South African Orthopaedic Journal TRAUMA AND GENERAL ORTHOPAEDICS DOI 10.17159/2309-8309/2022/v21n2a1Foster M et al. SA Orthop J 2022;21(2) Citation: Foster M, Du Plessis J, Jansen van Vuuren M, Jingo M, Pietrzak JRT. The impact of the Covid-19 lockdown restrictions on orthopaedic trauma admissions in a central academic hospital in Johannesburg. SA Orthop J. 2022;21(2):70-75. http://dx.doi. org/10.17159/2309-8309/2022/ v21n2a1 Editor: Prof. Nando Ferreira, Stellenbosch University, Cape Town, South Africa Received: August 2021 Accepted: November 2021 Published: May 2022 Copyright: © 2022 Foster M. This is an open-access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. Funding: No funding was received for this study. Conflict of interest: The authors declare they have no conflicts of interest that are directly or indirectly related to the research. Abstract Background The novel coronavirus (SARS-CoV-2), commonly known as Covid-19, has caused a global economic and healthcare crisis. Many countries tried to curb the spread of the virus by implementing various lockdown restrictions to reduce transmission. The Republic of South Africa (RSA) implemented an alcohol ban as one of the lockdown restrictions. The objectives were to describe the effect of the lockdown alert levels and alcohol availability on orthopaedic trauma admissions, compared to the preceding two years. Methods A retrospective review of clinical records was conducted. Data included orthopaedic trauma admissions for the five-month period in a facility in Johannesburg from 27 March to 31 August in the years 2018, 2019 and 2020. Lockdown alert levels were categorised according to the Department of Health which included the ban, reintroduction and re-banning of alcohol con- sumption. Data collected for 2018, 2019 and 2020 included demographics of sex and age, as well as fracture location, open or closed injuries, polytrauma patients and gunshot injuries. Results Overall, 672, 621 and 465 patients were admitted in 2018, 2019 and 2020, respectively. There was a decrease of 25% of orthopaedic trauma admissions during the five-month lockdown period in 2020 compared to 2019 (p-value = 0.020) and 30% from 2020 compared to 2018 (p-value = 0.010). In 2020, admissions increased by 112% (n = 82) from alert level 4, when alcohol was banned, to alert level 3 (3a), when alcohol was reintroduced. Admissions decreased by 33% (n = 51) from alert level 3 (3a) to alert level 3 (3b), when alcohol was re-banned. Motor vehicle accidents (MVAs) were the commonest cause of admissions in alert level 3 (3a), accounting for 41% (n = 56). Covid-19 tests were positive in 10% (n = 34) of the 346 tests performed on orthopaedic trauma admissions. Conclusion Our study showed the decrease in orthopaedic trauma admissions due to the Covid-19 lockdown regulations. Furthermore, our study demonstrated the impact of alcohol availability on orthopaedic trauma admissions in a central academic hospital in Johannesburg. Level of evidence: Level 4 Keywords: Covid-19, orthopaedic trauma, alcohol The impact of the Covid-19 lockdown restrictions on orthopaedic trauma admissions in a central academic hospital in Johannesburg Matthew Foster,¹* Jason du Plessis,² Marike Jansen van Vuuren,¹ Maxwell Jingo,¹ Jurek RT Pietrzak² ¹ Division of Orthopaedic Surgery, University of the Witwatersrand, Johannesburg, South Africa ² Charlotte Maxeke Johannesburg Academic Hospital, Division of Orthopaedic Surgery, University of the Witwatersrand, Johannesburg, South Africa *Corresponding author: matthew@drfoster.co.za Introduction The novel coronavirus (SARS-CoV-2), commonly known as Covid-19, was declared a pandemic in March 2020 by the World Health Organization (WHO) and has caused a global health crisis.1 The virus has spread rapidly worldwide spanning 223 countries to date with more than 172 million cases diagnosed and more than 3 711 672 deaths.1 At the time of writing, in the Republic of South Africa (SA), 1 675 013 cases have been diagnosed with 56 711 deaths recorded.2 On 15 March 2020, in response to the escalating number of infections, President