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A series of recent reviews in publication are raising serious concerns about increased risks for fragility fractures during the ongoing coronavirus disease 2019 (COVID-19) pandemic.
Napoli et al1 predicted that “a dramatic surge in fractures and related mortality is expected in the next few months.” The implications are that proper treatment of fractures may be severely hampered by the diversion of resources for the prevention and treatment of COVID-19, as surgical options are postponed.2,3 Shariyate and colleagues4 warned that infection with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may undermine bone health and directly contribute to higher rates of fracture among elderly patients.
Fragility fractures are those that occur as a result of decreasing bone mass, and are generally not associated with high-impact events or direct trauma to the bones.5 In August 2019, a report compiled by the National Osteoporosis Foundation (NOF) showed that as of 2015, 2.3 million osteoporosis-related bone fractures were reported in approximately 2 million Americans receiving Medicare (including both fee-for-service and Medicare Advantage beneficiaries).5 The most common fracture sites were the hips and spine, accounting for 40% of all fracture events; women vs men had 79% higher rates of osteoporotic fracture (970,000 vs 410,000, respectively).5
The NOF report identified a significant risk for fragility fractures in more than 53 million Americans because of existing osteoporotic bone loss.5 Mortality associated with fragility fractures is very high because they occur most often in the elderly; hip fractures historically carry the highest 1-year mortality rates of about 20%, resulting in an estimated 740,000 deaths worldwide.5 Hip fractures are considered the leading cause of loss of mobility and function in older persons, which has been known to occur despite the availability of effective prevent treatments for osteoporosis and interventions after a fracture.
Fractures During the COVID-19 Pandemic
In a recent review of global fracture trends, Kumar Jain et al3 found that although the worldwide burden of fractures has been significantly lower during the COVID-19 pandemic, the rate of fragility fractures has remained the same. The review indicated that a majority of fractures occurred among patients with a mean age of 67 years, which included hip fractures caused by falls from a low height or while standing, and the vast majority of fractures now occurred in the home.3 The study authors also suggested that significant drops in fracture rates among younger people might be largely attributable to global limitations on activities outside the home, including travel, and work-and sports-related injuries.3
Traditional non-operative treatment of fractures follow principles of realigning the bone, reducing inflammation to surrounding tissue, and immobilizing and supporting the fracture with splints or casts to promote healing.6 However, fragility fractures affecting the hips and lower limbs often require surgical intervention to stabilize the bone and reduce inflammatory processes and infection.6
Kumar Jain et al3 reported “a massive breakdown in trauma orthopedic fracture surgeries in the world during the COVID-19 pandemic. The main approach of most orthopedic surgeons was to save the hospital resources, to decrease the risks [for] a nosocomial infection like COVID-19 and to protect their staff and colleagues.”
Pandemic Responses Creating Barriers to Care
In their review, Napoli et al1 point out that the clinical management of fragility fractures is already complex, and treatment gaps for fracture have been identified for decades before COVID-19, with only approximately 20% of patients with hip fracture receiving the appropriate standard of care. “It follows that during the pandemic, our dismal rates of treatment of patients who have had a fracture will probably drop to almost undetectable levels. This problem will be largely below the radar of most medical practices, as osteoporosis continues to be low on the list of clinical priorities,” they wrote.
The COVID-19 pandemic has caused a massive reallocation of medical resources in clinical settings, with a potential lack of appropriate attention to patients who may be recovering at home.1,3 Iyengar and colleagues6 noted the limited availability of healthcare staff and operating room slots along with a general reluctance to undertake surgeries in an environment that poses risks for SARS-CoV-2 infection to surgeons, staff, and the patients.
Interim Solutions and Strategies for Management
The overarching focus of several investigators and reviewers is on preventing what could be a silent epidemic of fragility fractures that are under-recognized and/or undertreated in the continuing environment of the COVID-19 pandemic. Consensus seems to defer to conservative, non-operative approaches whenever possible, while maintaining full adherence to treatment protocols, particularly given the barriers created by the current pandemic.
The review by Kumar Jain and colleagues3 concluded that because of a significantly higher risk for mortality in elderly patients with fractures, “they should only be operated in a facility with a robust intensive care.”
In their commentary published in Nature Reviews, Napoli et al1 summarized, “Alternative models of care are urgently needed, with multidisciplinary care teams eventually being organized to serve patients and their families with, for example, telemedicine tools. This approach not only has the potential to improve quality of life and survival outcomes but is also cost-effective, lowering the economic burden of fracture, and saving resources for tackling the COVID-19 pandemic.”
References
1. Napoli N, Elderkin AL, Kiel DP, Khosla S. Managing fragility fractures during the COVID-19 pandemic. Nat Rev Endocrinol. 2020;16(9):467-468.
2. Upadhyaya GK, Iyengar K, Jain VK, Vaishya R. Challenges and strategies in management of osteoporosis and fragility fracture care during COVID-19 pandemic. J Orthop. 2020;21:287-290.
3. Kumar Jain V, Lal H, Kumar Patralekh M, Vaishya R. Fracture management during COVID-19 pandemic: a systematic review. J Clin Orthop Trauma. 2020;11(Suppl 4):S431-S441.
4. Shariyate MJ, Kachooei AR. Association of new coronavirus disease with fragility hip and lower limb fractures in elderly patients. Arch Bone Jt Surg. 2020;8(Suppl1):297-301.
5. National Osteoporosis Foundation – Milliman Research Report. Medicare cost of osteoporotic fractures: the clinical and cost burden of an important consequence of osteoporosis. Published August 2019. Accessed September 22, 2020. http://assets.milliman.com/ektron/Medicare_cost_of_osteoporotic_fractures.pdf
6. Iyengar K, Vaish A, Vaishya R. Revisiting conservative orthopaedic management of fractures during COVID-19 pandemic. J Clin Orthop Trauma. 2020;11(4):718-720.
