What is the initial management of a Smith fracture in the emergency department?

Smith Fracture Management in the Emergency Department

Immediate pain control with paracetamol (acetaminophen) and cautious opioid use, followed by splinting in the position found, are the cornerstones of initial ED management for Smith fractures, with urgent orthopedic consultation for operative planning within 24-48 hours.

Immediate Pain Management

Administer regular paracetamol (acetaminophen) immediately as first-line analgesia unless contraindicated, as effective pain control is the foundation of acute fracture care. 1 Pain management should be initiated before diagnostic imaging to minimize patient suffering. 2

• Add opioid analgesia cautiously, particularly in elderly patients or those with unknown renal function, as approximately 40% of fracture patients have moderate renal dysfunction requiring dose adjustment. 1, 3
• Avoid NSAIDs until renal function is confirmed, as they are relatively contraindicated in fracture populations with high rates of renal impairment. 1, 3
• Consider regional nerve blocks (median and ulnar nerve blocks at the wrist level) for superior analgesia in distal radius fractures, though this requires appropriate expertise. 1

Immobilization and Splinting

Splint the fractured extremity in the position found to reduce pain, prevent further injury, and facilitate safe transport. 2, 1 Smith fractures are volar angulated distal radius fractures, and attempting reduction in the ED without adequate anesthesia may cause additional harm.

• It is reasonable to treat the deformed fracture in the position found unless straightening is necessary to facilitate safe transport. 2
• Apply a well-padded volar splint that immobilizes the wrist and forearm, extending from the metacarpal heads to just below the elbow. 2
• If an open wound is associated with the fracture, cover it with a clean dressing to lower the risk of contamination and infection. 2

Vascular and Neurovascular Assessment

If the fractured extremity is blue, purple, or pale, activate the emergency response system immediately, as this indicates poor perfusion and represents a limb-threatening injury. 2

• Document distal pulses (radial and ulnar arteries), capillary refill, and sensation in median, ulnar, and radial nerve distributions. 2
• Assess motor function of the hand, though this may be limited by pain. 2

Radiographic Evaluation

Obtain standard posteroanterior and lateral wrist radiographs to confirm the diagnosis and classify the fracture type. 4, 5 Smith fractures are classified into three types (Thomas classification):

• Type I: Extra-articular transverse fracture with volar angulation
• Type II: Intra-articular fracture involving the dorsal rim (reverse Barton fracture)
• Type III: Extra-articular oblique fracture extending from dorsal to volar 4, 6

Orthopedic Consultation and Disposition

Arrange urgent orthopedic consultation for operative planning, as most Smith fractures (particularly Types I and II) require surgical fixation with volar buttress plating. 4, 6, 7 Conservative treatment is typically insufficient for Types I and II fractures, though stable Type III fractures may be managed conservatively if anatomic reduction is achieved. 4

• Plan for definitive surgical fixation within 24-48 hours to optimize outcomes and reduce complications. 2
• Ensure appropriate preoperative assessment including basic metabolic panel, complete blood count, and coagulation studies. 2

Critical Pitfalls to Avoid

• Do not delay pain assessment and management while focusing on radiographic evaluation—pain control should be the immediate priority. 1
• Do not prescribe NSAIDs without checking renal function first, as fracture patients have high rates of renal impairment. 1, 3
• Do not attempt closed reduction in the ED without adequate anesthesia and orthopedic consultation, as Smith fractures are inherently unstable and typically require operative fixation. 4, 6
• Do not discharge patients with Smith fractures without orthopedic follow-up arranged, as delayed or inadequate treatment leads to chronic wrist dysfunction, malunion, and post-traumatic arthritis. 5, 6