O IMPACTO DA COVID-19 SOBRE O PERFIL EPIDEMIOLÓGICO DE FRATURAS

Acta Ortop Bras aob Acta Ortopédica Brasileira Acta ortop. bras. 1413-7852 1809-4406 ATHA EDITORA RESUMO Objetivo: Analisar a transição do perfil epidemiológico de fraturas de pacientes atendidos em um hospital terciário referência em traumatologia durante a pandemia de COVID-19, a fim de verificar mudanças no atendimento traumatológico. Métodos: Análise retrospectiva e descritiva dos dados de lesões ortopédicas admitidas no Instituto Doutor José Frota entre 16 de dezembro de 2019 e 16 de junho de 2020 (três meses antes e depois do primeiro caso de COVID-19 no Ceará). Resultados: Dos 913 pacientes avaliados, 28,5% eram mulheres e 71,5% homens. Houve redução significativa (p < 0,05) nas proporções de mulheres operadas no tempo analisado. Houve aumento na média da idade, sendo 35,40 anos pré-pandemia, e 38,48 (p = 0,04) no período seguinte. Os mecanismos de trauma mudaram significativamente (p < 0,05), com aumento proporcional de fraturas por alta energia e redução no número daquelas por queda ao solo. A quantidade de cirurgias ortopédicas reduziu em 11,9%, de 655 antes do primeiro caso de COVID-19 para 577 posteriormente (p = 0,071). A média do número de dias diminuiu para duração do internamento (p < 0,001) e para o tempo até a realização da cirurgia (p < 0,001). Conclusão: O impacto do lockdown neste hospital de trauma se deu principalmente pela diminuição na quantidade de casos operados e pela mudança do perfil e mecanismo de trauma dos pacientes. Nível de Evidência III, Estudo Retrospectivo Comparativo. INTRODUCTION At the end of 2019, a viral outbreak1 surprised China, putting countries around the world on alert as they observed the pronouncements of the World Health Organization (WHO)2 and the evolution of circumstances in the Chinese territory. In February 2020, Brazil would register its first official infection case by the new Coronavirus (SARS-CoV-2). (3 In Ceará, the first official notification of infection with COVID-19 occurred on March 16, 2020, (4 increasing to more than 690,000 confirmed cases and 18,000 deaths5 until the 17th Epidemiological Week (May 1, 2021). The WHO recommends that countries have a ratio of at least one doctor per 1,000 inhabitants. According to the latest data from its Federal Council of Medicine (CFM), (6 Brazil meets this requirement, with almost 2.2 such professionals per 1,000 Brazilian citizens. However, the particularities of COVID-19, such as its great capacity for dissemination and the poor knowledge of effective treatment, can still raise it to a level which would justify caution, forcing drastic measures from public managers and completely changing the routine of the Brazilian people. Social distancing, constant hand sanitizing, mandatory mask use, quarantine status, lockdown, and changes in the internal dynamics of health centers are among the guidelines to alleviate the spread of the virus. (7 This change also included orthopedic and trauma services. Some international hospitals, such as those in Italy and Nepal, have decided to suspend all elective or non-emergency procedures (except for cancer patients) since some orthopedic surgeries can lift possibly contaminated aerosols. (8 Additionally, such centers have aimed to make as many ICU beds vacant as possible for COVID-19+ patients, preserve health resources, and avoid possible hospital contamination for other patients. (9,10 Moreover, this conduct enables channeling orthopedic physicians and colleagues from other specialties (including residents) to meet the large number of individuals infected by the new Coronavirus. Note, however, that social isolation and