From the Guidelines
Management of a Smith fracture in the emergency department should prioritize prompt reduction, immobilization, and appropriate follow-up care to minimize morbidity and mortality, and improve quality of life. Initially, perform a thorough neurovascular assessment and obtain radiographs in multiple views to confirm the diagnosis of this volar-displaced distal radius fracture. Administer appropriate analgesia such as morphine 0.1 mg/kg IV or fentanyl 1-2 mcg/kg IV for pain control, as adequate pain relief is crucial in the preoperative and perioperative management of fragility fractures 1. Closed reduction should be performed under adequate sedation (e.g., procedural sedation with midazolam 0.05 mg/kg IV and ketamine 1 mg/kg IV) using longitudinal traction followed by dorsal displacement to correct the volar angulation. After reduction, immobilize the wrist in a sugar-tong splint with slight extension to maintain the reduction. The splint should extend from the metacarpal heads to just below the elbow, leaving the elbow free for movement.
Post-reduction radiographs are essential to confirm adequate alignment. Most Smith fractures are unstable and will require definitive surgical fixation, so orthopedic consultation should be obtained in the ED to ensure timely and appropriate management 1. Patients should be discharged with elevation instructions, pain management (typically ibuprofen 600 mg every 6 hours alternating with acetaminophen 1000 mg every 6 hours), and follow-up with orthopedics within 5-7 days. Early surgery within 24-48 hours after admission can significantly reduce short-term and mid-term mortality rates and reduce minor and major medical complications 1. Smith fractures are inherently unstable due to the volar displacement caused by the pull of the flexor tendons, which is why they often require surgical intervention despite successful initial reduction.
Key considerations in the management of Smith fractures include:
- Prompt reduction and immobilization to minimize pain and prevent further injury
- Adequate pain relief and management of underlying medical conditions
- Timely orthopedic consultation and surgical intervention when necessary
- Early mobilization and rehabilitation to improve functional outcomes and reduce the risk of complications. The goal of management should be to restore radial length, inclination, and tilt, as well as the realignment of the articular fracture fragments, to minimize the risk of long-term complications such as osteoarthritis 1.
From the Research
Smith Fracture Management in Emergency Department
- The management of Smith fractures in the emergency department involves assessing the type of displacement and the stability of the fracture 2.
- Conservative treatment is usually sufficient for types I and III Smith fractures, provided that reduction is anatomic and stable 2.
- The indication for internal fixation is given for all type II and unstable type III fractures, with a volar buttressing technique using the AO-T-plate being a described method 2.
- In terms of outcomes, a study found that the type of displacement has no significant effect on the final outcome of surgical plate fixation for distal radius fractures, which includes Smith fractures 3.
- However, the same study found that in fractures with dorsal displacement of fragments, it is more difficult to restore volar tilt from a volar approach 3.
- There is limited information available on the specific management of Smith fractures in the emergency department, with more general information available on the management of clavicle fractures 4 and shoulder injuries 5.