Smith's Fracture

A Smith's fracture (also called a "reverse Colles' fracture") is a transverse fracture of the distal radius with volar (palmar) displacement of the distal fragment — the opposite direction of the far more common Colles' fracture. [1] These fractures are inherently unstable due to the deforming forces of the wrist flexors and often require orthopedic consultation for definitive management. [2]

1. History

• Mechanism of injury: Most commonly a fall onto the palm of the hand (61% of cases), a direct strike to the dorsum of the wrist, or falling over bicycle handlebars [3]
• Finite element modeling shows Smith's fractures occur when the forearm-to-ground angle is 30°–45° in the sagittal plane and 75°–90° in the coronal plane [3]
• Ask about hand dominance, occupation, functional demands, and activity level
• Timing of injury, prior wrist injuries, and ability to move fingers/wrist post-injury
• Numbness or tingling in the median nerve distribution (thumb, index, middle finger)
• Anticoagulant use, osteoporosis history

2. Alarm Features

• Acute carpal tunnel syndrome: Progressively worsening pain and paresthesias in the median nerve distribution — this is a surgical emergency requiring decompression [4]
• Compartment syndrome: Pain out of proportion, pain with passive stretch of forearm muscles, tense forearm, paresthesias — irreversible damage can occur within 6 hours. Distal radius fractures with >35% translation or concurrent ipsilateral elbow injury carry particular risk [5-6]
• Open fracture (skin puncture over fracture site)
• Vascular compromise: absent radial pulse, cool/pale digits
• Associated radiocarpal dislocation (Barton's variant) — requires significant force and suggests high-energy mechanism [1]

3. Medications

• Acute analgesia: Acetaminophen, NSAIDs (ibuprofen 400–600 mg, naproxen 500 mg), opioids for severe pain
• Hematoma block: 5–10 mL of 1% lidocaine injected into the fracture hematoma for reduction
• Post-reduction/post-operative: Multimodal approach — scheduled acetaminophen + NSAID, limited opioid prescription (e.g., 20 tabs oxycodone 5 mg PRN) [7]
• Avoid prolonged immobilization in palmar flexion (Cotton-Loder position) — this can precipitate median nerve neuropathy [4]
• Consider calcium/vitamin D supplementation and osteoporosis workup in fragility fractures

4. Diet

• Adequate calcium (1,000–1,200 mg/day) and vitamin D intake for bone healing
• Protein-rich diet to support fracture recovery
• Hydration to support tissue healing and reduce swelling

5. Review of Systems

• Neurologic: Numbness/tingling in thumb, index, middle finger (median nerve); weakness of thumb opposition
• Vascular: Finger color changes, temperature, capillary refill
• Musculoskeletal: Ipsilateral elbow pain (rule out concurrent injury), shoulder pain, other extremity injuries
• Constitutional: Mechanism suggestive of syncope, seizure, or other medical cause of fall
• Endocrine: History of osteoporosis, menopause, thyroid disease

6. Collateral History and Family History

• Witnesses to the fall — mechanism clarification
• In elderly patients: assess for syncope, mechanical fall vs. medical cause
• Family history of osteoporosis or fragility fractures
• Social context: living situation, ability to perform ADLs with one functional hand, fall risk assessment

7. Risk Factors

• Osteoporosis — lower bone mineral density correlates with more severe fracture patterns [8]
• Female sex (21 of 26 patients in one series were female) [3]
• Elderly age with fall risk
• Cycling (falling over handlebars is a classic mechanism) [1]
• High-energy trauma in younger patients (motor vehicle accidents, sports)
• Prior distal radius fracture