traffic control can positively and negatively impact Brazilian medical services. On the one hand, secluding people in their homes promotes viral containment and reduces traffic accidents (as a study conducted in New Zealand11 has shown). On the other hand, it hinders the transit of older individuals or accident victims, especially those in rural areas or who use public transport in cities which reduced their operating fleet. All these changes modified the profile of patients treated by trauma centers throughout Brazil. (12 Understanding this transition, especially in a constantly changing pandemic, is important to enable the adjustment of care to ensure efficient service with the greatest possible safety for patients and healthcare providers. Thus, this study aims to analyze how the epidemiological profile of fractures in patients treated in a tertiary hospital (which is a reference in traumatology) changed during the COVID-19 pandemic to offer a panoramic view of what occurred regarding trauma care. METHODS This is a retrospective and descriptive analysis of records from patients with orthopedic lesions admitted 90 days before and after the first case of COVID-19 in Ceará State, Brazil, in a local tertiary trauma center. Data from patients admitted to Instituto Doutor José Frota (IJF), a regional reference trauma center, between December 16, 2019 and June 16, 2020, were analyzed, corresponding to periods between three months before the first COVID-19 case in Ceará and three months afterward. Patients of all genders with mature or immature skeletons - shown via radiography (i.e., those with closed epiphyseal plates) - who suffered orthopedic lesions and were treated and operated on at IJF from December 16, 2019 to June 16, 2020 were included in this study. Patients with fractures only on their ribs or face, those who had no orthopedic lesions on admission, who lacked adequate imaging tests, and who showed inadequate medical records were excluded from this study. Identification data (medical record number, age, gender), affected side, comorbidities, fractured bones, aspects of the trauma mechanism, date of the trauma, performed surgery dates, hospitalization length, time until surgeries, and number of performed surgeries were collected. Fractures types were systematized into large groups according to the affected body segment: Shoulder (clavicle, proximal humerus, and scapula), diaphyseal humerus fractures, elbow (distal humerus, olecranon, radial head, and elbow fracture-dislocation), forearm (radius and ulna diaphyseal fractures, alone or combined), wrist (distal radius and carpal fracture and fracture-dislocations), hand (phalanges and metacarpal bones), pelvis and acetabulum (pelvic ring and sacrum fracture-dislocations and acetabulum fractures), hip (neck, transtrochanteric, and subtrochanteric proximal femur fractures), femur diaphyseal fractures, knee (distal femur, patella, and tibial plateau), legs (leg bone diaphyseal fractures, alone or combined), ankle, tibial pilon, and foot (tarsal and metatarsal bones and phalanges). Minimums, maximums, medians, means, and standard deviations were used to describe quantitative variables and patient number and proportion, for qualitative ones. The Z-test was used to compare proportions between two analyzed periods; the Student’s t-test, normal distributions; and the Mann-Whitney test, abnormal distributions. The Shapiro-Wilk test was used to assess sample distribution normality. A p ≤ 0.05 statistical significance was considered. According to Resolution 466/2012 of the National Health Council, this study was approved by the Research Ethics Committee of the institution via opinion