Skip to main content

High-energy blunt pelvic ring injury incidence and polytrauma caseload in a single level I trauma center during COVID-19 related pseudo-lockdown measures: a retrospective cohort study based on a prospective registry

Abstract

Background

Pelvic ring injuries are potentially lethal lesions associated with polytrauma patients and need an efficient trauma team for their management. The purpose of this study was to evaluate the incidence of high-energy blunt pelvic ring injuries and the absolute number of polytrauma patients in a single level I trauma center during the 2020 pseudo-lockdown period related to the Coronavirus pandemic, and to compare it with corresponding periods in 2014–2019 in order to better understand the need of organized and dedicated personnel and infrastructures.

Methods

This retrospective cohort study was based on data prospectively recorded into the institutional Severely Injured Patients’ Registry. Data were obtained for each year period (January 1st to December 31st) and corresponding pseudo-lockdown period (March 16th to June 19th). High-energy blunt pelvic ring injuries inclusion criteria were: (1) Registry entry between January 1st, 2014 and December 31st, 2020; (2) age ≥ 16 years old; and (3) pelvic ring injury presence. Corresponding exclusion criteria were: (1) death before admission; (2) transfer from another institution > 24 h after trauma; (3) penetrating, blast, burn and electrical injuries, drownings; (4) patients living outside the defined institution’s catchment area; and (5) any document attesting the patient’s will to not participate in any study. Polytrauma patients inclusion criteria were: (1) Registry entry between January 1st, 2014 and December 31st, 2020; (2) age ≥ 16 years old; and (3) Injury Severity Score ≥ 16. Corresponding exclusion criteria were: (1) death before admission; (2) transfer from another institution > 24 h after trauma; and (3) any document attesting the patient’s will to not participate in any study. Categorical variables were reported using proportions and continuous variables using medians and interquartile ranges. Because data were exhaustive for the authors’ level I trauma center, no inferential statistics were computed.

Results

The incidence of high-energy blunt pelvic ring injuries and the absolute number of polytrauma patients remained within range of previous years despite pseudo-lockdown measures.

Conclusions

These observations bring better knowledge about pseudo-lockdown’s impact on trauma and may help for future health strategy planning by pointing out the importance of maintaining the activity of level I trauma centers in terms of personnel and infrastructures.

Background

The 2020 Coronavirus disease (COVID-19) pandemic impacted the healthcare system globally and forced to introduce restrictions such as lockdown and pseudo-lockdown measures to limit inter-personal contacts and viral transmission [1,2,3]. These measures also prevented engaging in high-risk activities in order to decrease trauma related hospital admissions and relieve the overburden healthcare system allowing for reallocation of personnel and infrastructures [2]. Although these actions seemed logical [1, 2, 4], preliminary reports have shown confusing results regarding their efficiency [5,6,7,8,9,10,11,12,13]. A better understanding about the impact of these measures on trauma related hospital admissions could help for future health strategy planning.

The purpose of this study was to evaluate the incidence of high-energy blunt pelvic ring injuries (PRI) and the absolute number of polytrauma patients (PP) in a single level I trauma center during the 2020 pseudo-lockdown period related to COVID-19 pandemic and the whole 2020 year period, and to compare them with corresponding periods in 2014–2019. The hypothesis was that these restrictions reduced high-energy blunt PRI incidence and PP caseload. To the best of the authors’ knowledge, this is the first publication assessing high-energy blunt PRI incidence in a defined population during the pseudo-lockdown period.

Methods

Study design

This retrospective cohort study was based on data prospectively recorded into the institutional Severely Injured Patients’ Registry (SIPR). The SIPR contains around 300 items for each patient admitted with a suspected or confirmed high-energy trauma or polytrauma. Among these items, demographic data, trauma details and mechanism, treatments, outcomes, Abbreviated Injury Scale (AIS) codes [14] and Injury Severity Scores (ISS) [15, 16] are recorded. A trained and accredited study nurse was responsible for AIS and ISS coding [14,15,16].

