Buried versus exposed wires in hand and wrist fractures

Plain English summary of protocol

Background and study aims
Fractures of the bones of the hand and wrist are the most common subtype of hand trauma, accounting for about 50% of all injuries. Although most do not need surgery, a proportion will be unstable and will require manipulation and fixation with metalwork to restore hand function. Recent UK studies indicate that over 50,000 hand and wrist fractures are operated on per year in the NHS. If a hand or wrist fracture requires fixation, then K-wires are usually employed to stabilise the bone following manipulation and reduction of the fracture.

Once a fracture has been fixed with K-wires, the wires are routinely removed when the bone has healed. When the wires are placed, the ends of the wires may be cut short and buried beneath the skin, or the end of the wires can be left exposed outside of the skin. There is currently no reliable data to inform practice, nor any health economic data to inform national guidelines. Based on our national clinician survey, the key rationale for burying the end of the wire is the perceived reduction in risk of infection. The interface between an exposed wire and the skin is a site of potential Surgical Site Infection (SSI), commonly referred to as a ‘pin site infection’. Pin site infections are superficial SSIs that usually require treatment with antibiotics, with or without removal of the wire. A major concern is deep SSI, where the bone and/or joint becomes infected due to bacterial transport along the wire and into the bone in which it is placed. For patients, the consequences of SSI following hand and wrist trauma surgery include worse and prolonged pain, continued antibiotic prescription, re-operation, hospital admission, delayed rehabilitation and in severe cases, amputation of all or part of the affected hand. Acquiring an SSI doubles the length of hospital stay and leads to substantial additional direct healthcare costs.

Who can participate?
Adult participants, aged 16 or over, with fractures of the hand or wrist which require fixation with k-wires.

What does the study involve?
The aim of this study is to conduct a randomised controlled trial to evaluate the clinical and cost effectiveness of burying K-wires compared to leaving them exposed following fixation of adult hand or wrist fractures in terms of reducing SSI. We will compare the risk of SSI by 90 days post- randomisation between treatment groups.
This study will be run in at least 22 hospitals around the UK, to make sure the results represent the whole country. Results from this study will help us decide how best to treat patients with broken hand and wrist bones that need surgery.

If an individual wishes to join the study, a researcher will discuss the study with them, answer any questions they may have, and ask them to fill in a consent form. They will then answer some questions about themselves, their health, and their quality of life. There will also be questions that ask how well they could do everyday tasks before they broke their hand or wrist, and how well they can do those now. Completing these questions will take about 15 minutes. Similar questions will be asked during their recovery at 3 and 6 months.

To compare the treatments, participants will be put into two groups:
Exposed K-wires: The broken bones in the hand or wrist will be held in place by wires where the end of the k-wires is left sticking OUT of the skin. The ‘exposed’ part is short (about 2–3cm/1 inch), they might get stitches, and the exposed k-wire will be covered with a sterile dressing and usually a cast. The dressing/cast might be replaced after a few weeks. After about 6 weeks, they will come back to hospital where the k-wires will be removed during their usual follow-up hospital appointment.

Buried K-wires: The broken bones in the hand or wrist will be held in place by k-wires with the ends buried UNDER the skin. At the end of the operation, they will usually get stitches and a plaster cast. After some weeks, this cast will then get replaced with a brace/splint. They might need to come to hospital to have their wound/stitches checked. After about 6 weeks, they will come back to hospital where the k-wires will be removed, usually in an operating room. They will receive a local anaesthetic, and a small cut will be made in the skin to remove the k-wires.

What are the possible benefits and risks of participating?
There is no direct benefit in taking part in the study. The information we receive will help in improving care for patients in the future. We do not know whether there is a difference in recovery for patients who get buried or exposed k-wires. This is why we are doing this research. If you join in, it will help us make treatment better for future patients with similar injuries. This study will also help us find out if one treatment costs more than the other. This will allow the NHS to make a decision about how to best spend their funds.
The risks in this study are the same as standard care because both treatments are carried out in routine care. Although there is no additional risk in taking part, both treatments have disadvantages. For those patients where the k-wires are not buried under the skin, there might be a slightly higher risk of infection. On the contrary, patients with buried k-wires will have to return to hospital for a second operation to have the k-wires removed.

Where is the study run from?
The University of Oxford is sponsoring this study. This study will be overseen by Oxford Clinical Trials Research Unit (OCTRU) with the day to day running of the study being completed by Oxford Trauma and Emergency Care at the University of Oxford, led by Mr Justin Wormald, Chief Investigator and Clinical Lecturer.

When is the study starting and how long is it expected to run for?
The study enrolment is planned for January 2026, over approximately a 15 month period at least 22 UK hospitals.

Who is funding the study?
National Institute for Health and Care Research (NIHR) Research for Patient Benefit programme, UK.

Who is the main contact?
Mr Justin Wormald, HAWAII-DRIFT@ndorms.ox.ac.uk

Contact information

Mr Justin Wormald
Scientific, Principal investigator

Mr (NIHR Academic Clinical Lecturer in Plastic Surgery)
Oxford Trauma & Emergency Care, NDORM, University of Oxford, Kadoorie Centre, John Radcliffe Hospital
Oxford
OX3 9DU
United Kingdom

ORCID ID	0000-0001-6197-4093
Phone	+44 01865 612709
Email	HAWAII-DRIFT@ndorms.ox.ac.uk

Study information

Eligibility

Locations

Countries of recruitment

• United Kingdom
• England

Study participating centres

Results and Publications

Study outputs

Editorial Notes

03/11/2025: Study's existence confirmed by National Institute for Health and Care Research (NIHR) (UK).