no. 4,140,174. RESULTS Of 913 evaluated patients, 260 (28.5%) were women and 653 (71.5%), men (Table 1). We found a significant reduction (p < 0.05) in the proportion of female patients operated before and during the first three months of restrictive measures (Table 2). Table 1 Number and percentage of patients per variable. Variable N % Gender Female 260 28.5 Male 652 71.5 Comorbidities No 794 87.8 Yes 103 11.4 Comorbidities* SAH 52 5.8 DM 30 3.3 Cadiopathy 9 1 Joint GW No 53 71.6 Yes 21 28.4 Articular GW with bone loss No 25 86.2 Yes 4 13.8 Multiple answers; SAH: systemic arterial hypertension; DM: diabetes mellitus, GW: gunshot wound. Table 2 Number and percentage of patients by variable and period. Gender Period N % p* Female Before 160 61.5 < 0.001 After 100 38.5 Male Before 337 51.7 0.193 After 315 48.3 Comorbidity SAH Before 24 4.8 0.092 After 28 6.7 DM Before 16 3.2 0.434 After 14 3.4 Cardiopathy Before 7 1.4 0.077 After 2 0.5 Joint GW No Before 21 39.6 - After 32 60.4 Yes Before 12 57.1 - After 9 42.9 Articular GW with bone loss No Before 10 40.0 - After 15 60 Yes Before 2 50.0 - After 2 50.0 Z-test for difference in proportions; SAH: systemic arterial hypertension; DM: diabetes mellitus; GW: gunshot wound. We found that the mean age of patients evaluated in the period before the pandemic (35.40 years) increased during the evaluated social isolation to 38.48 years (p = 0.04) (Table 3) Table 3 Descriptive statistics of quantitative variables. Variables n Minimum Maximum Median Mean SD Age 912 2 97 32.0 36.80 22.74 Hospitalization length (days) 911 1 155 11.0 17.64 18.29 1st surgery (days) 912 0 83 3.0 6.92 10.00 2nd surgery (days) 231 0 86 13.0 18.35 16.00 3rd surgery (days) 37 4 89 30.0 32.62 20.18 4th surgery (days) 10 5 84 38.5 42.60 24.86 5th surgery (days) 4 15 125 47.5 58.75 47.26 6th surgery (days) 2 44 146 95.0 95.0 72.12 Surgery amount 912 0 6 1.0 1.35 0.65 Hips (13.43%), forearms (12.27%), and elbows (11.11%) were the body segments which showed the highest number of operations in the first studied period. During social isolation, they consisted of legs (16.09%), knees (11.87%), and hips (11.68%). We found a significant difference (p < 0.05) between trauma mechanisms in the evaluated periods, with a proportional increase of fractures caused by car accidents, aggressions, cars running over pedestrians, and gunshot wounds (GW) and a reduced number of fractures resulting from falls to the ground (Table 4). Table 4 Number and percentage of patients by trauma mechanism and period. Trauma mechanism Period n % p* Car accident Before 19 3.8 < 0.001 After 46 11.1 Bicycle Accident Before 9 1.8 0.447 After 8 1.9 Motorcycle accident Before 180 36.1 0.126 After 135 32.5 Aggression Before 4 0.8 0.007 After 13 3.1 Pedestrian versus motor vehicle accidents Before 19 3.8 0.025 After 28 6.7 GW Before 38 7.6 0,038 After 46 11.1 Fall to the ground Before 179 35.9 < 0.001 After 92 22.2 Fall from height Before 34 6.8 0.354 After 31 7.5 Other falls Before 12 2.4 0.220 After 7 1.7 Others Before 4 0.8 0.048 After 9 2.2 *Z-test for difference in proportions; GW: gunshot wound. We found no statistically relevant difference among comorbidities in both evaluated patient groups. Among the comorbidities reported in the first period, 24 patients (4.8%) showed systemic arterial hypertension; 16 (3.2%), diabetes mellitus; and 7 (1.0%), heart disease. Of the patients evaluated in the following three months, 28 (6.7%) reported SAH (p = 0.092); 14 (3.4%), diabetes (p = 0.434); and 2, (0.5%) cardiopathies (p = 0.077). Other pathologies showed very low percentages (< 1%) in both evaluated periods and most patients (87%) showed no comorbidities (Table 2). The number of orthopedic surgeries performed decreased by 11.9%, from 655, before the first case of COVID-19 in Ceará, to 577 after it (p = 0.071). We found a significant difference between both analyzed periods regarding hospitalization length (p < 0.001) and time until surgery(ies) (p < 0.001), with a decrease in their mean number of days (Table 5). Table 5 Descriptive statistics and comparison between periods before and after the pandemic. Period Period n Minimum Maximum Median Mean SD p Age(years) Before 498 2 96 30.0 35.40 23.97 0.04a After 414 2 97 36.0 38.48 21.06 Hospitalization length (days) Before 498 1 155 15.5 21.55 19.60 < 0.001a After 413 1 151 8.0 12.93 15.31 1st surgery (days) Before 498 0 83 5.0 9.19 11.82 < 0.001a After 414 0 67 2.0 4.18 6.22 2nd surgery (days) Before 126 0 86 17.0 23.05 18.31 < 0.001a After 105 2 72 10.0 12.71 10.22 3rd surgery (days) Before 19 4 89 36.0 39.47 21.82 0.024b After 18 6 72 26.0 25.39 15.82 4th surgery (days) Before 6 5 71 37 41.00 25.08 - After 4 17 84 39.5 45.00 28.15 5th surgery (days) Before 2 15 56 35.5 35.50 28.99 - After 2 39 125 82.0 82.00 60.81 6th surgery (days) Before 0 - - - - - - After 2 44 146 95.0 95.0 72.12 Surgery amount Before 498 0 5 1.0 1.32 0.61 0.071 After 414 1 6 1.0 1.39 0.68 a Student’s t-test; b Mann-Whitney test. DISCUSSION The pandemic is still a reality in 2021, despite the development of vaccines against SARS-CoV-2. For example, according to data from its Ministry of Health, (3 the number of daily deaths in Brazil due to the second wave of the COVID-19 pandemic reached 4,249 on April 8, 2021. In the same period, massive vaccination decreased the number of cases in the United States, in contrast to its alarming and uncontrolled spread in India. (13 These data reflect how the pandemic affects nations differently, either by more than one wave of contamination, by the varying number of lives lost or by the adopted containment policies. The trauma hospital which is the focus of this study conducted 11.9% less orthopedic surgeries throughout the analyzed periods, which we expected due to restrictive measures reducing urban mobility and suspending elective surgeries. Other orthopedic and trauma sectors outside Brazil14), (15 saw the same reduction trend. Additionally, orthopedic centers in Southeastern Brazil12 and trauma hospitals in London16 also observed a decrease in waiting time for surgeries and hospitalization time, respectively. These aspects align management to reduce risk of exposure to the virus and attempt to allocate as many beds and inputs as possible for patients with COVID-19. Another parameter we observed was the subtle increase in the mean age of treated patients: 35.4 years in the “pre-COVID” period and 38.5 years in the following one. This trend, which other studies also report, (17 may relate to the imposed restrictive measures probably reducing the participation of young people in motorcycle accidents, whose prevalence is due to greater recklessness and recreational use. The studied period also shows increased fractures due to high-energy traumas, such as automobile accidents, assaults, cars running over pedestrians, and GW. This trend is unexpected since restrictive measures should reduce circulating vehicles and the number of people on the streets, as other trauma centers15,17 have reported. However, some factors may explain this non-reduction of high-energy traumas. The late lockdown officialization in the region of the studied trauma hospital18 (only in the first week of May, after Decree No. 33,574) may be one such explanation, before which the region only had a few looser isolation measures. Another cause to be