Cyril Ramaphosa declared a national state of disaster in SA.3 The SA government made the decision to implement a nationwide lockdown in order to ‘flatten the curve’ and prepare an under-resourced healthcare system for the inevitable outbreak.2 The lockdown consisted of five alert levels, decreasing in stringency on restrictions of freedom of movement and accessibility to alcohol, with alert level 5 implemented on the 27 March 2020; at the time of writing, we are still under lockdown. A number of unique restrictions were enforced in SA that differed from the rest of the world. One such restriction was the prohibition of selling and distributing alcohol.3-5 Trauma-related injuries claimed 4.9 million lives in 2016, of which 29% were as a result of road traffic accidents.6,7 The leading cause of death between the ages of 5 and https://orcid.org/0000-0001-7709-9529 Page 71Foster M et al. SA Orthop J 2022;21(2) 45 years in low- to middle-income countries was injury, which is consistent with SA statistics, as trauma-related orthopaedic injuries currently remain the largest burden on orthopaedic departments across government hospitals.8 Alcohol is a significant contributing factor to trauma-related injuries. The WHO predicts three million deaths worldwide are attributed to alcohol, representing 5.3% of all deaths and is a causal factor in over 200 conditions including injury.9 The devastating socioeconomic and healthcare sector impact caused by the burden of alcohol in SA is well documented, with 62 300 adults dying from alcohol-attributed deaths in 2015.10,11 The tangible financial cost of harmful alcohol use in SA is estimated at R37.9 billion or 1.6% of the GDP.12 Worldwide, the impact of lockdown levels on orthopaedic trauma admissions has been widely documented (Table I). Waseem et al. reviewed over 665 studies noting a decrease in trauma admission rates ranging from 20.3% up to 84.6%.13 Many studies from Europe, Asia, Australasia and the United States of America have all shown varying degrees of a decrease in orthopaedic trauma admissions (Table I).14-21 The aim of this study is to determine the impact of lockdown restrictions and subsequent alcohol prohibition imposed in response to the Covid-19 pandemic on orthopaedic trauma admissions at a central academic hospital in Johannesburg, compared to the preceding two years. Methods Our study was a retrospective review of patients admitted to a central academic hospital in Johannesburg with a trauma orthopaedic injury for the five-month period from 27 March to 31 August in the years 2018, 2019 and 2020, respectively. All research data were collected with approval from both the hospital board and a local research ethics committee. Our study defined acute orthopaedic trauma injuries as: fractures or dislocations of the upper and lower limbs, traumatic joint injuries, soft tissue injuries to the lower limbs, pelvis injuries and polytrauma patients. These were included in the study population. The legal age for alcohol consumption in South Africa is 18 years; therefore, only patients above 18 years were included in this study. All patients with chronic orthopaedic injuries, musculoskeletal infection, hand fractures distal to the carpus, upper limb tendon injuries, spinal fractures as well as paediatric patients, were excluded as they were attended to by different specialist units. Admission data were collected from a variety of sources includ- ing: trauma admission data sheets collected by the orthopaedic department daily, orthopaedic trauma admission books, clinical audits compiled by the orthopaedic departments six-monthly, as well as morbidity and mortality meeting statistics. All data were collected by the principal investigator (MF), and the results were collated using Microsoft Excel (Microsoft, Seattle, Washington). Table I: Global decrease of orthopaedic trauma admissions14-21 Author Country of research report Decrease in orthopaedic trauma admissions during lockdown policies Hampton et al. UK 53.7% Wong et al. Hong Kong 41.2% Carkci et al. Turkey 81.8% MacDonald et al. Scotland 26.6% Luceri et al. Italy 