英国莱斯特大学医院NHS信托Joseph J Dias团队比较了手术与石膏固定治疗成人腕舟骨骨折的效果。2020年8月8日，该研究发表在《柳叶刀》杂志上。

腕舟骨骨折占腕骨骨折的90％，主要发生在年轻人中。并未有足够的证据表明与非手术治疗相比，立即手术固定治疗这类骨折的疗效更好。

研究组进行了一项实用、平行组、多中心、开放标签、双臂、随机优势试验，2013年7月23日至2016年7月26日，在英格兰和威尔士的31家医院招募了439名骨科就诊的成年人（16岁及以上），X线片确诊腕舟骨骨折明显移位。将其按1：1随机分组，其中219名接受早期手术固定（手术组）；220名行肘下石膏固定（石膏固定组），若证实骨折不愈合，则立即行手术固定。主要结局是第52周的患者总腕关节评估（PRWE）分数。

主要分析共包括408名（93%）患者，其中手术组203名，石膏固定组205名。手术组在52周时的校正后平均PRWE得分为11.9分，石膏固定组为14.0分，组间无显著差异。手术组手术并发症的发生率为14%，显著高于石膏固定组（1%）；但石膏相关并发症发生率为2%，显著低于石膏固定组（18%）。两组患者医疗并发症的发生率分别为2%，无显著差异。

总之，成人腕舟骨骨折移位2mm及以下的患者应首先固定石膏，若固定后确认骨折不愈合再立即行手术固定，该治疗策略可降低手术风险。

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