成人腕舟骨骨折2mm以下可優先考慮石膏固定治療

成人腕舟骨骨折2mm以下可優先考慮石膏固定治療

作者：

小柯機器人

發布時間：2020/8/10 13:50:57

英國萊斯特大學醫院NHS信託Joseph J Dias團隊比較了手術與石膏固定治療成人腕舟骨骨折的效果。2020年8月8日，該研究發表在《柳葉刀》雜誌上。

腕舟骨骨折佔腕骨骨折的90％，主要發生在年輕人中。並未有足夠的證據表明與非手術治療相比，立即手術固定治療這類骨折的療效更好。

研究組進行了一項實用、平行組、多中心、開放標籤、雙臂、隨機優勢試驗，2013年7月23日至2016年7月26日，在英格蘭和威爾斯的31家醫院招募了439名骨科就診的成年人（16歲及以上），X線片確診腕舟骨骨折明顯移位。將其按1：1隨機分組，其中219名接受早期手術固定（手術組）；220名行肘下石膏固定（石膏固定組），若證實骨折不癒合，則立即行手術固定。主要結局是第52周的患者總腕關節評估（PRWE）分數。

主要分析共包括408名（93%）患者，其中手術組203名，石膏固定組205名。手術組在52周時的校正後平均PRWE得分為11.9分，石膏固定組為14.0分，組間無顯著差異。手術組手術併發症的發生率為14%，顯著高於石膏固定組（1%）；但石膏相關併發症發生率為2%，顯著低於石膏固定組（18%）。兩組患者醫療併發症的發生率分別為2%，無顯著差異。

總之，成人腕舟骨骨折移位2mm及以下的患者應首先固定石膏，若固定後確認骨折不癒合再立即行手術固定，該治療策略可降低手術風險。

附：英文原文

Title: Surgery versus cast immobilisation for adults with a bicortical fracture of the scaphoid waist (SWIFFT): a pragmatic, multicentre, open-label, randomised superiority trial

Author: Joseph J Dias, Stephen D Brealey, Caroline Fairhurst, Rouin Amirfeyz, Bhaskar Bhowal, Neil Blewitt, Mark Brewster, Daniel Brown, Surabhi Choudhary, Christopher Coapes, Liz Cook, Matthew Costa, Tim Davis, Livio Di Mascio, Grey Giddins, Helen Hedley, Catherine Hewitt, Sebastian Hinde, Jonathan Hobby, Stephen Hodgson, Laura Jefferson, Kanagaratnam Jeyapalan, Phillip Johnston, Jonathon Jones, Ada Keding, Paul Leighton, Andrew Logan, Will Mason, Andrew McAndrew, Ian McNab, Lindsay Muir, James Nicholl, Matthew Northgraves, Jared Palmer, Rob Poulter, Zulfi Rahimtoola, Amar Rangan, Simon Richards, Gerry Richardson, Paul Stuart, Nicholas Taub, Adel Tavakkolizadeh, Garry Tew, John Thompson, David Torgerson, David Warwick

Issue&Volume: 2020/08/08

Abstract: Background

Scaphoid fractures account for 90% of carpal fractures and occur predominantly in young men. The use of immediate surgical fixation to manage this type of fracture has increased, despite insufficient evidence of improved outcomes over non-surgical management. The SWIFFT trial compared the clinical effectiveness of surgical fixation with cast immobilisation and early fixation of fractures that fail to unite in adults with scaphoid waist fractures displaced by 2 mm or less.

Methods

This pragmatic, parallel-group, multicentre, open-label, two-arm, randomised superiority trial included adults (aged 16 years or older) who presented to orthopaedic departments of 31 hospitals in England and Wales with a clear bicortical fracture of the scaphoid waist on radiographs. An independent remote randomisation service used a computer-generated allocation sequence with randomly varying block sizes to randomly assign participants (1:1) to receive either early surgical fixation (surgery group) or below-elbow cast immobilisation followed by immediate fixation if non-union of the fracture was confirmed (cast immobilisation group). Randomisation was stratified by whether or not there was displacement of either a step or a gap of 1–2 mm inclusive on any radiographic view. The primary outcome was the total patient-rated wrist evaluation (PRWE) score at 52 weeks after randomisation, and it was analysed on an available case intention-to-treat basis. This trial is registered with the ISRCTN registry, ISRCTN67901257, and is no longer recruiting, but long-term follow-up is ongoing.

Findings

Between July 23, 2013, and July 26, 2016, 439 (42%) of 1047 assessed patients (mean age 33 years; 363 [83%] men) were randomly assigned to the surgery group (n=219) or to the cast immobilisation group (n=220). Of these, 408 (93%) participants were included in the primary analysis (203 participants in the surgery group and 205 participants in the cast immobilisation group). 16 participants in the surgery group and 15 participants in the cast immobilisation group were excluded because of either withdrawal, no response, or no follow-up data at 6, 12, 26, or 52 weeks. There was no significant difference in mean PRWE scores at 52 weeks between the surgery group (adjusted mean 11·9 [95% CI 9·2–14·5]) and the cast immobilisation group (14·0 [11·3 to 16·6]; adjusted mean difference 2·1 [95% CI 5·8 to 1·6], p=0·27). More participants in the surgery group (31 [14%] of 219 participants) had a potentially serious complication from surgery than in the cast immobilisation group (three [1%] of 220 participants), but fewer participants in the surgery group (five [2%]) had cast-related complications than in the cast immobilisation group (40 [18%]). The number of participants who had a medical complication was similar between the two groups (four [2%] in the surgery group and five [2%] in the cast immobilisation group).

Interpretation

Adult patients with scaphoid waist fractures displaced by 2 mm or less should have initial cast immobilisation, and any suspected non-unions should be confirmed and immediately fixed with surgery. This treatment strategy will help to avoid the risks of surgery and mostly limit the use of surgery to fixing fractures that fail to unite.

DOI: 10.1016/S0140-6736(20)30931-4

Source: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30931-4/fulltext