Background: Coronavirus disease 2019 (COVID-19) is a worldwide pandemic, with a case mortality ratio of approximately 6.4% at the time of writing (May 2020). Mortality increases in elderly patients with comorbidities. Patients with hip fracture have an average age of 80 years, with an estimated 2.8 comorbidities per patient. Evidence is lacking regarding the mortality rate of patients with hip fracture admitted during the COVID-19 pandemic. Our aim was to investigate the mortality rate among patients with a proximal femoral fracture who were admitted to our hospital during the COVID-19 pandemic. Methods: We conducted a retrospective review of all patients with a proximal femoral fracture admitted to Southend University Hospital in the U.K. from March to April 2020 (during the COVID-19 pandemic). Data collected included demographics (patient age, body mass index, sex), comorbidities, and blood test values along with COVID-19 diagnosis (based on positive microbiological sample and clinical and radiographic findings) and operative characteristics (time to operation, length of stay, American Society of Anesthesiologists [ASA] classification, Nottingham Hip Fracture Score). The primary outcome was the 30-day mortality rate for patients with a hip fracture who were COVID-19 positive or negative. Kaplan-Meier survival analysis was conducted along with Mann-Whitney U tests and Fisher exact tests. Results: Forty-one patients were included in the study, of whom 37 had an available SARS-CoV-2 (severe acute respiratory syndrome-coronavirus 2) swab test result. The overall 30-day mortality was 22%. Eleven patients tested positive for COVID-19. There was a significant difference in the mortality rate between those who tested positive and those who tested negative (54.5% versus 7.69%, respectively; Fisher exact test, p = 0.004) and between the operative patients who tested positive and the operative patients who tested negative (37.5% versus 4.34%, respectively; Fisher exact test, p = 0.043). Conclusions: Patients with a proximal femoral fracture may be at higher risk for mortality during the COVID-19 pandemic. We noted that patients with a proximal femoral fracture who tested positive for COVID-19 had a higher 30-day mortality rate compared with those who tested negative. Additional research is required to ascertain the benefits of a reduction in time to operation. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

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Steinmann pins are known to be used as a shoulder stabilisation device in recurrent dislocation. Although rare, their potential to migrate within the thorax has been reported. We present the case of an 87-year-old man who was treated for recurrent left shoulder dislocation with pinning using a Steinmann pin. He presented eight days postoperatively with the pin impaling the aortic adventitia. To our knowledge, this is only the fifth case report of such an event. Awareness of this complication and attempts to prevent its occurrence are critical as the outcome can be fatal. KEYWORDSSteinmann pin/wire -Recurrent shoulder dislocation -Intrathoracic migration Case HistoryAn 87-year-old man was referred to the orthopaedic department with a dislocated left shoulder (Fig 1). As well as recurrent atraumatic dislocation of the left shoulder, he had multiple co-morbidities including ischaemic heart disease, atrial fibrillation, a previous stroke and dementia. However, he had developed persistent pain in the joint and an operation was therefore deemed suitable. He underwent manipulation under anaesthesia and stabilisation of the glenohumeral joint in January 2013. Although we would typically use a thin Steinmann pin for shoulder fixation, none were available and so a larger (6mm) Steinmann pin was used. Figure 2 shows the intraoperative radiography of the reduced shoulder and Steinmann pin in situ. It was not possible to bend the exposed end of the larger pin. As a result, the pin was left straight.The patient presented to the emergency department three days later following a fall. Figure 3 shows the radiography at this time. The shoulder joint was dislocated and the Steinmann pin had retracted out of the glenoid. He was discharged from the emergency department and an orthopaedic opinion was not sought at this point.Five days later, the patient re-presented to the fracture clinic for a follow-up appointment complaining of chest pain and shortness of breath. Figure 4 shows the radiography revealing a left-sided pneumothorax with the pin reaching the mediastinal space. Such an injury would probably have developed into a life threatening tension pneumothorax. Further computed tomography showed the pin to be resting in the aortic adventitia, at the level of the arch between the arch and the pulmonary artery branch (Fig 5).The patient was tachycardic (heart rate 110bpm) but normotensive with an oxygen saturation of 90% on air. A chest drain was immediately inserted and he was resuscitated with high flow oxygen. He was transferred to a cardiothoracic unit where the pin was found to be impaling but not penetrating the aortic adventitia. It was removed via video assisted thoracic surgery (VATS) and he was further managed with a chest drain. A left-sided pneumothorax was the only complication and he made a swift recovery. He now has a chronically dislocated left shoulder with no movement at the joint. He is, however, pain free and no further surgery is planned.

Introduction Coronavirus disease 2019 (COVID-19) is a worldwide pandemic with a case mortality ratio of approximately 6.4%. Hip fracture patients are vulnerable if contracting COVID-19. Evidence is lacking regarding the mortality rate of hip fracture patients admitted during the COVID-19 pandemic. Method Retrospective review of all patients admitted to Southend University Hospital from March – April 2020. Demographic data (age, BMI, gender, co-morbidities) along with diagnosis of COVID-19 (clinical + (radiology +/- microbiology positive) and operative characteristics (time to operation, length of stay, ASA grading, Nottingham Hip Fracture Score), blood tests. Primary outcome was 30-day mortality rate in COVID-19 positive/negative patients who had hip fracture. Results 41 patients were included in the study of which 37 had a COVID-19 swab. Overall mortality in the group was 22%. Eleven patients tested positive for COVID-19. There was a statistically significant difference in mortality between those testing positive compared to those testing negative (54.5% versus 7,69% respectively, Fisher’s exact test, p = 0.004) and when comparing those who had an operation and tested positive for COVID-19 against those who had an operation and tested negative (37.5% versus 4,34% respectively, Fisher’s exact test, p = 0.043). Conclusions COVID-19 increases the 30-day mortality in neck of femur fracture patients.

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