How do you manage Smith fractures?

Management of Smith Fractures

Smith fractures should be managed based on fracture type, with conservative treatment appropriate for stable Type I and III fractures if anatomic reduction is achieved, while Type II and unstable Type III fractures typically require surgical intervention with volar buttress plating to ensure optimal functional outcomes and prevent complications. 1, 2

Understanding Smith Fractures

Smith fractures (reverse Colles fractures) are characterized by:

• Volar displacement of the distal radius fragment
• Typically occur from a fall on a supinated hand that is forced into pronation 3
• Less common than Colles fractures (only 18 out of 416 distal radius fractures in one study) 3

Classification and Treatment Approach

Type I (Extra-articular) Smith Fractures

• Initial Management:
  • Appropriate analgesia including regular paracetamol/acetaminophen 4
  • Closed reduction under appropriate anesthesia
  • Immobilization in a well-molded cast with wrist in slight extension
• Treatment Options:
  • Conservative management if reduction is anatomic and stable 1
  • Consider surgical fixation if unstable or if reduction cannot be maintained

Type II (Intra-articular) Smith Fractures

• Recommended Treatment: Operative fixation 1, 2
• Surgical Technique:
  • Volar buttressing with T-plate (AO technique) 1
  • Hardware removal recommended after 3 months to prevent complications from bone overgrowth 2

Type III (Intra-articular with Volar Barton component) Smith Fractures

• Treatment Options:
  • Conservative treatment if stable and anatomically reduced 1
  • Operative fixation for unstable fractures 1, 2

Immobilization Technique

When using conservative management:

• Apply well-padded cast with appropriate three-point molding
• Position the wrist in slight extension (unlike Colles fractures which are immobilized in flexion)
• Ensure the cast is not too tight to prevent compartment syndrome 5
• Monitor closely for signs of displacement during follow-up

Surgical Management

• Surgical intervention is indicated for:

  • All Type II fractures 1, 2
  • Unstable Type III fractures 1
  • Failed closed reduction
  • Intra-articular fractures with significant displacement 3

• Technique:

  • Volar approach with buttress plating
  • Anatomic reduction of articular surface
  • Stable fixation to allow early mobilization
  • Hardware removal after 3 months recommended 2

Post-Reduction/Post-Operative Care

• Immobilization:

  • Protected weight-bearing with appropriate immobilization
  • Elevation and ice to control swelling 4

• Rehabilitation:

  • Begin gentle isometric exercises after acute pain subsides
  • Progress to active range of motion exercises after adequate healing
  • Gradual return to activities based on functional progress 4

Monitoring for Complications

• Regular radiographic follow-up to ensure maintenance of reduction
• Monitor for:
  • Pressure sores
  • Compartment syndrome
  • Stiffness
  • Malunion 5

Outcomes

Studies show good functional outcomes with appropriate management:

• One study reported 77.2% good to excellent functional results with operative treatment, regardless of fracture type 6
• Another study showed excellent or good results in all nine surgically treated patients 2
• Better wrist mobility and intact distal joint surfaces are achieved with surgical treatment of intra-articular fractures 3

Key Considerations

• Anatomic reduction is crucial for good functional outcomes
• Intra-articular fractures generally benefit from surgical intervention
• Hardware removal after healing helps prevent complications
• Early mobilization after stable fixation improves functional outcomes