Anatomic Manipulation and Immobilization of Smith Fracture
For Smith fractures, surgical intervention is recommended for cases with palmar displacement of the distal fragment, interfragmentary gap >3 mm, involvement of more than one-third of the articular surface, failed closed reduction, unstable reduction, or significant displacement/angulation. 1
Initial Assessment and Classification
- Smith fractures (reverse Colles fractures) involve volar displacement of the distal fragment of the radius
- Evaluate for:
- Degree of displacement and angulation
- Articular involvement
- Associated soft tissue injuries
- Stability of the fracture
Manipulation Technique
Closed Reduction Technique:
- Administer appropriate analgesia/anesthesia (regional block preferred)
- Apply longitudinal traction to the hand with the wrist in slight flexion
- Apply counter-traction to the forearm
- Correct the volar displacement by applying dorsal pressure on the distal fragment while simultaneously extending the wrist
- Correct any radial/ulnar deviation as needed
- Confirm reduction with fluoroscopy or radiographs
Immobilization After Reduction:
- For stable fractures after reduction, immobilize with a well-molded cast 1, 2
- Position the wrist in slight extension (10-20°) to counteract the tendency for volar displacement
- Include the elbow in the initial immobilization to prevent rotation
- Ensure proper molding around the fracture site to maintain reduction
Post-Reduction Management
- Obtain post-reduction radiographs to confirm adequate alignment
- Schedule follow-up radiographs at 10-14 days to evaluate position 1
- Monitor for signs of re-displacement, which is common in Smith fractures
Indications for Surgical Management
Smith fractures frequently require surgical intervention due to their inherent instability. Consider surgery for:
- Unstable fractures with volar displacement tendency
- Intra-articular fractures (especially Type II and III)
- Failed closed reduction or re-displacement in cast 3, 4
- Interfragmentary gap >3 mm
- Articular involvement >1/3 of joint surface 1
Surgical options include:
- Open reduction with Kirschner wire fixation
- Volar plating (preferred for most Smith fractures)
- External fixation for severely comminuted fractures
Rehabilitation Protocol
- Immobilization period typically 3-4 weeks
- Begin progressive range of motion exercises after immobilization 1
- Full recovery expected within 6-8 weeks
- Consider directed home exercise programs to prevent stiffness 1
Complications to Monitor
- Joint stiffness (most common)
- Malunion or nonunion
- Post-traumatic arthritis
- Chronic pain
- Tendon rupture or adhesions
Special Considerations
- Functional outcomes are generally better with surgical treatment for unstable Smith fractures 4
- Anatomic restoration should remain the primary goal of management 2
- Tolerable deformity limits: radial deviation of 20-30°, sagittal tilt of 10-20°, and radial shortening of 0-2 mm 2
- Consider removal of surgical hardware after 3 months to prevent complications from bone overgrowth 5
Smith fractures have a higher tendency for re-displacement compared to Colles fractures, making careful assessment of stability and appropriate choice of treatment method crucial for optimal outcomes.