What is the management for a Smith fracture?

Management of Smith Fracture

Smith fractures (volar displaced distal radius fractures) should be treated with either cast immobilization for stable non-displaced fractures or operative management with locking plates, Kirschner wires, or external fixation for displaced or unstable fractures. 1

Initial Assessment and Classification

• Smith fracture is a distal radius fracture with volar displacement (opposite of Colles fracture)
• Mechanism: typically occurs from a fall on the supinated hand that is forced into pronation 2
• Key assessment points:
  • Degree of displacement (>2-3mm step-off or >1-4mm displacement indicates potential instability)
  • Articular involvement
  • Integrity of the extensor mechanism
  • Neurovascular status

Treatment Algorithm

Non-operative Management

• Indicated for stable, non-displaced Smith fractures (<2-3mm step-off and <1-4mm displacement)
• Treatment approach:
  1. Closed reduction under appropriate analgesia/anesthesia
  2. Application of a well-padded volar splint or cast immobilization
  3. Regular radiographic follow-up at 1-2 week intervals initially to ensure maintained reduction

Operative Management

• Indicated for:
  • Unstable fractures
  • Displaced fractures where adequate reduction cannot be maintained
  • Intra-articular fractures with significant displacement
  • Failed conservative management
• Surgical options include:
  • Open reduction and internal fixation (ORIF) with volar locking plates
  • Kirschner wire fixation
  • External fixation
  • Combined techniques

Post-treatment Care

For Non-operative Management

1. Immobilization for 4-6 weeks depending on fracture healing
2. Early finger motion is essential to prevent edema and stiffness 1
3. Regular radiographic follow-up to ensure maintained reduction
4. After immobilization is discontinued, aggressive finger and hand motion exercises are necessary to achieve optimal outcomes 1

For Operative Management

1. Post-operative immobilization as directed by surgeon (typically shorter than non-operative)
2. Early finger motion to prevent stiffness
3. Removal of hardware may be recommended after approximately 3 months to prevent complications from overgrowth of bone 3
4. Progressive rehabilitation program focusing on:
   • Range of motion exercises
   • Strengthening
   • Functional activities

Rehabilitation Protocol

1. Early phase (0-4 weeks):

   • Maintain immobilization
   • Active finger, elbow and shoulder exercises to prevent stiffness
   • Edema control measures

2. Intermediate phase (4-8 weeks):

   • Begin gentle wrist range of motion exercises after immobilization removal
   • Progress to active-assisted range of motion as tolerated
   • Continue edema management if needed

3. Late phase (8+ weeks):

   • Advance to strengthening exercises
   • Focus on functional activities and return to pre-injury activities

Complications to Monitor

• Malunion or loss of reduction
• Stiffness and limited range of motion
• Complex regional pain syndrome
• Tendon irritation or rupture (particularly with hardware)
• Carpal tunnel syndrome
• Hardware complications (if surgically treated)

Special Considerations

• For elderly patients with osteoporotic bone, surgical fixation may require specialized techniques or implants
• Prolonged immobilization should be avoided to prevent complications such as chronic pain, joint stiffness, and muscle atrophy 4
• Careful monitoring is essential for all patients in casts or splints to ensure proper recovery 5

Follow-up Schedule

• Initial follow-up: 1-2 weeks after treatment
• Subsequent follow-ups: Every 2-3 weeks until fracture healing is evident
• Final follow-up: After rehabilitation completion to assess functional outcomes

The management approach should be determined based on fracture characteristics, patient factors, and surgeon experience, with the primary goal of restoring function and preventing long-term complications.