SWIFFT trial results support cast treatment of scaphoid waist fractures
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Evidence from a major study published in Lancet showed most scaphoid waist fractures achieve union with casting alone, reserving an indication for surgery for a limited number of cases, a presenter said.
At the American Society for Surgery of the Hand Annual Meeting, Joseph J. Dias, MBBS, FRCS, FRCS (Edinburgh), MD, of University Hospitals of Leicester NHS Trust in Leicester, United Kingdom, discussed results of the Scaphoid Waist Internal Fixation for Fractures Trial (SWIFFT), for which he was lead investigator.
“We found that there was no difference across the time period between whether they were fixed or whether they were treated in a cast,” Dias said.
To clarify the study findings, Dias said results of SWIFFT showed scaphoid waist fractures with less than 2 mm of displacement are amenable to nonoperative treatment with casting.
However, scaphoid waist fractures that are displaced more than 2 mm can undergo percutaneous operative fixation during which the distal pole is identified, a wire is put down the scaphoid and then the wire is replaced by a headless screw. Once the position of the screw is confirmed to be accurate under image intensification, the patient can undergo splinting, casting or have the wrist left free for a short amount of time, according to Dias.
Indications for surgery
“If there is a trans-scaphoid peri-lunate dislocation, that is another clear indication to stabilize because you are now stabilizing the proximal carpal row” he said.
It is not clear from the results whether proximal pole scaphoid fractures, defined as a fracture of the proximal 20% of the scaphoid, should be operatively treated, Dias said, “because two-thirds of these could join.”
SWIFFT data showed patients could also be offered surgery for a fracture that presents after 1 month, as well as for open fractures and multiple fractures, according to Dias, who suggested discussing the pros and cons of surgery with patients and presenting all the alternatives whenever there are relative surgical indications.
Casts for nonoperative care
SWIFFT researchers recruited and followed up 219 patients to have surgery immediately after a scaphoid waist fracture with less than 2 mm of displacement and 220 patients to be put in a cast initially. Nearly the entire cast group was placed in casts that did not include the thumb, Dias said. At 6 weeks, casted patients in whom a fracture nonunion was suspected underwent CT to confirm fracture status. Patients in that group who had a nonunion at that time underwent surgical fixation.
Researchers followed all patients with both domains of the patient-rated wrist evaluation – pain and functional.
“The two groups were similar for pain and function, but look at this,” Dias said. “Return to work was only 2 days different between the two groups, and I suspect that reflects the type of cast that we use, which was a below-elbow cast where the thumb was left free, so you could use the hand to perform tasks.”
“The healing rate was almost exactly the same. It was 96% union if you treated it in a cast and 98% union if treated with early fixation,” he said.
Different complication rates
“Complications were different as one would expect, that less than 2% had complications if they were treated in a cast and around 12% had moderate complications if they had internal fixation,” Dias said, discussing some of the possible, and sometimes rare, surgical complications, including screw failure and articular cartilage damage from a screw left proud.
“Infection, of course all of us know it leads to excavation and almost a hollow scaphoid, and that is difficult to salvage,” he said.
References:
Dias JJ, et al. Lancet. 2020;doi:10.1016/S0140-6736(20)30931-4.
Editor's Note: This article was revised on Nov. 2, 2021 to better reflect the study.
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Dias JJ. Is ORIF better than casting? Lessons learned from the SWIFFT trial. Presented at: American Society for Surgery of the Hand Annual Meeting. Sept.30 - Oct. 2, 2021; San Francisco (hybrid meeting).
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