Study setting and population

This study was conducted in a 1900-bed urban academic center serving around 500,000 inhabitants (University Hospitals of Geneva, Switzerland) and corresponding to a level I trauma center according to national and international medical authorities’ definitions [17, 18] with about 100–150 patients with an ISS ≥ 16 and 70–100 patients with an ISS ≥ 20 managed each year.

Pseudo-lockdown measures description

Federal government issued a nation-wide pseudo-lockdown following the COVID-19 pandemic from March 16th to June 19th, 2020 [19, 20]. Measures included social distancing, quarantine, restricted travels, on-line education and office work, sports and leisure facilities’ closure, building sites’ standstill, and limited out-of-the house displacement [19]. Medical resources were mainly reallocated to COVID-19 patients. Minor trauma patients were mostly redirected to other healthcare facilities, but severely injured patients continued to be admitted at the authors’ institution.

Participants’ characteristics

The main outcomes were the incidence of high-energy blunt PRI and the absolute number of PP. Inclusion criteria for the incidence of high-energy blunt PRI were: (1) SIPR entry between January 1st, 2014 and December 31st, 2020; (2) ≥ 16 years old; and (3) PRI presence as defined by specific AIS codes (856,100.2 and 856,101.3 corresponding to PRI not further specified; 856,151.2 and 856,152.3 corresponding to PRI with intact posterior arch; 856,161.3, 856,162.4, 856,163.4 and 856,164.5 corresponding to rotationally unstable PRI; 856,171.4, 858,172.4, 856,173.5 and 856,174.5 corresponding to vertically and rotationally unstable PRI) [14]. Corresponding exclusion criteria were: (1) death before Emergency Room (ER) admission; (2) transfer from another institution > 24 h after trauma; (3) penetrating, blast, burn and electrical injuries, drownings; (4) patients living outside the defined institution’s catchment area; (5) any document attesting the patient’s will not to participate in any study. Inclusion criteria for the absolute number of PP were: (1) SIPR entry between January 1st, 2014 and December 31st, 2020; (2) ≥ 16 year old; and (3) ISS ≥ 16 [21]. The ISS cutoff of 16 was chosen as the most common definition of PP found in the literature [21]. Corresponding exclusion criteria were: (1) death before ER admission; (2) transfer from another institution > 24 h after trauma; and (3) any document attesting the patient’s will not to participate in any study. Death before ER admission was an exclusion criterion because of the usual lack of diagnostic assessment in these cases. Transfer from another institution > 24 h after trauma was also an exclusion criterion since initial medical data may be difficult to collect. Penetrating, blast, burn and electrical injuries, as well as drownings, were exclusion criteria because these injury patterns are rare in the authors’ institution and would have added heterogeneity to the study collective. Finally, patients living outside the defined institution’s catchment area were excluded to obtain incidence values for high-energy blunt PRI which were interpreted as an indirect measure of population’s compliance to pseudo-lockdown restrictions. Alternatively, the absolute number of PP was chosen as a general indicator of the level I trauma center activity, without patients’ origin distinction—within or outside the defined catchment area.

The SIPR was used to extract age, gender, residential address (within defined catchment area or not), accident’s date, trauma mechanism, AIS codes, ISS, survival, death’s date if applicable, complications (defined as any serious secondary condition appearing during hospital stay), intensive care unit (ICU) length of stay, total acute hospital length of stay, hemodynamic instability at admission (defined as prehospital systolic blood pressure < 90 mmHg or prehospital heart rate > 100 bpm or need for packed red blood cell (PRBC) in the ER), number of PRBC units received during the first 24 h. Radiological images were reviewed by two authors and PRI classified according to the AO/OTA classification [22]. Only type B and C PRI were considered for this study as they may be associated with hemodynamic instability and usually need surgical fixation [23]. Population description of the defined catchment area of the institution was obtained from the government's Statistics Office [24]. Polytrauma patients were further stratified using ISS cutoffs of 20 (definition of severe trauma in Switzerland) [18] and 24 (definition of critical trauma in some publications) [25].

