Title: Surgical versus non-surgical treatment for metacarpal shaft fracture(s) affecting the triphalangeal fingers in adults: a feasibility study
Funder: Department of Health and Social Care

Abstract: Research QuestionIs a multi-centre, pragmatic, randomised controlled trial (RCT) comparing surgical to non-surgical treatment for metacarpal shaft fractures (MSF) of the triphalangeal fingers in adults feasible?BackgroundMSF are common traumatic injuries, accounting for 44% of hand injuries, affecting over 100,000 people per year.(2, 3) They place a significant burden on healthcare resources and society, commonly affecting young (economically active) patients.Identifying the most beneficial and cost-efficient treatment will ensure optimisation of care and provide economic value for the NHS. It will inform healthcare policy and decision makers to optimise treatment pathways and allow appropriate allocation of resources. Aims and objectivesObjective 1:Quantify magnitude of MSF, assess variation in practice and evaluate costs of treatment. Objective 2: Assess feasibility, acceptability and practicality of a RCT.Objective 3:Identify barriers to research participation and develop novel solutions to engage patients with MSF in clinical research. Methods Workstream 1: A systematic review to summarise available evidence and highlight areas of uncertainty. A national survey of practice to assess heterogeneity of treatment and willingness to participate in a RCT. A multi-centre observational study to define the epidemiology, variation in practice, complications following standard care and to estimates costs of treatment. Workstream 2: A prospective cohort study of MSF for assessment of eligibility, recruitment and retention rates, completion of follow-up and selection of appropriate outcome measures for a future trial. Calculation of the minimal clinically important difference for the primary outcome measures using quantitative and qualitative assessments. Workstream 3: A nested qualitative study to gain insight into patient experience and assess barriers to participation in research. Collaboration with patients and information-technology specialists to develop novel health technology solutions to optimise participation in research. Timeline for deliveryOctober 2018 WS1 begins.October 2019 WS1 ends. WS2 and WS3 begins.March 2021 WS2 and WS3 end.Apr - Oct 2021 Write-up thesis.October 2021 Completion of PhD.Anticipated impact and disseminationAnticipated ImpactThis research will directly inform the design and delivery of a RCT to identify the most effective treatment for MSF. This will inform national guidelines and directly impact patient care through optimisation and standardisation of treatment protocols, while maximising value for money for the NHS. It will also aid clinicians and researchers to improve the design and implementation of RCTs within other surgical specialities, thus having a wider impact beyond the field of hand surgery. DisseminationA minimum of five publications will be generated in journals such as the British Medical Journal, Journal of Hand Surgery and Journal of Bone and Joint Surgery. Social media platforms, local media and feedback from the Patient Advisory Group will be used to maximise circulation of findings to patients and the public.I will ensure dissemination throughout the wider community via presentation at the following conferences; British Society for Surgery of the Hand Meeting Federation of European Societies for Surgery of the Hand Meeting American Society for Surgery of the Hand Meeting International Federation of Societies for Surgery of the Hand Meeting

Lay abstract: AimIs it possible and practical to carry out a large-scale trial comparing surgery to non-surgical treatment for metacarpal shaft fractures (MSF) in adults?BackgroundThe metacarpals lie in the hand, between the wrist and fingers. The shaft is the middle part of the bone. They are very common, almost half of all hand fractures. As they affect people of working age, they have a huge impact on society.At the moment, we do not know how best to treat them. This means patients receive different care throughout the country. The best way of finding out is to perform a large-scale trial comparing treatments, which usually costs millions of pounds. So it is very important to make sure the trial is going to work before you start.My research will assess whether it is possible and how best to carry out the trial, which will tell us the most effective way of treating these fractures. This will ensure that people with this injury receive the best care throughout the NHS, and that this represents value for money for the health service.Lessons from this project will also help researchers outside hand surgery, to improve how they design and carry out surgical trials.Design and Methods How big is the problem? I will review the scientific evidence to find out what is already known and what we still need to know. I will undertake a national survey of hand surgeons to find out how they treat these injuries and whether they would be willing to take part in a trial. I will study the treatment pathways and outcomes for patients in different hospitals in the UK. I will also calculate the costs of different treatments. How do we carry out a trial in the future? I will closely follow a group of patients treated at two hospitals, to collect information about the patients, their injury, the treatment they receive and various tests about their hand recovery afterwards. This will help us to check whether we are using the right types of tests, or following people for the right amount of time. It will also help us to make sure the tests we use are reliable and accurate. How to encourage young working men to take part in research studies? By talking to patients about their experiences of the injury and their thoughts on taking part in research. Working together with patients and information-technology specialists to develop new ways of encouraging participation in research studies using software applications (apps) or social media. Patient and Public InvolvementThe 'James Lind Alliance Priority Setting Partnership on common conditions affecting the hand and wrist' involved 231 patients and 306 clinicians. The need to determine whether surgical or non-surgical treatment of hand injuries is better was chosen as a top ten research priority.(1)I coordinated a workshop attended by patients with MSF, researchers, clinicians and therapists to inform the design of my project. I will carry out patient interviews and focus groups to find out what is most important to them, in terms of the injury, treatments, recovery and participation in future research. I will set up a Hand Injury Patient Advisory Group, which will meet regularly to discuss the progress of my project and advise on any issues that arise. Dissemination of the research I will seek feedback from the Patient Advisory Group regarding the most effective means of sharing my results and findings, including newsletters, local media publications and social media. I will publish my findings in suitable scientific journals and present my work at conferences both nationally and internationally.

Research activity codes: 6.4 SURGERY
Health categories: INJURIES AND ACCIDENTS