73.8% DiFazio et al. USA 44.9% Christey et al. New Zealand 43% Jacob et al. Australia 23‒34% Data is expressed as percentages. Table II: Summary of lockdown alert levels Level 5 Level 4 Level 3 (3a) Level 3 (3b) Level 2 Alcohol availability Banned Banned Sales permitted with conditions Banned Sales permitted with conditions Movement Compulsory mask wearing No inter-provincial travel – only allowed to leave home to get essential goods or for healthcare Compulsory mask wearing No inter-provincial travel except for returning home or exceptional conditions (e.g. funerals) Walking/jogging allowed from 06:00–09:00 Compulsory mask wearing No inter-provincial travel except for special circumstances: work travel, moving homes, funerals, obtaining medical therapy Compulsory mask wearing No inter-provincial travel except for special circumstances: work travel, moving homes, funerals, obtaining medical therapy Compulsory mask wearing Inter-provincial travel allowed Sectors permitted Only essential services permitted All essential services, limited number of sectors with high economic value All economic activity permitted except where rate of transmission is high All economic activity permitted except where rate of transmission is high All economic activity permitted except where rate of transmission is high Retail Only essential goods permitted including food, medical supplies and hygiene products As per level 5, plus education supplies and stationery Restaurants and takeaways only for delivery All retail permitted with strict health precautions and limitations of people All retail permitted with strict health precautions and limitations of people All retail permitted with strict health precautions and limitations of people Gatherings All public gatherings prohibited All public gatherings prohibited All public gatherings prohibited Six people indoor and 15 people outdoor permitted Limited to 50 people Curfew No persons allowed to leave home 20:00–05:00 except essential workers 22:00–04:00 21:00–04:00 22:00–04:00 Public transport Taxis and buses to transport essential workers, limited hours and capacity restrictions Passenger rail, taxis and buses may operate subject to restrictions Passenger rail, taxis and buses may operate subject to restrictions All allowed at 50% capacity No restrictions Page 72 Foster M et al. SA Orthop J 2022;21(2) Patients’ data were categorised into a variety of groups: demo- graphics, fracture location and morphology, polytrauma, open or closed injuries and mechanism of injury. Demographic data included the patients’ sex and age groups, which were divided into those patients younger than 30 years, 31–50 years, 51‒70 years and older than 70 years. Fracture location was divided into upper limb, lower limb, pelvis and acetabulum, and polytrauma patients. Upper limb injuries are defined from the clavicle down to carpal bones; lower limb injuries are defined as femoral head to phalanges of the foot; pelvis is defined as injuries to the ischium, ileum and pubis. Hand injuries distal to the carpus and tendon injuries to the upper limb were excluded as they are managed by plastic surgery in our facility. Upper limb and lower limb injuries were further categorised into the location of injury. Pelvis injuries included injuries to the pelvic ring and acetabular fractures. Polytrauma was categorised into more than two long bone fractures, a long bone with a pelvis injury and a long bone with other injury. Open or closed injuries were defined as to whether the associated fracture had an associated breach of skin resulting in an open fracture or a traumatic joint injury. Gunshot wounds (GSWs) were recorded in 2018, 2019, 2020, but other mechanisms of injury (MOI) were only recorded for 2020. These included a fall from standing height (FFSH), fall from height (FFH) (recorded as a fall greater than one step), motor vehicle/motor bike accident (MVA/MBA), pedestrian vehicle accidents (PVA) and not otherwise specified. Covid-19 results were recorded in 2020 and this is defined if the patient tested positive for Covid-19 on a polymerase chain reaction (PCR) nasal