The Unexpected Consequences of Quarantine

By Jennifer Vanderbeck, MD
Associate Professor of Orthopaedics
Shoulder & Elbow Specialist
VCU Health

As orthopaedic surgeons we are committed to helping our patients maintain a healthy, active lifestyle. Many of us see a balance of elective surgery and fracture care in our practice. When COVID-19 hit, the practice of elective orthopaedic surgery came to a grinding halt. Orthopaedic trauma, however, did not.

On March 25, Governor Ralph S. Northam and State Health Commissioner M. Norman Oliver signed the Order of Public Health Emergency Two prohibiting the performance of procedures and surgeries “which if delayed, are not anticipated to cause harm to the patient by negatively affecting the patient's health outcomes, or leading to disability or death.” Violation of this Order would result in a Class 1 misdemeanor. Aside from the small percentage of cases in which delay of surgery would cause obvious and immediate harm to the patient, most elective orthopaedic surgical cases were canceled. Although this Order was originally set to expire on April 24, it was extended to May 1.

While elective orthopaedic surgery was on hold, most of us sat and waited. We waited for the spike in COVID-19 cases. We waited for COVID-19 testing to ramp up so we could more accurately track the virus. We waited for a clear directive on the use of our PPE. We waited for the Governor to grant permission to resume our normal practices. Although we were waiting, it was a period of unrest. While we were not able to identify our true exposure risks, many of us were anxious to get back into the operating room.

On March 30, the Governor issued a statewide Stay at Home Order to remain in effect through June 10. Virginians were directed to stay at home unless absolutely required, but were given the allowance to “engage in outdoor activity with strict social distancing requirements.” Some people were working from home and some were out of work. Many took to the outdoors to discover new ways to pass the time. Shortly after the Stay at Home Order was issued, I began to see an unexpected spike in traumatic shoulder injuries from recreational activities. What I didn’t anticipate was that I would be treating the most complicated fractures of my career.

In the four weeks immediately following the Stay at Home Order, I surgically treated 3 scapula fractures, each one more severe than the next. In each of these three cases, the patient was participating in a novel outdoor recreational activity, specifically, mountain biking and four-wheeling. Scapula fractures are uncommon and typically occur with high energy trauma. Ten percent or less of all scapula fractures will require operative fixation. In my practice before the COVID-19 pandemic, most of the scapula fractures meeting surgical criteria were from high energy automobile accidents. Of all the scapula fractures I see in practice, six or less per year will typically require surgery. The scapula fractures I treated during the early phases of this pandemic were severe and devastating injuries. They were all sustained participating in high risk recreational activities that were new to the patient.

In late March and early April there was a mixture of uncertainty, hesitation and even excitement of the staff in the operating room. There were more questions than answers about exposure risk. At that time we were not screening asymptomatic patients for COVID-19, and were unable to identify the true risk of exposure when performing fracture surgery. Because of this, many team members questioned how one could participate in any activity that had potential for injury. We are now screening all patients for COVID-19 before surgery, elective and emergent. As we enter phase 2 and begin our new normal, things seem to be leveling out and I have not seen a scapula fracture requiring surgery in 6 weeks. Although, as orthopaedic surgeons, we are not treating COVID patients on the front line, but we have contributed in the way we know best; picking our patients up after they have fallen and making them whole again.