considered is that the studied health center treats patients from several nearby regions, who received the announcement of the lockdown at different times - whether, in some municipalities, at the end of May and, in others, only in June. (19 We stress that, in fact, some localities left the lockdown while others were adopting the regime, both assisted by this same reference trauma center, contributing once again to the non-reduction of high-energy traumas. Additionally, the increase in violence resulting from unemployment20 (especially from individuals unassisted by the national emergency aid, established on April 2, 2020, by Law No. 13,982, (21 but whose concession had a late onset) (22 and the shutdown of Ceará23 military police activities for about two weeks in the first quarter, which may have contributed to the greater number of GW we found. According to the Violence Monitor, a tool developed by the Center for the Study of Violence at Universidade de São Paulo in partnership with the Brazilian Public Security Forum and G1, Brazil recorded 5% more murders in 2020 than in 2019 - and the Northeast negatively stood out for its significant 20% occurrence increase. (24 Although we can satisfactorily observe an epidemiological transition in the profile of treated patients, the short period this study analyzed may be a limiting factor to finding more expressive changes. Thus, analysis of a longer period and mapping the origin of serviced patients could more accurately illustrate the impacts of the lockdown in each region, providing more solid bases for local health managers’ future decision-making, favoring a specific alignment of care to ensure a more efficient and safe service for all. Regarding future perspectives, we must highlight the protagonism of telemedicine. In fact, hospitals have implemented hybrid care into their orthopedic services during the pandemic, involving face-to-face contact with patients and steps performed over the telephone and obtaining good results regarding complaint resolution. (25 As of this study, Brazil is experiencing its second COVID-19 pandemic wave, with restrictive locomotion and commercial activities measures periodically still in vogue. Thus, analyzing the implementation of telemedicine in stages of care at the IJF would prove timely and with advantageous possibilities for patients and healthcare providers. CONCLUSION The impact of the lockdown during the first wave of the Coronavirus pandemic in a reference trauma hospital decreased the number of operated cases and changed trauma mechanism patterns and the profile of patients undergoing surgery. Understanding the transition of patients’ profile and trauma treated during the pandemic enabled the planning of strategies and optimized its approach and trauma care during this phase of the pandemic and for the subsequent waves of COVID-19 cases which will overload the health system. REFERENCES 1 1. Zhang J, Litvinova M, Liang Y, Wang Y, Wang W, Zhao S, et al. Changes in contact patterns shape the dynamics of the COVID-19 outbreak in China. Science. 2020;368(6498):1481-6. Zhang J Litvinova M Liang Y Wang Y Wang W Zhao S Changes in contact patterns shape the dynamics of the COVID-19 outbreak in China Science 2020 368 6498 1481 1486 2 2. World Health Organization. Coronavirus disease 2019 (COVID-19): Situation Report - 51. Geneva: WHO; 2020. World Health Organization Coronavirus disease 2019 (COVID-19): Situation Report - 51 2020 Geneva WHO 3 3. Brasil. Ministério da Saúde. CORONAVÍRUS BRASIL [homepage on the Internet]. Brasília, DF: Ministério da Saúde; 2020 [updated on 2022 May 16; acessed on 2020 May 16]. Available from: