SWIFFT

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

Dias JJ, Brealey SD, Fairhurst C, et al. Lancet (London, England) 2020 · PMID 32771106 · doi:10.1016/s0140-6736(20)30931-4

Question

In adults with a bicortical scaphoid waist fracture displaced by 2 mm or less, does early surgical fixation give better outcomes than cast immobilisation with urgent fixation reserved for fractures that fail to unite?

Design

Pragmatic multicentre open-label randomised superiority trial in 31 hospitals in England and Wales, run through the York Trials Unit and funded by the NIHR HTA programme.

Patients

Adults (16 and over) presenting with a radiographically confirmed bicortical scaphoid waist fracture with minimal or no displacement.

Intervention

Early surgical fixation with a headless compression screw

Comparison

Below-elbow cast immobilisation, with urgent fixation if non-union was confirmed

Primary outcome

Patient-Rated Wrist Evaluation (PRWE) total score at 52 weeks

Key result

There was no clinically or statistically significant difference in PRWE at one year between early fixation and casting. Complications potentially linked to surgery were more frequent in the fixation group, whereas the cast group needed occasional later fixation for non-union.

Limitations

Open-label design with a patient-reported primary outcome; fractures displaced by more than 2 mm and proximal pole fractures were excluded, so the findings do not apply to those injuries.

Impact on practice

Supports cast immobilisation as the default treatment for minimally displaced scaphoid waist fractures in the UK, with CT surveillance and prompt fixation if union fails, rather than routine early surgery.