Management of Smith's Fractures
Smith's fractures require different management approaches based on fracture type, with conservative treatment appropriate for stable type I and III fractures, while surgical intervention with volar plating is necessary for all type II and unstable type III fractures to ensure optimal functional outcomes and prevent complications. 1, 2
Classification and Assessment
Smith's fractures (reverse Colles' fractures) are classified according to Thomas classification:
- Type I: Extra-articular transverse fracture with volar displacement
- Type II: Intra-articular fracture with volar displacement
- Type III: Oblique fracture with volar displacement
Treatment Algorithm
Conservative Management
- Indicated for:
- Stable Type I fractures
- Stable Type III fractures
- Requirements:
- Anatomic reduction must be achieved
- Reduction must be stable
- Technique:
- Closed reduction
- Cast immobilization
- Regular radiographic follow-up to ensure maintained reduction
Surgical Management
- Indicated for:
- All Type II fractures
- Unstable Type I or III fractures
- Failed closed reduction
- Soft tissue interposition preventing anatomic reduction
- Technique:
- Open reduction and internal fixation (ORIF)
- Volar buttressing technique with AO-T-plate or volar locking plate
- Careful attention to extensor tendon protection
Post-Operative Care
- Immobilization Period: Shorter immobilization periods (≤1 week or 2-3 weeks) show better outcomes compared to 5-6 weeks of immobilization 3
- Hardware Removal: Recommended after three months to prevent bone overgrowth that may complicate later removal 2
- Rehabilitation: Early mobilization improves patient-reported outcomes and functional outcomes
Complications to Monitor
Extensor Pollicis Longus (EPL) Tendon Entrapment: A rare but serious complication
- Warning signs: inability to extend thumb, dorsal wrist pain along EPL course, tenodesis effect, difficulty achieving anatomic reduction 4
- Requires surgical exploration and possible tendon reconstruction
Other Potential Complications:
- Malunion
- Nonunion
- Post-traumatic arthritis
- Stiffness
Special Considerations
Pediatric Patients: Most pediatric distal radius fractures can be treated nonoperatively, but Smith's fractures may require surgical intervention, especially with:
- Open fractures
- Highly unstable fractures
- Concomitant neurovascular injuries
- Soft tissue interposition 4
Elderly Patients: Consider bone quality and functional demands
- May benefit from volar locking plates for better fixation in osteoporotic bone
- Multimodal analgesia and early mobilization are important
Follow-up Protocol
- Regular imaging to assess healing progression
- Radiographs at 2,6, and 12 weeks for surgically treated fractures
- Assessment of wrist function and range of motion
- Monitoring for complications
The management of Smith's fractures differs significantly from other distal radius fractures due to the volar displacement pattern, which often requires specific reduction techniques and fixation methods to counteract the deforming forces.