The COVID-19 Pandemic: The effect on hand trauma in Europe's busiest major trauma centre.

Dear Sir,

The World Health Organisation (WHO) declared the COVID-19 outbreak as a global emergency on the 30th January 2020. Healthcare systems have had to rapidly expand their intensive care capacity to meet the demands for ventilatory support. By mid-April, London had expanded its ICU capacity by over one-third. Treatment of non-COVID-19 related conditions, including hand surgery, has had to adapt to conserve health resources and protect both healthcare professional and patient from nosocomial virus exposure. All elective surgery has been cancelled and the management of hand trauma has had to become more streamlined to still provide a service to urgent cases despite a reduction in facilities and staffing.

We report our experiences of managing hand trauma during the COVID-19 pandemic in a London major trauma centre (MTC), the highest tier of trauma care within the regional network and the busiest centre in Europe.

We performed a retrospective study of hand trauma patients presenting to our MTC during the first four weeks of lockdown. Patient data was collected for the same dates in 2019 to provide a control group. All adult patients that presented to the hospital between 24th March and 19th April 2020, with trauma to the hand or forearm requiring operative intervention, were included.

50% of plastic surgery clinicians were redeployed to ICU at the start of lockdown, elective surgeries were postponed and hand trauma moved to the private sector. Clinics were rationalised, with the majority of elective and follow-up cases reviewed virtually.

We observed a 62% reduction in ED presentations from 24th March to 19th April 2020 compared to the equivalent time frame in 2019. Plastics referrals were similarly reduced by 63%. 23% of patients referred during lockdown required operative intervention, compared with 31% in 2019.

Injuries sustained were similar between cohorts and included fractures, tendon, nerve or vessel injury, infections and fingertip insults. The 2019 cohort had a variety of injury mechanisms, whereas the majority of the lockdown cohort occurred from household incidences (Figure 1 ). The location of injury was significantly different between cohorts (at home versus outside the home), 24% of the 2019 cohort occurred at home, compared with 67% of the lockdown cohort (p<0.05, Fisher's exact test).

Figure 1

Mechanism of injury by patient cohort.

All included patients underwent an operation in a theatre environment. Time to surgery (from presentation) and first hand therapy appointment (from surgery) varied according to condition (Table 1 ). We identified a significant reduction in the time to fracture operations during lockdown (p=0.022, MWU test) and a non-significant reduction for tendon repairs. There was also a significant reduction in the time to hand therapy (tendons p=0.0012 and fractures p=0.0003, MWU test).

Table 1

Breakdown of most common injuries sustained, time to surgery and hand therapy for each condition (average, measured in days).

Injury	2019			2020
	Frequency	Time to surgery (days)	Time to hand therapy (days)	Frequency	Time to surgery (days)	Time to hand therapy (days)
Extensor Tendon	14	4.2	16	5	3.6	4.3
Flexor Tendon	12	3.7	7.2	8	3.4	4.4
Digital Nerve	12	4.5	10	5	3.4	4.6
Fingertip injury	7	5.4		2	4.5
Infection	11	1.3	6.5	1	1
Closed fracture	41	6.27	18.3	5	4.4	6.7

Our unit saw a significant drop in ED attendances and hand trauma presentations during lockdown, likely resulting from fewer people partaking in higher risk activities (construction work, sport, driving) and fewer people on the streets (altercations, assaults). This is in concordance with Metropolitan Police data, who report a 13% reduction in total offences and a 6.2% decrease in violent offences across London in March 2020 compared with March 2019. We have noticed an increase in the proportion of injuries taking place at home, likely as a result of individuals taking up DIY, gardening or cooking-related activities. BAPRAS predicted this and a social media campaign was carried out to encourage people to avoid such injuries. Our results suggest that this campaign has been beneficial: although the proportion of household injuries has increased, the frequency has reduced.

The reduction in hand trauma presentations combined with the halting of elective surgeries has allowed us to deliver a more efficient service. We have noticed a significant decrease in the time to surgery and to hand therapy. The improvement is likely as a result of the move to private sector operating, where theatres are booked according to trauma workload on a day-to-day basis. The shift to one-stop assessment and treatment clinics has also been beneficial. The delay to hand therapy in 2019 is of concern and is a result of prolonged underfunding and short-staffing levels in the therapy department. Interestingly, despite the loss of further therapists during the pandemic, delays have improved as a result of virtual clinics and the cancellation of elective cases.

There are many lessons to learn in hand surgery following COVID-19. It is imperative that trusts continue to foster the energy, enthusiasm and resultant innovation that has been so prevalent amongst all healthcare staff during this terrible global pandemic.

Our unit will be retaining the following improvements:

Same day trauma clinic assessments and operations for cases likely requiring surgery.

The use of virtual clinics for routine assessments and hand therapy follow ups.

Use of WALANT or regional anaesthesia where possible.

One-stop follow up clinics with combined hand surgery and therapy assessment post operatively.

Funding

None.

Ethics approval

Not required.

Declaration of Competing Interest

None.