swab. The time periods were categorised according to the months and lockdown alert levels in 2020, as published in the Government Gazette by the Department of Health, and corresponding time periods in 2018 and 2019.3-5 Lockdown levels included alert level 5 which commenced on 27 March 2020 and lasted until 30 April 2020. Restrictions included, but were not limited to, a complete ban of alcohol sales, a curfew, work from home except for essential workers with forced closure of all takeaway outlets and restaurants (Table II). Alert level 4 commenced on 1 May 2020 until 31 May 2020 with a slight ease of restrictions, including allowing for takeaway outlets to operate but maintaining the alcohol prohibition. Lockdown alert level 3 (3a) commenced on 1 June 2020 until 12 July during which time alcohol sales were permitted but subject to specific restrictions. Revised alert level 3 (3b) was from 13 July to 17 August 2020, which did not allow alcohol sales or distribution (Table II). Data analysis Categorical variables were described using counts and percentages. Two categorical variables were compared using chi-square test or Fisher’s exact test when appropriate. Logistic regression was used to determine associations between binary outcomes (e.g., hospitalisations in 2019 vs 2020 and hospitalisations in alert level 3 (3a) vs 3 (3b) and age, sex, MOI and site. Incidence rates were calculated as the number of events divided by the number of days in the given period. Incidence rates were compared using an exact Poisson test. Results Overall, 672 patients were admitted in 2018, 621 admitted in 2019 and 465 in 2020, during the five-month time period from 27 March to 31 August. There was a significant decrease of admissions by 25% between 2019 and 2020 (p-value = 0.020) and 30% between 2018 and 2020 (p-value = 0.010 ) (Figure 1). In alert level 5 lockdown, 81 patients were admitted in 2020 compared to 116 in 2019 and 145 in 2018 for the same time periods. In alert level 4 lockdown, admissions decreased by 42% from 126 in 2019 to 73 patients in 2020 (p-value < 0.001). 200 180 160 140 120 100 80 60 40 20 0 2018 Level 5 Level 4 Level 3a Level 3b Level 2 2019 2020 Figure 1. Orthopaedic trauma admissions during lockdown alert levels in 2020 and corresponding time periods in 2018 and 2019 160 140 120 100 80 60 40 20 0 Level 5 Level 5 Level 5Level 4 Level 4 Level 4Level 3a Level 3a Level 3aLevel 3b Level 3b Level 3b 2018 2019 2020 Level 2 Level 2 Level 2 Lower limb Upper limb Polytrauma Open ClosedPelvis & acetabulum Figure 2. Site, open and closed injuries according to lockdown alert levels in 2018, 2019 and 2020 Page 73Foster M et al. SA Orthop J 2022;21(2) Table III: Total number of orthopaedic admissions in 2018, 2019 and 2020 2018 2019 2020 p-value 2020 vs 2018 p-value 2020 vs 2019 Admissions 672 621 465 0.010 0.010 Age (years) < 30 194 (29%) 165 (27%) 132 (28%) 0.020 0.021 30–50 330 (49%) 303 (49%) 243 (52%) 0.85 0.060 51–70 104 (16%) 107 (17%) 56 (12%) 0.002 0.291 > 70 44 (7%) 46 (7%) 34 (7%) 0.081 0.412 Sex Female 231 (34%) 220 (35%) 157 (34%) 0.022 0.112 Male 441 (66%) 401 (65%) 308 (66%) 0.011 0.029 Fracture location Clavicle 18 (3%) 16 (2%) 12 (3%) 0.022 0.655 Proximal humerus 10 (2%) 5 (1%) 11 (2%) 0.855 0.034 Midshaft humerus 35 (5%) 27 (4%) 13 (3%) < 0.001 0.568 Distal humerus 5 (1%) 2 (0.3%) 1 (0.2%) 0.65 > 0.999 Proximal forearm 15 (2%) 15 (2%) 9 (2%) 0.079 0.596 Radius/ulna shaft 19 (3%) 13 (2%) 9 (2%) < 0.001 0.852 Distal radius/ulna 77 (12%) 58 (9%) 51 (11%) 0.03 0.072 Carpus 1 (0.1%) 1 (0.1%) 1 (0.2%) > 0.999 0.309 Other upper limb 20 (3%) 11 (2%) 6 (1%) < 0.001 0.770 Per trochanteric 41 (6%) 46 (7%) 42 (92%) 0.665 0.113 Femur shaft 54 (8%) 39 (6%) 19 (4%) < 0.001 0.229 Distal femur 4 (1%) 4 (1%) 8 (2%) 0.004 0.046 Patella 11 (2%) 17 (3%) 11 (2%) 0.043 0.637 Proximal tibia 16 (2%) 19 (3%) 26 (6%) 0.201 0.021 Tibia shaft 105 (16%) 81 (13%) 38 (8%) < 0.001 0.233 Pilon and ankle 133 (20%) 145 (23%) 80 (17%) 0.087 0.465 Foot 45 (7%) 19 (3%) 32 (7%) 0.022 0.002 Other lower limb 17 (3%) 21 (3%) 14 (3%) 0.034 0.701 Pelvis/acetabulum 17 (3%) 8 (1%) 20 (4%) 0.288 0.002 Polytrauma Two long bones 22 (3%) 45 (7%) 35 (8%) < 0.001 0.582 Long bone + pelvis 6 (1%) 19 (3%) 9 (2%) 0.001 > 0.999 Long bone + other 1 (0.1%) 4 (1%) 17 (4%) < 0.001 < 0.001 Open injury Open 98 (15%) 99 (16%) 83 (18%) 0.217 0.082 Closed 574 (85%) 522 (84%) 382 (82%) 0.010 0.043 Injury site Lower limb 426 (63%) 394 (63%) 272 (59%) 0.001 0.067 Upper limb 199 (30%) 146 (24%) 111 (24%) 0.002 0.086 Pelvis/acetabulum 17 (3%) 8 (1%) 20 (4%) 0.045 < 0.001 Polytrauma 30 (5%) 73 (12%) 62 (13%) < 0.001 0.077 Data is expressed as counts with frequencies in parentheses. 