8. Differential Diagnosis

• Colles' fracture: Dorsal displacement (silver fork deformity) — opposite direction from Smith's [1]
• Barton's fracture: Distal radius fracture with radiocarpal dislocation/subluxation (volar or dorsal); a Smith's fracture with dislocation is essentially a volar Barton's [1][9]
• Chauffeur's (Hutchinson) fracture: Radial styloid fracture, intra-articular [1]
• Scaphoid fracture: Anatomic snuffbox tenderness, often occult on initial radiographs
• Distal radioulnar joint (DRUJ) injury: Isolated ligamentous injury without fracture
• Galeazzi fracture: Radial shaft fracture with DRUJ dislocation [1]

9. Past Medical History

• Prior wrist fractures or injuries
• Osteoporosis or osteopenia (DEXA results)
• Rheumatoid arthritis or other inflammatory arthropathy
• Carpal tunnel syndrome (pre-existing median neuropathy)
• Diabetes (affects healing and neuropathy assessment)
• Anticoagulation therapy

10. Physical Exam

• Inspection: Volar displacement of the distal fragment produces a "garden spade" deformity (opposite of the dorsal "dinner fork" deformity of Colles')
• Palpation: Tenderness over the distal radius, assess for DRUJ tenderness and ulnar styloid tenderness
• Neurovascular exam: Mandatory — assess median nerve function (sensation to thumb/index/middle finger, thumb opposition), radial and ulnar pulses, capillary refill
• Wrist edema, deformity, and pain with pronation are strong predictors of fracture (combined sensitivity 94%) [1][10]
• Ecchymosis is the most specific finding for fracture (97.8%) [10]
• Assess for skin integrity (open fracture), forearm compartment tension
• Examine ipsilateral elbow and shoulder

11. Lab Studies

• Labs are generally not required for isolated Smith's fractures
• In elderly/fragility fractures: consider CBC, BMP, calcium, vitamin D, TSH, and DEXA scan as outpatient
• If surgical intervention planned: CBC, BMP, coagulation studies, type and screen per institutional protocol
• In high-energy trauma: standard trauma labs as indicated

12. Imaging

• First-line: PA and lateral wrist radiographs — essential to evaluate displacement direction, angulation, and articular involvement [1][11]
• The lateral view is critical for identifying volar angulation/displacement that defines a Smith's fracture
• Assess radiographic parameters: radial shortening, volar tilt, intra-articular step-off, DRUJ alignment
• CT scan: Consider for intra-articular fractures to better characterize articular involvement and guide surgical planning [12]
• Post-reduction radiographs are mandatory to confirm acceptable alignment
• Imaging is unnecessary only if clinical exam reliably excludes fracture (rare in this context)

13. Special Tests

Thomas Classification (specific to Smith's fractures): [9][13]

• Type I: Extra-articular transverse fracture with volar displacement (most classic)
• Type II: Oblique fracture line from dorsal lip to volar cortex with volar displacement of the distal fragment along with the carpus (essentially a volar Barton's fracture)
• Type III: Extra-articular fracture with volar displacement and intra-articular extension into the radiocarpal joint

AAOS/ASSH surgical indications (for distal radius fractures in patients <65 years): [14-15]

• Post-reduction radial shortening >3 mm
• Dorsal tilt >10°
• Intra-articular displacement or step-off >2 mm

Point-of-care ultrasound (POCUS) can be used as an adjunct for fracture identification in some settings. [1]

14. ECG

• Not routinely indicated for isolated Smith's fracture
• Consider ECG if the fall may have been caused by syncope, arrhythmia, or other cardiac etiology — particularly in elderly patients
• Obtain ECG if procedural sedation is planned for reduction

15. Assessment

Smith's fracture is an inherently unstable distal radius fracture pattern due to the volar displacement and the deforming pull of the wrist flexors. Unlike Colles' fractures, Smith's fractures are more difficult to maintain in reduction with casting alone, and many ultimately require operative fixation. [2] The Thomas classification helps guide management: Type I and II fractures tend to have moderate results with conservative management, while Type III (extra-articular) may be more amenable to non-operative treatment. [2]

Key complications include:

• Median nerve injury — the most common early neurologic complication of distal radius fractures [4][16]
• Malunion with persistent volar angulation
• Post-traumatic arthritis (especially with intra-articular involvement)
• Complex regional pain syndrome (CRPS)
• Tendon irritation or rupture

16. Treatment Plan

Initial stabilization (ED):

• Analgesia: hematoma block or procedural sedation for reduction
• Closed reduction: Apply longitudinal traction, then dorsally directed pressure on the volar-displaced distal fragment to restore alignment. Unlike Colles' reduction, the wrist should be immobilized in slight dorsiflexion and supination to counteract the volar deforming forces
• Apply a well-molded sugar-tong splint after reduction [1]
• Post-reduction PA and lateral radiographs to confirm acceptable alignment

Acceptable reduction parameters: [1][14]

• Radial shortening ≤2–3 mm
• Volar/dorsal tilt <10°
• Intra-articular step-off ≤2 mm
• Congruent DRUJ

Operative management: Smith's fractures frequently require surgical fixation due to inherent instability. Volar locking plate fixation is the most commonly used technique, providing earlier functional recovery. [7] Operative treatment is recommended for non-geriatric patients (<65 years) with fractures that do not meet acceptable reduction parameters. [14-15] In patients >65 years, strong evidence shows no difference in patient-reported outcomes between operative and non-operative treatment. [15]

Post-operative: Removable wrist brace, early digit ROM, multimodal analgesia. [7]

17. Disposition

• Discharge: Nondisplaced or acceptably reduced fractures with intact neurovascular exam, adequate pain control, and reliable follow-up
• Orthopedic consultation in ED: Displaced fractures requiring reduction, concurrent dislocation, open fracture, neurovascular compromise, compartment syndrome [1]
• Admission criteria: Open fracture requiring operative washout, acute carpal tunnel syndrome requiring emergent decompression, compartment syndrome, polytrauma
• Observation: Consider for patients with borderline neurovascular exam or significant swelling at risk for compartment syndrome
• Most Smith's fractures warrant early orthopedic follow-up (within 3–7 days) given the high rate of redisplacement — 28% of conservatively managed distal radius fractures redisplace within 6 weeks [17]

18. Follow Up / Return Precautions

• Follow-up: Orthopedic/hand surgery follow-up within 5–7 days for repeat radiographs and reassessment of alignment
• Radiographic follow-up at 2 weeks, then as clinically indicated (evidence supports case-by-case radiographic frequency) [7][15]
• Immobilization duration: 3–6 weeks depending on fracture stability and healing [1]

Return precautions — instruct patients to return immediately for:

• Increasing numbness or tingling in the fingers (especially thumb, index, middle)
• Increasing pain despite medication, or pain with passive finger extension
• Fingers turning blue, white, or cold
• Inability to move fingers
• Splint becoming too tight from swelling
• Fever, drainage, or foul odor from the splint

Expected recovery: Most patients regain functional wrist motion by 3–6 months. Grip strength recovery may take up to 12 months. Consider osteoporosis evaluation and fall prevention in elderly patients with fragility fractures.

References

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2. Common Fractures of the Radius and Ulna. — Patel DS, Statuta SM, Ahmed N. American Family Physician. 2021.

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4. Operative Treatment of Smith-Goyrand Fractures. — van Leeuwen PA, Reynders PA, Rommens PM, Broos PL. Injury. 1990.

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6. Smith's Fracture Generally Occurs After Falling on the Palm of the Hand. — Matsuura Y, Rokkaku T, Kuniyoshi K, et al. Journal of Orthopaedic Research : Official Publication of the Orthopaedic Research Society. 2017.

7. Smith's Fracture Generally Occurs After Falling on the Palm of the Hand. — Matsuura Y, Rokkaku T, Kuniyoshi K, et al. Journal of Orthopaedic Research : Official Publication of the Orthopaedic Research Society. 2017.

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