Statistical analysis

The incidence of high-energy blunt PRI and the absolute number of PP were individualized for each year period (January 1st to December 31st) and the corresponding pseudo-lockdown period (March 16th to June 19th) from 2014 to 2020. Categorical variables were reported using proportions and continuous variables using medians and interquartile ranges. Because data were exhaustive for the authors’ level I trauma center, no inferential statistics were computed.

Results

The incidence of high-energy blunt PRI during both 2020 pseudo-lockdown period and 2020 year period remained within range of previous years (Table 1 and Fig. 1). High-energy blunt PRI patients’ characteristics are shown in Table 2. Median ISS and hemodynamic instability rate remained within range of previous years for both 2020 pseudo-lockdown and year periods. Death rate was 0% for both 2020 pseudo-lockdown and year periods. The ICU rate and hospital length of stay remained within range of previous years during the 2020 pseudo-lockdown period and were lower during the 2020 year period.

Table 1 Absolute number and incidence of high-energy blunt pelvic ring injuries in the defined population (2014–2020)
Fig. 1
figure 1

Incidence of high-energy blunt pelvic ring injuries (AO/OTA type B & C) over time. Full year incidence (yellow line and markings) and pseudo-lockdown period (March 16th to June 19th) incidence (orange line and markings) are shown for each year, with respective horizontal color lines indicating minimal and maximal incidences over the period 2014–2020

Table 2 High-energy blunt type B and C pelvic ring injury patients’ characteristics (2014–2020)

The absolute number of PP during both 2020 pseudo-lockdown period and 2020 year period remained within range of previous years (Table 3 and Fig. 2). The number of PP admitted with an ISS ≥ 20 or an ISS ≥ 24 was inferior to or at the lower range of previous years. Characteristics of PP are shown in Table 4. Self-inflicted trauma rate was the lowest during both 2020 pseudo-lockdown and year periods. Median ISS was lower during the 2020 pseudo-lockdown period and within range of previous years during the 2020 year period. Death rate, ICU rate, and hospital length of stay remained within range of previous years during the 2020 pseudo-lockdown period and were lower during the 2020 year period.

Table 3 Absolute number of polytrauma patients (2014–2020)
Fig. 2
figure 2

Absolute number of polytrauma patients over time. Full year absolute number (yellow line and markings) and pseudo-lockdown period (March 16 th to June 19th) absolute number (orange line and markings) are shown for each year, with respective horizontal color lines indicating minimal and maximal absolute numbers over the period 2014–2020

Table 4 Polytrauma patients’ characteristics (2014–2020)

Discussion

This study showed no change in the incidence of high-energy blunt PRI (AO/OTA type B or C) nor in the absolute number of PP (ISS ≥ 16) in a single level I trauma center during 2020 pseudo-lockdown period and 2020 year period in comparison to previous years (2014–2019). Severity of PRI was stable when analyzing related ISS and hemodynamic instability rates. The type of PP was generally less severe with lower ISS during 2020 pseudo-lockdown period and 2020 year period in comparison to previous years.

These findings suggest that pseudo-lockdown restrictions may not have reached the desired effect in reducing the population exposure to trauma [19]. Stable ICU rate, hospital length of stay, and good survival rate during the pseudo-lockdown period suggest that sufficient resources were allocated to high-energy PRI patients. Lower ICU rate and hospital length of stay during the 2020 year period could be due to prompter management as a consequence of the overburden healthcare system, without negative impact on survival rate.