60 50 40 30 20 10 0 Level 5 Level 4 Level 3a Level 3b Level 2 MVAGSW PVA FFH FFSH Figure 3. Mechanism of injury during lockdown alert levels in 2020 180 160 140 120 100 80 60 40 20 0 Level 5 Alcohol prohibited Level 4 Alcohol prohibited Level 3a Alcohol allowed Level 3b Alcohol prohibited Level 2 Alcohol allowed Figure 4. Total admissions through different stages of lockdown Page 74 Foster M et al. SA Orthop J 2022;21(2) Demographics, fracture morphology and site of all admissions in 2018, 2019 and 2020 are illustrated in Table III. Open fractures accounted for 16% and closed fractures accounted for 84% of the admissions in 2018, whereas in 2020, the proportion of open fractures increased to 18% (p-value = 0.157) and closed fractures decreased to 82%, respectively (p-value = 0.010) (Figure 2). Admissions increased by 112% (n = 82) in alert level 3 (3a) from alert level 4, followed by a decrease of admissions by 33% (n = 51) in alert level 3 (3b), from level 3 (3a) (p-value = 0.050). The incidence rate (IR) of admissions during alert level 3 (3a) vs 3 (3b) is 1.27 (95% CI: 0.99, 1.65). During alert level 3 (3a), patients < 30 years accounted for 34% of admissions compared to 20% in level 3 (3b). Patients admitted in the 30‒50 years age group were 2.16 times more likely than patients < 30 years to be admitted in alert level 3 (3b) compared to alert level 3 (3a) (p-value = 0.020). From initiation of mandatory testing of all orthopaedic admis- sions from 19 May 2020, 346 Covid-19 tests were performed on orthopaedic trauma admissions, of which 10% were positive (n = 34) (p-value = 0.001). Of the 34 positive patients, 71% (n = 24) of patients were male (p-value = 0.001). No patients that were Covid-19 positive sustained GSWs and 3% (n = 1) of Covid-19 positive patients sustained an open fracture (p-value < 0.001). During alert level 5, FFSH were the commonest MOI accounting for 42% (n = 28) of admissions. MVAs were the commonest cause of admissions in alert level 3 (3a), accounting for 41% (n = 56) whereas in alert level 3 (3b), MVAs decreased to 12% (n = 12) (p-value = 0.001) (Figure 3). In alert level 3 (3b), FFSH was again the MOI which attributed to the most admissions at 39% (n = 38). GSWs remained constant through all alert levels of lockdown ranging from 11% (n = 7) of admissions in alert level 5, up to 16% (n = 8) in alert level 2. Discussion Our study showed that there was a decrease of 31% and 25% in orthopaedic trauma admissions from the initiation of lockdown compared to the same time periods in 2018 and 2019, respectively. Global reports have shown similar trends; however, many of these were conducted over a short time period, whereas this study has a longer time period to compare data. Hampton et al. showed a decrease of 53.7% of orthopaedic trauma admissions in a United Kingdom (UK) hospital from a two-week pre-lockdown time period to a two-week lockdown time period, and compared these rates to 2019.14 Christey et al. noted a decrease of 43% of admissions in a New Zealand facility and DiFazio et al. showed a 44.9% decrease in a USA facility, for a two-week period pre- and post-lockdown, but without the 2019 comparison.15,20 If we compare the combination of alert levels 4 and 5, referred to as the hard lockdown, to the same time period in 2019, the decrease in admissions was 36% which was more consistent with international data. SA has a higher burden of trauma relating to interpersonal violence compared to developed nations, where the majority of injuries in developed nations