https://covid.saude.gov.br/. Brasil. Ministério da Saúde CORONAVÍRUS BRASIL homepage on the Internet 2020 DF Ministério da Saúde 2022 May 16 Available from: https://covid.saude.gov.br/ 4 4. Brasil. Secretaria de Saúde do Governo do Estado do Ceará. Boletim epidemiológico: doença pelo novo coronavírus (COVID-19). Fortaleza: Sesa; 2020. (Boletim Epidemiológico Covid-19; no. 15). Brasil. Secretaria de Saúde do Governo do Estado do Ceará Boletim epidemiológico: doença pelo novo coronavírus (COVID-19) 2020 Fortaleza Sesa Boletim Epidemiológico Covid-19 15 5 5. Secretaria de Saúde do Governo do Estado do Ceará. Boletim epidemiológico: Doença pelo novo coronavírus (COVID-19). Fortaleza: Sesa; 2021. (Boletim Epidemiológico Covid-19; no. 17). Secretaria de Saúde do Governo do Estado do Ceará Boletim epidemiológico: Doença pelo novo coronavírus (COVID-19) 2021 Fortaleza Sesa Boletim Epidemiológico Covid-19 17 6 6. Conselho Federal de Medicina (BR). Demografia médica: Brasil possui médicos ativos com CRM em quantidade suficiente para atender demandas da população [Internet]. Brasília, DF: CFM; 2018 [accessed on 2020 May 16]. Available from: https://portal.cfm.org.br/noticias/demografia-medica-brasil-possui-medicos-ativos-com-crm-em-quantidade-suficiente-para-atender-demandas-da-populacao/. Conselho Federal de Medicina Demografia médica: Brasil possui médicos ativos com CRM em quantidade suficiente para atender demandas da população 2018 DF CFM Internet 2020 May 16 Available from: https://portal.cfm.org.br/noticias/demografia-medica-brasil-possui-medicos-ativos-com-crm-em-quantidade-suficiente-para-atender-demandas-da-populacao/ 7 7. Li T, Liu Y, Li M, Qian X, Dai SY. Mask or no mask for COVID-19: a public health and market study. PLoS One. 2020;15(8):e0237691. Li T Liu Y Li M Qian X Dai SY Mask or no mask for COVID-19 a public health and market study PLoS One 2020 15 8 e0237691 8 8. Jain VK, Vaishya R. COVID-19 and orthopaedic surgeons: the Indian scenario. Trop Doct. 2020;50(2):108-10. Jain VK Vaishya R COVID-19 and orthopaedic surgeons the Indian scenario Trop Doct 2020 50 2 108 110 9 9. Placella G, Salvato D, Delmastro E, Bettinelli G, Salini V. CoViD-19 and Ortho and trauma surgery: the Italian experience. Injury. 2020;51(6):1403-5. Placella G Salvato D Delmastro E Bettinelli G Salini V CoViD-19 and Ortho and trauma surgery the Italian experience Injury 2020 51 6 1403 1405 10 10. Pradhan NMS, Acharya BM, Devkota P, Gyawali B, Bhatta TR, Pokhrel PM, et al. Orthopaedic services during COVID-19 lockdown at Patan Hospital, Nepal. Journal of Patan Academy of Health Sciences. 2020;7(1):19-24. Pradhan NMS Acharya BM Devkota P Gyawali B Bhatta TR Pokhrel PM Orthopaedic services during COVID-19 lockdown at Patan Hospital, Nepal Journal of Patan Academy of Health Sciences 2020 7 1 19 24 11 11. Christey G, Amey J, Campbell A, Smith A. Variation in volumes and characteristics of trauma patients admitted to a level one trauma centre during national level 4 lockdown for COVID-19 in New Zealand. N Z Med J. 2020;133(1513):81-8. Christey G Amey J Campbell A Smith A Variation in volumes and characteristics of trauma patients admitted to a level one trauma centre during national level 4 lockdown for COVID-19 in New Zealand N Z Med J 2020 133 1513 81 88 12 12. Lima EBS, Belangero PS, Falótico GG, Mansur NSB, Luzo MVM, Reis FB. Protocolo de intervenção do Departamento de Ortopedia e Traumatologia de um hospital universitário de alta complexidade para enfrentamento da pandemia de COVID-19. Rev Bras Ortop. 