How should we treat scaphoid fractures?

Summary
In a trial across 31 NHS hospitals, surgical treatment and cast immobilization for scaphoid waist fractures showed "similar" outcomes at 52 weeks.

Deep-Dive: Good Design!
The multicentric study has broad applicability but potential open-label biases. More long-term data is needed. Detailed results and recruitment enhance validity. Validated tools and multiple analyses highlight the study's rigor and transparency.

Take-Home Point: When to Operate!
Surgery and cast methods for scaphoid fractures show similar outcomes. Despite a surgical trend, 73 fractures need surgery over casting to prevent one non-union; larger displacements favor surgery

Further Reading!
Check out this other RCT on scaphoid fractures from 2005.

Level of Evidence: Multicentre RCT

Background:
Scaphoid fractures, representing a staggering 90% of carpal fractures, predominantly affect young men. Scaphoid fractures have seen an increasing trend towards surgical management, even though evidence of its superiority over non-surgical treatments remains inconclusive.


Aim
This study aimed to compare the clinical effectiveness of the two treatments, especially for fractures displaced by 2mm or less.


Methods
The study employed a robust design: a multicentre, randomized superiority trial. Adults aged 16 or older with a bicortical fracture of the scaphoid waist were included. Two groups were formed: one received early surgical fixation, and the other received cast immobilisation with immediate fixation for fractures failing to unite.

Results
The study observed no significant difference in pain and function between the surgery and cast immobilisation groups beyond 12 weeks. However, complications such as infection, nerve issues, and CRPS were more likely post-surgical fixation. Notably, screw penetration of joints was higher than anticipated in the surgery group, risking potential irreversible damage.


Conclusions
While surgery might offer short-term benefits in pain and function, the long-term outcomes between the two treatments show little difference. The broader trends in surgical treatments indicate an increasing preference for surgical intervention. The study's results, consistent with prior research, stress the importance of achieving fracture union.