Despite other authors having highlighted a decrease in PP admissions during lockdown period [9,10,11], the present study did not show comparable results. Some other investigations came to the same conclusion [7, 12, 13] and even reported an increase in PP cases [5, 6]. A possible explanation might be that the authors’ institution was the only level I trauma center serving the region and no reorganization of polytrauma management was made during pseudo-lockdown; thus, some less severe PP were not re-directed to level II trauma centers. Interestingly polytrauma cases were less severe with lower ISS as reported by Chiba et al. [10]. This might be related to population’s behavioral adaptations to restrictions, with potentially less road traffic accidents and changes in trauma etiology linked to illicit substance use, self-inflicted trauma, and interpersonal violence [8, 10]. Data available for the present study did not allow further analysis of trauma mechanism and cause, except for self-inflicted injury rates which were lower for both 2020 pseudo-lockdown period and 2020 year period. This was in contradiction with other studies having highlighted higher rates of self-inflicted injuries, possibly linked with emotional stress due to isolation [8, 10]. Stable death rate, ICU rate, and hospital length of stay during the pseudo-lockdown period might indicate that despite the burden of COVID-19 patients management, sufficient resources were allocated for PP allowing stable survival rates. Decreased death rate, ICU rate, and hospital length of stay during the 2020 year period might be related to their lower ISS.

Analysis of both main outcomes showed no decrease in exposure to trauma nor in the level I trauma center activity during the pseudo-lockdown period. This is the first publication highlighting the stability of the incidence and severity of high-energy blunt PRI during the 2020 pseudo-lockdown period and 2020 year period in comparison with previous years in a single level I trauma center.

This study had several limitations. Its retrospective design made it prone to several biases, despite data being prospectively collected. Due to its monocentric setting, conclusions might apply only to the authors’ institution. Furthermore, polytrauma definition as ISS ≥ 16 might not be universally accepted [26], but it was constant throughout the whole study period.

Conclusions

During the 2020 pseudo-lockdown period, no decrease was found in the incidence of high-energy blunt PRI nor in the absolute number of PP in the authors’ level I trauma center demonstrating no change in its activity. These observations bring better knowledge about pseudo-lockdown’s impact on trauma and may help for future health strategy planning by pointing out the importance of maintaining the activity of level I (and possibly level II and III) trauma centers in terms of personnel and infrastructures.

Availability of data and materials

All data generated or analyzed during this study are included in this published article and its Additional files 1, 2.

Abbreviations

AIS:

Abbreviated Injury Scale

AO/OTA:

Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association

COVID-19:

Coronavirus disease 2019

ER:

Emergency Room

ICU:

Intensive Care Unit

ISS:

Injury Severity Score

PRBC:

Packed Red Blood Cell

PRI:

Pelvic Ring Injuries

PP:

Polytrauma Patients

SIPR:

Severely Injured Patients’ Registry

References

  1. Mustafa S, Zhang Y, Zibwowa Z, Seifeldin R, Ako-Egbe L, McDarby G, et al. COVID-19 preparedness and response plans from 106 countries: a review from a health systems resilience perspective. Health Policy Plan. 2022;37(2):255–68.

    Article  PubMed  Google Scholar 

  2. Verma BK, Verma M, Verma VK, Abdullah RB, Nath DC, Khan HTA, et al. Global lockdown: an effective safeguard in responding to the threat of COVID-19. J Eval Clin Pract. 2020;26(6):1592–8.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Ferguson NM, Laydon D, Nedjati-Gilani G, Imai N, Ainslie K, Baguelin M, et al. Report 9: impact of non-pharmaceutical interventions (NPIs) to reduce COVID-19 mortality and healthcare demand. Imp Col Lond. 2020;10:491.

    Google Scholar 

  4. World Health Organization. Health service continuity planning for public health emergencies: a handbook for health facilities. Interim version for field testing. Geneva: World Health Organization; 2021.