2020;55(3):269-77. Lima EBS Belangero PS Falótico GG Mansur NSB Luzo MVM Reis FB Protocolo de intervenção do Departamento de Ortopedia e Traumatologia de um hospital universitário de alta complexidade para enfrentamento da pandemia de COVID-19 Rev Bras Ortop 2020 55 3 269 277 13 13. World Health Organization. WHO Coronavirus (COVID-19) Dashboard: situation by region, country, territory or area [Internet]. Geneva: WHO; 2020 [accessed on 2021 May 3]. Available from: https://covid19.who.int/. World Health Organization WHO Coronavirus (COVID-19) Dashboard: situation by region, country, territory or area 2020 Geneva WHO Internet 2021 May 3 Available from: https://covid19.who.int/ 14 14. Maniscalco P, Poggiali E, Quattrini F, Ciatti C, Magnacavallo A, Caprioli S, et al. The deep impact of novel CoVID-19 infection in an Orthopedics and Traumatology Department: the experience of the Piacenza Hospital. Acta Biomed. 2020;91(2):97-105. Maniscalco P Poggiali E Quattrini F Ciatti C Magnacavallo A Caprioli S The deep impact of novel CoVID-19 infection in an Orthopedics and Traumatology Department the experience of the Piacenza Hospital Acta Biomed 2020 91 2 97 105 15 15. Ruggieri P, Trovarelli G, Angelini A, Pala E, Berizzi A, Donato D. COVID-19 strategy in organizing and planning orthopedic surgery in a major orthopedic referral center in an area of Italy severely affected by the pandemic: experience of the Department of Orthopedics, University of Padova. J Orthop Surg Res. 2020;15:279. Ruggieri P Trovarelli G Angelini A Pala E Berizzi A Donato D COVID-19 strategy in organizing and planning orthopedic surgery in a major orthopedic referral center in an area of Italy severely affected by the pandemic experience of the Department of Orthopedics, University of Padova J Orthop Surg Res 2020 15 279 279 16 16. Tahmassebi R, Bates P, Trompeter A, Bhattacharya R, El-Daly I, Jeyaseelan L, Pearse M. Reflections from London's Level-1 Major Trauma Centres during COVID crisis. Eur J Orthop Surg Traumatol. 2020;30:951-4. Tahmassebi R Bates P Trompeter A Bhattacharya R El-Daly I Jeyaseelan L Pearse M Reflections from London's Level-1 Major Trauma Centres during COVID crisis Eur J Orthop Surg Traumatol 2020 30 951 954 17 17. Maniscalco P, Ciatti C, Gattoni S, Quattrini F, Puma Pagliarello C, Patane' AC, et al. Proximal humerus fractures in COVID-19 lockdown: the experience of three orthopedics and traumatology departments in the first ten weeks of the Italian epidemic. Acta Biomed. 2021;92(1):e2021104. Maniscalco P Ciatti C Gattoni S Quattrini F Puma Pagliarello C Patane' AC Proximal humerus fractures in COVID-19 lockdown the experience of three orthopedics and traumatology departments in the first ten weeks of the Italian epidemic Acta Biomed 2021 92 1 e2021104 18 18. Brisa M. Primeiro lockdown em Fortaleza durou 24 dias, entre maio e junho de 2020. O Povo [Internet]. 2021 Mar 3 [accessed on 2021 May 6]. Available from: https://www.opovo.com.br/coronavirus/2021/03/03/primeiro-lockdown-em-fortaleza-durou-24-dias--entre-maio-e-junho-de-2020.html Brisa M Primeiro lockdown em Fortaleza durou 24 dias, entre maio e junho de 2020 O Povo Internet 03 03 2021 2021 May 6 Available from: https://www.opovo.com.br/coronavirus/2021/03/03/primeiro-lockdown-em-fortaleza-durou-24-dias--entre-maio-e-junho-de-2020.html 19 19. Almeida G. Primeiro lockdown decretado em municípios cearenses durou em média um mês; relembre. O Povo [Internet]. 2021 Mar 12 [accessed on 2021 May 6]. Available from: https://www.opovo.com.br/coronavirus/2021/03/12/primeiro-lockdown-decretado-em-municipios-cearenses-durou-em-media-um-mes--relembre.html Almeida G Primeiro lockdown decretado em municípios cearenses durou em média um mês; relembre O Povo Internet 12 03 2021 2021 May 6 Available from: https://www.opovo.com.br/coronavirus/2021/03/12/primeiro-lockdown-decretado-em-municipios-cearenses-durou-em-media-um-mes--relembre.html 20 20. PNAD Contínua: taxa de desocupação é de 14,4% e taxa de subutilização é de 29,2% no trimestre encerrado em fevereiro. Agência IBGE Notícias [Internet]. 