Common Wrist Fracture Does Not Need Surgical Repair in Most Cases

By Linda Carroll

August 10, 2020

(Reuters Health) - Most scaphoid waist fractures in adults do not need to be repaired surgically, a new study finds.

Outcomes from just over 400 patients with scaphoid waist fractures who were randomly assigned to receive either surgery or a plaster cast show that casting is the better option, researchers report in The Lancet.

"This injury in most patients does not need surgery," said study leader Dr. Joseph Dias, a professor of hand and orthopedic surgery at the University Hospitals of Leicester.

"Treatment with a cast is the best treatment available across the world, regardless of the pandemic," Dr. Dias said in an email. Previously it was suggested surgery would speed healing and return to activity. But "there is no difference in return to work," he said.

Scaphoid fractures account for 90% of all carpal fractures and 2% to 7% of all fractures, Dr. Dias and his colleagues write. "This type of fracture is an important public health problem as they predominantly affect young (mean age, 29), active individuals in their most productive working years," the researchers explain. "Scaphoid fractures are typically caused when the wrist is suddenly extended, either when putting the hand out to break a fall or when the palm is struck forcibly by an object."

In the current study, the average age was 33 and in both groups, just over 80% were male. All had fracture displacement of 2mm or less.

One year after the initial injury, patients were assessed on a number of factors, including wrist pain and function, bone healing, complications from treatment and number of days of work lost with a patient-rated wrist evaluation (PRWE) questionnaire.

There was essentially no difference between the two groups on the PRWE. However, the surgery group had more potentially serious complications, including numbness, infection and newly developed complex regional pain syndrome.

"All of us - surgeons, health systems, patients - assume that something new is better than nature and surgeons often adopt treatments without requiring evidence of safety or efficacy, unlike drugs," Dr. Dias said.

The study confirms what many surgeons know, said Dr. Michael Hausman, a professor of orthopedic surgery at the Icahn School of Medicine at Mount Sinai and chief of hand and upper extremity surgery for the Mount Sinai Health System.

"It's a well done confirmation of previous evidence and what is generally accepted practice," Dr. Hausman said. "It confirms that 85% of scaphoid fractures will heal in a cast and not require surgery. And they do it in a very rigorous and well controlled prospective study that took many years. This is about as good as evidence gets."

Most scaphoid fractures are treated with a cast, Dr. Hausman said. But sometimes, when an athlete is in a rush to get back to play, for example, surgery might be chosen.

"Some surgeons are very aggressive and would let the athlete return to play within a week or two," he said. "Others of us think it's too risky to return to play that quickly because the screw (holding the bone together) is not totally rigid. In fact, we have written about using two screws rather than one to control the rotation of the fragments better."

Ultimately Dr. Hausman would not want to see athletes return to play before six weeks even if they've gotten surgery, because the bone can re-fracture. "This is a critical bone in the wrist that maintains the length between hand and forearm and when it's broken and collapses the wrist can become arthritic," he said.

SOURCE: The Lancet, online August 8, 2020.