Initial cast immobilization is a reasonable option in persons with scaphoid fractures

Référence

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;396(10248):390-401.

Sommaire

These researchers randomized persons 16 years or older with a clear bicortical fracture of the scaphoid who presented to one of 31 orthopedic departments in England and Wales to receive either surgical fixation (n = 219) or cast immobilization (n = 220). To be eligible, the persons had to be evaluated within 2 weeks of injury and have a 2-mm or less displacement. The casts, worn for 6 weeks to 10 weeks, sat below the elbow and did not have to include the thumb. In the casted patients, if a follow-up radiograph taken 6 weeks to 12 weeks later suggested nonunion, the patient underwent computed tomography and subsequent surgical fixation if the nonunion was confirmed. After 52 weeks, the researchers evaluated the primary outcome—the score on a 100-point scale that assesses wrist pain and disability. The authors didn't use the conservative intention-to-treat approach to evaluate the data. They also report that a 6-point difference on this scale is, conservatively, the minimal clinically important difference. After 52 weeks, they had primary outcome data on 186 (85%) of the surgically treated patients and 176 (80%) of the casted patients. Losing 20% of patients is a worrisome degree of loss. Patients in both groups experienced improvements in their pain and disability scores compared with baseline with virtually no net difference between them. Of the casted patients, 17 (7.7%) had subsequent surgery for nonunion. More surgically treated patients (31/219, 14%) had a potentially serious surgical complication than did casted patients (3/220, 1.4%), but more of the casted patients had cast-related problems (18% vs 2%). Additionally, after one year, 2% of casted patients had nonunion compared with 1% of surgically treated patients. So the total number of cast or surgical complications between the groups was similar. This seems like the perfect scenario for shared decision-making: 2 options, one more invasive than the other, each with trade-offs but comparable outcomes.