A study led by University Hospitals of Leicester NHS Trust has found that plaster casts are just as effective at healing scaphoid waist fractures in the wrist as surgery. The SWIFFT trial, funded by the National Institute for Health Research, concludes that for a scaphoid waist fracture in the wrist, a plaster cast should be used in the first instance, with surgery only being considered if the bone does not heal. The findings have been published by The Lancet.
Fracture of the scaphoid bone is common in young, active people, caused by a fall on the hand or the hand being suddenly forced backward. The new research suggests that by opting for a plaster cast, patients can avoid the risk of surgery, while hospitals can keep service delivery simple and cost effective, without compromising patient outcomes.
A total of 439 adult patients with a scaphoid waist fracture of the wrist were enrolled between 2013 and 2016 at 31 NHS hospitals across UK. Patients who agreed to take part were randomly assigned to 1 of 2 arms of the trial: either surgery using a special screw for fixation of the fractured scaphoid or use of a plaster cast. After 6 weeks, surgery was offered to patients in the plaster cast group whose fractures had not yet healed.
One year from the initial injury, the researchers assessed and compared wrist pain and function, bone healing, complications from treatment, and average days of work across treatment groups.
To measure wrist pain and function, patients were asked to complete a questionnaire that had a total score of between 0 and 100, with a higher score indicating worse pain and function. At 1 year, patients in the surgery group had a score of 12, compared with a score of 14 in the plaster group, showing no significant difference in patient-reported outcomes. Days of work lost were comparable between the groups: 17 days for surgical patients, and 18 days for plaster cast patients.
No significant difference was seen in the number of fractures that did not heal properly between groups: 2% for the surgical group and 4% for the plaster cast group. However, patients who had surgery had more complications following treatment (12%) than patients in the plaster cast group (2%).
“This study confirms that putting a wrist with a broken scaphoid in a plaster cast provides as good healing as surgery, so long as the few that do not re-join are identified and fixed by the medical team,” said Professor Joseph Dias, orthopaedic surgeon at the University Hospitals of Leicester NHS Trust and Chief Investigator for the SWIFFT trial.
“Fixing the scaphoid by surgery does not speed up healing and the time taken to return to work is the same as when a cast is used. Despite a recent rise in surgical procedures to fix scaphoid fractures, there is no evidence that surgery produces better outcomes for patients.
“With our research, patients and medical practitioners can be confident that we can treat patients with this fracture safely and effectively in a cast, resorting to surgery only when the bone doesn’t heal.”
The researchers also considered the health economics of surgery versus plaster cast. Over the year, the cost of surgery to the NHS was significantly higher at £2,350 (US $3030), compared with the cost of plaster cast treatment, which was £727 (US $932) for each patient.
Dias JJ, Brealey SD, Fairhurst C, et al. Surgery versus cast immobilisation for adults with a bicortical fracture of the scaphoid waist (SWIFFT): a pragmatic, multicentre, open-label, randomised superiority trial. Lancet. 2020 Aug 8;396(10248):390-401. doi: 10.1016/S0140-6736(20)30931-4.