are caused by MVAs or falls, and much less violence.22 A reasonable assumption can be made about the decrease in trauma admissions during lockdown. This was due to policies enforced by government such as: non- essential service employees working from home, a curfew, school closures and a ban on alcohol and cigarettes. This would result in fewer MVAs/PVAs and sporting injuries, and less interpersonal violence and crime. All of the above would be further decreased without the exaggerated harmful effects of intoxication, as alcohol has been proven in SA to have a severe negative impact on society.10 In SA, Moustakis et al. looked at all surgical admissions in the North West in alert level 5, noting a 53% reduction in trauma- related conditions.23 Navsaria et al. noted similar results with a decrease of 53% of all surgical trauma admissions during the hard lockdown in Cape Town.24 Waters et al. specifically looked at the reduction of orthopaedic services from 01 January to 30 April 2020 at Groote Schuur hospital to compare pre-lockdown and lockdown admission rates, noting a decrease of orthopaedic admissions by 40% in April. Our data was consistent with our colleagues in Cape Town, comparing a tertiary hospital in Cape Town to one in Johannesburg; however, our study further looked at the availability and prohibition of alcohol, and the effects thereof.25 Our study showed a significant increase in admissions of 112% from when alcohol was banned in alert level 4, to when it was available in alert level 3 (3a) (Figure 4). The change in admissions between alert levels 4, 3 (3a) and 3 (3b) suggests the influence alcohol has on orthopaedic trauma. Reuter et al. stated that 62 300 South Africans die of alcohol-attributable causes annually and noted a sharp reduction in unnatural related deaths from pre-lockdown of 800‒1 000 per week to a rate of 400 per week during lockdown.26 Furthermore, there was a 45% decrease in orthopaedic admissions from two weeks pre-lockdown to the first two weeks of lockdown from the hospital in George where Reuter et al. conducted their research.26 The decrease in admissions due to MVAs from 41% in alert level 3 (3a) to 13% in alert level 3 (3b) identified the significant impact alcohol availability had on MVAs. The association between alcohol and MVAs is consistent with global trends as Papalimperi et al. identified 40.7% of all MVAs over a seven-year period were alcohol related.27 Shneider et al. looked at the burden of disease attributed to alcohol in SA, noting that interpersonal violence and road traffic accidents contributed significantly to disability adjusted life years, clearly illustrating the harmful effects of alcohol on South African society.28 When comparing 2018, 2019 and 2020, males have consistently accounted for almost two-thirds of admissions. Our study showed no difference in this trend during lockdown, which is in keeping with global literature, as males are more prone to trauma-related injuries due to increased risk-taking behaviour and higher levels of interpersonal violence.9,29 When alcohol was allowed in alert level 3 (3a), the age group younger than 30 years accounted for 34% of admissions compared to 16% in alert level 4, when alcohol was banned. This illustrated the impact alcohol has on those younger than 30 years, which was consistent with Caamaño-Isorna et al.’s results, which showed the increase in alcohol-associated injuries in college students in Spain.30 Mandatory Covid-19 testing of all admissions was not present during the early lockdown alert levels so the incidence of 10% was during our peak time period. Pillai et al. concluded that the number of Covid-19 positive patients increased with the easing of lockdown regulations to level 3 in Gauteng, which is consistent with our data.31 In the Covid-19 positive population, demographics, fracture pattern and mechanism of injury were similar to that of Covid-19 negative patients. Globally, the socioeconomic impact of orthopaedic trauma and alcohol is immense. In the USA, an estimated $53.1 billion is spent annually to treat musculoskeletal injuries, with