    Google Scholar 

  5. Wahnert D, Colcuc C, Beyer G, Kache M, Komadinic A, Vordemvenne T. Effects of the first lockdown of the COVID-19 pandemic on the trauma surgery clinic of a German level I trauma center. Eur J Trauma Emerg Surg. 2021. https://doi.org/10.1007/s00068-021-01635-x.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Moore A, Singleton A, Hiatt L, Miller R, Phillips S, Leskovan JJ. An assessment of the impact of SARS-CoV-2 on a level 1 trauma center including subgroup analysis of orthopedic injuries and mechanism of injury. Cureus. 2022;14(1): e20954.

    PubMed  PubMed Central  Google Scholar 

  7. Sephton BM, Mahapatra P, Shenouda M, Ferran N, Deierl K, Sinnett T, et al. The effect of COVID-19 on a major trauma network. An analysis of mechanism of injury pattern, referral load and operative case-mix. Injury. 2021;52(3):395–401.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  8. Olding J, Zisman S, Olding C, Fan K. Penetrating trauma during a global pandemic: changing patterns in interpersonal violence, self-harm and domestic violence in the Covid-19 outbreak. Surgeon. 2021;19(1):e9–13.

    Article  PubMed  Google Scholar 

  9. Andrzejowski PA, Howard A, Vun JSH, Manzoor N, Patsiogiannis N, Kanakaris NK, et al. COVID-19: the first 30 days at a UK level 1 trauma centre and lessons learnt. Cureus. 2020;12(11): e11547.

    PubMed  PubMed Central  Google Scholar 

  10. Chiba H, Lewis M, Benjamin ER, Jakob DA, Liasidis P, Wong MD, et al. “Safer at home”: the effect of the COVID-19 lockdown on epidemiology, resource utilization, and outcomes at a large urban trauma center. J Trauma Acute Care Surg. 2021;90(4):708–13.

    Article  PubMed  Google Scholar 

  11. Hampton M, Clark M, Baxter I, Stevens R, Flatt E, Murray J, et al. The effects of a UK lockdown on orthopaedic trauma admissions and surgical cases: a multicentre comparative study. Bone Jt Open. 2020;1(5):137–43.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Ludwig TE, Samuel TL, Vergouwen M, White NJ. COVID-19 orthopaedic trauma volumes: a Canadian experience during lockdown and staged reopening. OTA Int. 2021;4(2): e134.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Park C, Sugand K, Nathwani D, Bhattacharya R, Sarraf KM. Impact of the COVID-19 pandemic on orthopedic trauma workload in a London level 1 trauma center: the “golden month.” Acta Orthop. 2020;91(5):556–61.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Gennarelli TA, Wodzin E. The abbreviated injury scale 2005. Update 2008. Des Plaines: American Association for Automotive Medicine; 2008.

    Google Scholar 

  15. Baker SP, O’Neill B, Haddon W Jr, Long WB. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma. 1974;14(3):187–96.

    Article  CAS  PubMed  Google Scholar 

  16. Copes WS, Champion HR, Sacco WJ, Lawnick MM, Keast SL, Bain LW. The injury severity score revisited. J Trauma. 1988;28(1):69–77.

    Article  CAS  PubMed  Google Scholar 

  17. American College of Surgeons Committee on Trauma. Resources for optimal care of the injured patient. Chicago: American College of Surgeons; 2006.

    Google Scholar 

  18. Organe de décision de la Convention intercantonale relative à la médecine hautement spécialisée (Organe de décision MHS). Décision concernant la planification de la médecine hautement spécialisée (MHS) dans le domaine de la prise en charge des blessés graves. 20 May 2011. https://www.admin.ch/opc/fr/federal-gazette/2011/4350.pdf. Accessed 31 Aug 2023.

  19. Ordonnance 2 sur les mesures destinées à lutter contre le coronavirus (COVID-19) (Ordonnance 2 COVID-19) du 13 mars 2020. 16 March 2020. https://fedlex.data.admin.ch/filestore/fedlex.data.admin.ch/eli/cc/2020/141/20200313/fr/pdf-a/fedlex-data-admin-ch-eli-cc-2020-141-20200313-fr-pdf-a.pdf. Accessed 31 Aug 2023.

