What is the treatment approach for a Smith fracture using Open Reduction and Internal Fixation (ORF)?

Treatment Approach for Smith Fracture Using Open Reduction and Internal Fixation (ORIF)

Open reduction and internal fixation (ORIF) with volar plating is the preferred treatment approach for unstable Smith fractures to achieve optimal functional outcomes and reduce complications.

Understanding Smith Fractures

Smith fractures are volar-displaced distal radius fractures (the reverse of Colles fractures) that typically result from a fall onto a flexed wrist. According to Thomas classification:

• Type I: Extra-articular fracture with volar displacement
• Type II: Intra-articular fracture involving the radiocarpal joint
• Type III: Intra-articular fracture with volar displacement of a small fragment

Indications for ORIF in Smith Fractures

ORIF is specifically indicated for:

• All Type II Smith fractures 1
• Unstable Type III Smith fractures 1
• Unstable Type I fractures that cannot maintain reduction with closed methods
• Fractures with significant displacement (>2mm) 2
• Fractures with rotational instability 3

Surgical Technique for ORIF of Smith Fractures

1. Patient Positioning and Preparation:

   • Supine position with arm on radiolucent table
   • Prophylactic antibiotics (cefazolin or clindamycin if allergic) 3
   • Prepare surgical site with alcohol-based antiseptic 3

2. Surgical Approach:

   • Volar approach (Henry's approach) to the distal radius
   • Incision along the radial border of the flexor carpi radialis tendon
   • Careful protection of the median nerve and radial artery

3. Fracture Reduction and Fixation:

   • Anatomic reduction of the fracture fragments
   • Volar buttressing technique using a T-plate or anatomic volar locking plate 1
   • Temporary K-wire fixation may be used to maintain reduction during plating
   • Fluoroscopic confirmation of reduction and hardware placement

Advantages of ORIF over External Fixation

Research demonstrates several advantages of ORIF compared to external fixation:

• Better grip strength (90% vs 78% of uninjured side at 1 year) 4
• Improved range of motion, particularly pronation/supination (150° vs 136°) 4
• Lower complication rates (RR=0.71,95% CI 0.59-0.85) 5
• Lower infection rates (RR=0.27,95% CI 0.16-0.45) 5
• Better DASH scores (lower by 5.67 points, 95% CI -8.31--3.04) 5
• Better restoration of volar tilt 5
• Faster return to function 6

Post-Operative Management

1. Immediate Post-Op Care:

   • Splint immobilization for 1-2 weeks
   • Elevation to control swelling
   • Pain management

2. Early Rehabilitation (2-6 weeks):

   • Transition to removable splint
   • Initiate early mobilization to prevent stiffness 7
   • Begin gentle active range of motion exercises

3. Progressive Rehabilitation (6-12 weeks):

   • Advance to strengthening exercises
   • Progressive resistance training
   • Focus on grip strength recovery

Monitoring and Complications

• Regular radiographic follow-up to ensure proper healing and alignment 7
• Monitor for complications:
  • Hardware irritation or failure
  • Tendon irritation or rupture
  • Infection (rare with proper technique)
  • Malunion (less common with ORIF than external fixation) 4
  • Complex regional pain syndrome

Special Considerations

• Timing of Surgery: Perform definitive fixation within 24 hours in hemodynamically stable patients 3
• Elderly Patients: Consider bone quality and potential need for augmentation techniques
• Open Fractures: Follow appropriate open fracture protocols with thorough debridement and antibiotic coverage 3

Conclusion

For unstable Smith fractures, ORIF with volar plating provides superior functional outcomes, lower complication rates, and faster return to function compared to external fixation or closed reduction. The volar buttressing technique with anatomic plates is particularly well-suited for the volar displacement pattern characteristic of Smith fractures.