over a million hospital discharges recorded for fractures.32 Probst et al. identified the socioeconomic effect of alcohol on the South African population, noting that 60% of deaths due to alcohol occur in patients within the low socioeconomic status group.10 Martin et al. calculated that the cost of treating an orthopaedic trauma patient secondary to a GSW in SA was $2 940 (R24 945 at the time), three hours of theatre time with an average stay of 9.75 days.33 The combination of financing healthcare costs, acute and chronic disability of patients, hospital stay and rehabilitation, as well as the time off work, places severe strain on our economy. Alcohol is a major contributing factor, as demonstrated by this report, and the effects of which can be minimised. The WHO has led a global initiative to assist governments in decreasing alcohol-associated harm.34 Page 75Foster M et al. SA Orthop J 2022;21(2) Covid-19 and the effects of the lockdown policies have demon- strated significant associations between alcohol and orthopaedic trauma admissions. The data collected during this period can be utilised to guide government policies in limiting the harmful effects of alcohol on our society. Data collection at our institution was not uniform and multiple sources were recorded to obtain data to get a global perspective. Additional limitations included government lockdown bias as a curfew was imposed. This may contribute to diminished orthopaedic trauma admissions in conjunction with no alcohol availability. Moultrie et al. concluded that the complete prohibition of alcohol had a significant reduction in unnatural deaths regardless of the length of the curfew.35 Lastly, with the anticipated reintroduction of alcohol restrictions, people may have stockpiled alcohol, making it available to them during the time of repeat restrictions. Conclusion Covid-19 and the lockdown policies enforced by governments worldwide has had a significant effect on decreasing orthopaedic trauma admissions, with SA consistent with global trends. Alcohol availability clearly has a major impact on orthopaedic trauma admissions which, through correct legislation, can be minimised. Our study will hopefully allow government and policy makers to rethink the current legislature around alcohol availability and consider enforcing further regulations limiting alcohol access and the consequence thereof on our healthcare system. Ethics statement The authors declare that this submission is in accordance with the principles laid down by the Responsible Research Publication Position Statements as developed at the 2nd World Conference on Research Integrity in Singapore, 2010. All research data were collected with approval from both the hospital board and University of the Witwatersrand Human research ethics committee (HREC) (Clearance number: M200877). All procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008. Declaration The authors declare authorship of this article and that they have followed sound scientific research practice. This research is original and does not transgress plagiarism policies. Author contributions MF: study conceptualisation, data capture, data analysis, manuscript preparation, revision and approval of final manuscript JdP: manuscript revision and approval of final manuscript MJvV: data collection and approval of final manuscript MJ: manuscript revision and approval of final manuscript JRTP: study conceptualisation, manuscript revision and approval of final manuscript ORCID Foster M https://orcid.org/0000-0001-7709-9529 Du Plessis J https://orcid.org/0000-0002-4617-9742 Jingo M https://orcid.org/0000-0003-2715-5742 Pietrzak JRT http://orcid.org/0000-0001-5694-0016 References 1. WHO. Emergency diseases: Novel Coronavirus 2019 [Internet]. Available from: https://www. who.int/emergencies/diseases/novel-coronavirus-2019. Aaccessed 10 August 2021. 2. Department Of Health. SA Coronavirus [Internet]. Available from: https://sacoronavirus.co.za/. Accessed 10 August 2021. 3. Department of Health. Government Gazette Staatskoerant. 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