2021 Apr 30 [accessed on 2021 May 6]. Available from: https://agenciadenoticias.ibge.gov.br/agencia-sala-de-imprensa/2013-agencia-de-noticias/releases/30599-pnad-continua-taxa-de-desocupacao-e-de-14-4-e-taxa-de-subutilizacao-e-de-29-2-no-trimestre-encerrado-em-fevereiro PNAD Contínua: taxa de desocupação é de 14,4% e taxa de subutilização é de 29,2% no trimestre encerrado em fevereiro Agência IBGE Notícias Internet 30 04 2021 2021 May 6 Available from: https://agenciadenoticias.ibge.gov.br/agencia-sala-de-imprensa/2013-agencia-de-noticias/releases/30599-pnad-continua-taxa-de-desocupacao-e-de-14-4-e-taxa-de-subutilizacao-e-de-29-2-no-trimestre-encerrado-em-fevereiro 21 21. Brasil. Lei nº 13.982, de 2 de abril de 2020. Diário Oficial da União [Internet]. 2020 Apr 2 [accessed on 2021 May 6];1:1. Available from: http://www.planalto.gov.br/ccivil_03/_ato2019-2022/2020/lei/l13982.htm Brasil Lei nº 13.982, de 2 de abril de 2020 Diário Oficial da União Internet 02 04 2020 2021 May 6 1 1 1 Available from: http://www.planalto.gov.br/ccivil_03/_ato2019-2022/2020/lei/l13982.htm 22 22. G1. Veja o calendário completo de pagamentos do Auxílio Emergencial. G1 [Internet]. 2021 Apr 7 [accessed on 2021 May 6]. Available from: https://g1.globo.com/economia/noticia/2020/04/07/como-sera-feito-o-pagamento-do-auxilio-emergencial-de-r-600.ghtml G1 Veja o calendário completo de pagamentos do Auxílio Emergencial G1 Internet 07 04 2021 2021 May 6 Available from: https://g1.globo.com/economia/noticia/2020/04/07/como-sera-feito-o-pagamento-do-auxilio-emergencial-de-r-600.ghtml 23 23. Mendes W. Policiais militares encerram motim após 13 dias de paralisação. Diário do Nordeste [Internet]. 2020 Mar 2 [accessed on 2021 May 7]. Available from: https://diariodonordeste.verdesmares.com.br/politica/policiais-militares-encerram-motim-apos-13-dias-de-paralisacao-1.2217238 Mendes W Policiais militares encerram motim após 13 dias de paralisação Diário do Nordeste Internet 02 03 2020 2021 May 7 Available from: https://diariodonordeste.verdesmares.com.br/politica/policiais-militares-encerram-motim-apos-13-dias-de-paralisacao-1.2217238 24 24. G1. Brasil tem aumento de 5% nos assassinatos em 2020, ano marcado pela pandemia do novo coronavírus; alta é puxada pela região Nordeste. G1 [Internet]. 2021 Feb 12 [accessed on 2021 May 7]. Available from: https://g1.globo.com/monitor-da-violencia/noticia/2021/02/12/brasil-tem-aumento-de-5percent-nos-assassinatos-em-2020-ano-marcado-pela-pandemia-do-novo-coronavirus-alta-e-puxada-pela-regiao-nordeste.ghtml G1 Brasil tem aumento de 5% nos assassinatos em 2020, ano marcado pela pandemia do novo coronavírus; alta é puxada pela região Nordeste G1 Internet 12 02 2021 2021 May 7 Available from: https://g1.globo.com/monitor-da-violencia/noticia/2021/02/12/brasil-tem-aumento-de-5percent-nos-assassinatos-em-2020-ano-marcado-pela-pandemia-do-novo-coronavirus-alta-e-puxada-pela-regiao-nordeste.ghtml 25 25. Miguela Álvarez SM, Bartra Ylla A, Salvador Carreño J, Castillón P, García Cardona C, Anglès Crespo F. Telephone consultation service in orthopedics during COVID-19 pandemic. Rev Esp Cir Ortop Traumatol (Engl Ed). 2021;65(3):167-71. Miguela Álvarez SM Bartra Ylla A Salvador Carreño J Castillón P García Cardona C Anglès Crespo F Telephone consultation service in orthopedics during COVID-19 pandemic Rev Esp Cir Ortop Traumatol (Engl Ed) 2021 65 3 167 171 2 The study was conducted at Instituto Doutor José Frota.