  20. Ordonnance 2 sur les mesures destinées à lutter contre le coronavirus (COVID-19) (Ordonnance 2 COVID-19) du 13 mars 2020. 19 June 2020. https://fedlex.data.admin.ch/filestore/fedlex.data.admin.ch/eli/cc/2020/141/20200620/fr/pdf-a/fedlex-data-admin-ch-eli-cc-2020-141-20200620-fr-pdf-a.pdf. Accessed 31 Aug 2023.

  21. Boyd CR, Tolson MA, Copes WS. Evaluating trauma care: the TRISS method. Trauma score and the injury severity score. J Trauma. 1987;27(4):370–8.

    Article  CAS  PubMed  Google Scholar 

  22. Meinberg EG, Agel J, Roberts CS, Karam MD, Kellam JF. Fracture and dislocation classification compendium-2018. J Orthop Trauma. 2018;32(1):S1–170.

    Article  PubMed  Google Scholar 

  23. Wong JM, Bucknill A. Fractures of the pelvic ring. Injury. 2017;48(4):795–802.

    Article  PubMed  Google Scholar 

  24. République et canton de Genève. Office cantonal de la statistique. Etat et évolution de la population. https://www.ge.ch/statistique/domaines/01/01_01/tableaux.asp#5. Accessed 31 Aug 2023.

  25. Palmer C. Major trauma and the injury severity score–where should we set the bar? Annu Proc Assoc Adv Automot Med. 2007;51:13–29.

    PubMed  PubMed Central  Google Scholar 

  26. Pape HC, Lefering R, Butcher N, Peitzman A, Leenen L, Marzi I, et al. The definition of polytrauma revisited: an international consensus process and proposal of the new “Berlin definition.” J Trauma Acute Care Surg. 2014;77(5):780–6.

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

The authors would like to thank Prof Angèle Gayet-Ageron, MD, PhD, and Dr Cyril Jaksic, PhD, who carried out the statistical analysis for this study (Clinical Research Center & Division of Clinical Epidemiology, Department of health and community medicine, University of Geneva & University Hospitals of Geneva, 4 Rue Gabrielle-Perret-Gentil, CH-1211 Geneva 14, Switzerland).

Funding

Open access funding provided by University of Geneva. There was no external source of funding or financial support for this study.

Author information

Authors and Affiliations

Authors

Contributions

VM, AG: study idea and design, full data access and verification, data analysis and interpretation, drafting and revision of the manuscript, literature search; MZ, AA, SV: full data access, data acquisition, analysis and interpretation, revision of the manuscript; EA: registry management, full data access, data acquisition, analysis and interpretation, revision of the manuscript. All the authors gave their final approval of the version to be published and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Corresponding author

Correspondence to Axel Gamulin.

Ethics declarations

Ethics approval and consent to participate

Approval was obtained from the institutional research ethics board (Commission Cantonale d’Ethique de la Recherche, République et Canton de Genève, reference number 2021–02368) before initiation of the study. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 declaration of Helsinki on medical research involving human subjects and its later amendments. For this type of study formal consent to participate was not required and was waived by the institutional research ethics board, even for minors under 18 years old. Concurrently, the SIPR itself was separately approved by the same ethics board and under the same conditions (reference number 13-143R in 2013, re-approval reference number PB_2021-00045 in 2021).

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Additional file 1.

Polytrauma patients database.

Additional file 2.

Pelvic ring injury patients database.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Morello, V., Zingg, M., Andereggen, E. et al. High-energy blunt pelvic ring injury incidence and polytrauma caseload in a single level I trauma center during COVID-19 related pseudo-lockdown measures: a retrospective cohort study based on a prospective registry. Eur J Med Res 28, 325 (2023). https://doi.org/10.1186/s40001-023-01313-1

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s40001-023-01313-1

Keywords