. We grouped the injury aetiologies in to 15 different broad categories and location was grouped into either ‘domestic’ or ‘workplace’.

A total of 109 adult patients were referred and scheduled for surgery during the COVID-19 lockdown period (Cohort-P), 248 patients in Cohort-R; an overall reduction of 56.0% (p<0.0001) (Fig. 1 ). There were no differences in the distribution of age and sex between cohorts. The aetiology of injuries is shown in Table 1 . There was a significant increase in injuries sustained from using tools at home from 2.0% in Cohort-R to 11.9% in Cohort-P (p=0.002). There was no change in the proportion of injuries sustained at work with tools [6.0% and 5.5%, p=1.00]. There was a reduction in injuries to the hand at the workplace from 5.2% to 1.8% although this did not quite reach statistical significance (p=0.16).

Fig. 1

Total number of new cases listed for surgery each week since COVID-19 lockdown commenced on the 23rd March 2020 (Cohort-P) compared to the same period in 2019 (Cohort-R)

Table 1

Grouped aetiologies of injuries sustained by all patients during the COVID-19 lockdown period (Cohort-P) and the same time last year (Cohort-R).

Injury Aetiology	Cohort-R (n)	(%)	Cohort-P (n)	(%)	p-value
Animal Bite	16	6.5	8	7.3	0.82
Domestic hand injuries	65	26.2	29	26.6	1.00
Deliberate self-harm	7	2.8	6	5.5	0.23
Falls	29	11.7	14	12.8	0.73
Infections	22	8.9	7	6.4	0.53
Injury from tools at home	5	2.0	13	11.9	0.002
Injury from tools at work	15	6.0	6	5.5	1.00
Interpersonal violence	16	6.5	5	4.6	0.63
Other	2	0.8	3	2.8	0.17
Paronychia	10	4.0	1	0.9	0.18
Punch injuries	13	5.2	6	5.5	1.00
Road traffic accidents	7	2.8	2	1.8	0.73
Surgical complications	7	2.8	2	1.8	0.73
Sports injuries	21	8.5	5	4.6	0.27
Workplace hand injuries	13	5.2	2	1.8	0.16
Total Count	248		109

There was a total of 31 paediatric injuries in Cohort-R and 6 in Cohort-P; a reduction of 80.6%. There was no significant change in any of the grouped aetiologies of injury between the two cohorts, see Table 2 .

Table 2

Grouped aetiologies of injuries sustained by paediatric patients during the COVID-19 lockdown period (Cohort-P) and the same time last year (Cohort-R).

Injury Aetiology	Cohort-R (n)	(%)	Cohort-P (n)	(%)	p-value
Domestic hand injuries	18	58.0	3	50.0	0.26
Infections	2	6.5	0	0.0	1.00
Interpersonal violence	1	3.2	0	0.0	1.00
Paronychia	2	6.5	0	0.0	1.00
Punch injuries	1	3.2	1	16.7	0.30
Sports injuries	7	22.6	1	16.7	1.00
Surgical complications	0	0.0	1	16.7	0.16
Total Count	31		6

The results show that our overall adult and paediatric caseload has decreased during the lockdown, but there has been a significant increase in the proportion of injuries associated with using tools at home (p=0.002). These were related to the use of circular saws, angle grinders, lawnmowers, chainsaws, hammers, electric planers, and hand saws. We also noted an increase in deliberate self-harm (DSH) injuries from 2.8% to 5.5%. Although this was not statistically significant (p=0.23), this is in keeping with evidence that social isolation can lead to an increase in depression, suicidal ideation, and low self-esteem. This vulnerable group may require additional support form primary care and mental health services during and after the lockdown period to reduce their risk of self-harm. The overall reduction of cases may also be explained by less referrals made by A&E, that may have dealt with cases that previously would have been referred.

As the UK government seeks to relax the COVID-19 lockdown incrementally, we can anticipate an upsurge in trauma cases, but also secondary spikes in COVID-19 cases, putting further pressure on NHS resources. Our study shows that there is a change in the aetiology of presenting hand trauma cases and also the need for more resources to prevent the spike in DSH cases. This can provide a framework for how units can manage resources and organise services when similar situations arise. We urge the public to be aware of the potential dangers associated with using tools at home, and emphasise the importance of receiving safety training, use of protective equipment, taking adequate breaks, and limiting working hours in order to prevent avoidable severe injuries.

Declarations

The authors of this article do not have any conflict of interest nor received any funding for this work.