Scaphoid Waist Internal Fixation for Fractures (SWIFFT) Trial (v1)
Research type
Research Study
Full title
A multi-centre randomised controlled trial evaluating cast treatment versus surgical fixation on wrist function for fractures of the scaphoid waist in adults
IRAS ID
118722
Contact name
Joseph Dias
Contact email
Sponsor organisation
University Hospitals of Leicester NHS Trust
ISRCTN Number
ISRCTN67901257
Research summary
Summary of Research
Fracture of the scaphoid bone (one of eight small bones in the wrist) is common in young active people, caused by a fall on the hand or the hand being suddenly forced backward. The usual treatment is to rest the wrist in a plaster cast for six to ten weeks and allow the broken bone to heal. In one in ten cases treated in a plaster cast, the bone does not heal and an operation is needed. In the operation, the broken bone is held still with a screw. In the last few years, it has become more common to fix the broken bone with a screw in the first few days after injury, instead of resting the wrist in plaster cast. It is not clear if fixing the bone early with a screw compared with resting the wrist in a cast gives better outcomes for patients and if one treatment gives more value for money to the National Health Service (NHS).In this study, 439 adult patients agreed to either have surgery to hold the broken scaphoid with a special screw or to have the wrist held still in a plaster cast (with surgery offered after six weeks to those that are still not healed). The decision about which treatment to use was made using randomisation, which is similar to tossing a coin. Patients reported their own wrist pain and function at six, 12, 26 and 52 weeks. Information was also collected on general health, bone healing, grip strength and range of movement, complications from treatment and costs.
Summary of Results
No important differences were found in patients’ wrist pain and function at 52 weeks. The bone did not heal properly in four patients in the surgery group compared with nine patients in the plaster cast group at 52 weeks. For one of these patients in the surgery group and four in the plaster cast group, the bone did not join at all. There were eight patients in the surgery group who had further surgery following their initial operation to fix their wrist, and one patient in the cast group who required repeated surgery because their bone did not join at all. The overall cost of treating with a plaster cast was cheaper than early surgery. The preferred treatment, therefore, is to use plaster cast initially and immediately fix the bone with a screw if it doesn’t heal.Further follow-up of patients was undertaken at 5 years, where similar outcomes (pain, function, grip strength and range of movement) were looked at. At five-years there was still no important difference between pain or function seen for these patients. There was also no difference between the grip strength, or range of movement. Of the four patients in the plaster group who did not have a joined bone at one-year, one was now almost joined, two still not joined, and one wasn’t seen at year five. The patient who had surgery but did not have a joined bone, still did not have a joined bone at five years. Thus in the longer term, the treatment preference is still to use plaster cast initially for most cases.
As part of our investigation, we also looked at how much the different treatment options cost the NHS, both in terms of the initial cost of providing plaster casting and surgery as well as the longer term care patients needed. These different costs were compared to the health of patients in the two groups, or their ‘quality adjusted life years’, to determine whether any changes in costs also led to better health. Over the five years of the study, we found that almost all patients in both arms had a good level of health once their injury had healed, similar to what we would expect to see in a group of people their age. The small difference in the health of the patients in the two trial groups, but the much higher cost of providing surgery than plaster casting, meant that proving surgery straight away after the injury was not worth the extra cost.
REC name
East Midlands - Derby Research Ethics Committee
REC reference
13/EM/0154
Date of REC Opinion
16 May 2013
REC opinion
Favourable Opinion