How Do You Treat a Hip Fracture in the Times of COVID-19?

The good news is that most of the fractures and the bone injuries will not need any urgent surgery during COVID and most fractures can be treated without any surgery. Several fractures or joint/ ligament injuries that were surgically fixed in the pre-COVID period are now conservatively treated or deferred for a later date and understandably so.

Let me give you a few examples: A fracture of the wrist was surgically fixed so that you could go back to work as soon as possible.

That’s mainly because, a conservative treatment most of the time implies, that you should don a plaster in the hand and arm for 6 weeks.

A shoulder fracture like a collar bone fracture was fixed so that you don’t have to restrict your shoulder movements for 6 weeks and you could start work sooner; a leg fracture was fixed so that you don’t have to carry around your leg and knee in a plaster for 6 weeks.

All these priorities seem to have been reversed now.

Plaster in the hand is better than having you exposed to the nuances of hospitalization. A sling or a brace for the shoulder fracture is better than to have you breathe the infectious air of the hospital. Rest at home with a plaster in the leg is better than treating you around other sick patients for 3-4 days in the hospital.

However, still there may be some cases where a surgical fixation may be needed because the long-term functional disabilities of a wrongly healed or unhealed fracture outweigh the risks of surgery and hospitalization. Having said that, it is a general understanding now, that during COVID, doctors are trying all the conservative means to treat most of the fractures, because:

1. Doctors want you to avoid any unnecessary hospital exposure.

2. Hospital resources should be better used for fighting COVID.

And if you do need a surgical fixation, there is definitely no need to hurry for any surgery.

There can always be a wait of a few days until all tests are done until you have decided to keep all options in mind and until the anesthesia fitness is obtained. Generally speaking, there is no fracture which, if conserved, will lead to a risk to one’s life. But there is one exception to this rule: a hip fracture.

The Conundrum Surrounding the Hip Fracture

Worldwide, the hip fracture has all the orthopedic surgeons in a bind.

Normally, a hip fracture is operated early because of the following reasons:

1. Firstly, the age of such patients is averagely above 50, so it helps in avoiding prolonged immobilization which in turn leads to better lung functions and early mobility.
2. Secondly, early mobility ensures that the muscles will work and pump blood efficiently.
3. Thirdly, the mobility avoids any stiffness of the knee, ankle, or the hip joints and the patient can be independent in his daily activities.

This thumb rule to operate early on hip fractures was followed religiously during the non-COVID times. However, COVID has complicated the decision-making protocol for hip fracture surgery.

Our experience shows that in highly endemic areas like Mumbai, there’s always a chance for a concomitant COVID infection to be detected in a patient who presents to the hospital with a fracture. Just last week, 5 patients who presented to the emergency room of our hospital, were also diagnosed as COVID positive.

Furthermore, because of the recently published literature, the common understanding amongst the orthopedic surgeons is that operating on any fracture with COVID symptoms is not good news.

One recently published paper from the UK and one paper from New York has shown that there is an elevated health risk after hip surgery if the patient is also COVID infected.

But then the decision to not operate should be simple? Not simple enough though! If a hip fracture is not fixed, it will lead to prolonged bed rest for the individual.

This does not bode well for the health of his lungs, apart from risking the fracture healing as well. The coronavirus affects the lungs of an individual, and by not operating on a hip fracture patient, we are certainly not helping his lungs in any way.

In the current solution that the doctors can think of is to wait until 2-3 weeks until the patient is non-infectious and then to repeat the COVID testing. If the test is negative, most surgeons will go ahead and operate the hip fracture. However, the 2 weeks is not a rule from any book.

The risks of a delay and the consequences of immobility have to be balanced against the dangers of operating on a patient with an underlying COVID infection. Some patients may still turn up positive after 2 weeks, and the decision to operate or not will then be individualized.

For example, maybe the wait would be a bit longer in a relatively healthier and younger individual, but the surgery may be expedited in an older individual after 2-3 weeks of the waiting period. There will be risks either way but hopefully, we will have more answers than questions as our knowledge about the pandemic improves. But we can at least have comfort in the knowledge that soon the infection will plateau out and we can go back to our new normal way of working with fewer doubts and more certainty.

“At times the world may seem an unfriendly and sinister place, but believe that there is much more good in it than bad. All you have to do is look hard enough. And what might seem to be a series of unfortunate events may in fact be the first steps of a journey.”

Lemony Snicket

( Dr. Dipit Sahu, M.S. Consultant Shoulder Surgeon at Sir H.N. Reliance foundation hospital, Jupiter Hospital Thane, Dr. RN Cooper hospital, Juhu Mumbai)