Smith’s frakture

Smith’s fracture is a break in the distal radius that occurs from a fall onto the back (dorsal side) of the hand—meaning with the wrist in flexion—and results in volar displacement of the distal fragment. The injury is often referred to as a “reverse Colles’ fracture” and was first described by Irish surgeon Robert William Smith in 1847. In French literature, it is also known as a Goyrand fracture¹.

Cause and Mechanism of Injury

The most common causes are a fall onto a flexed wrist or direct trauma to the back of the wrist.This can occur during:

• Tripping forward while walking

• Falling backward

• Bicycle accidents or other sports-related injuries

The mechanism of injury involves an axial load through the wrist that forces the radius volarly, causing the distal fragment to shift forward relative to the shaft² ³.

Epidemiology

Distal radius fractures are the most common fractures of the upper extremity and the second most common overall in older adults. Smith’s fractures account for approximately 5% of all radius/ulna fractures¹.

• Young men are most commonly affected after high-energy trauma

• Older women are more susceptible after low-energy falls, often related to osteoporosis

Classification

Smith’s fractures are divided into three types¹:

• Type I: Extra-articular fracture, the most common form (~85%)

• Type II: Intra-articular oblique fracture (also called “reverse Barton’s fracture”), about 13%

• Type III: Rare, juxta-articular oblique fracture (<2%)

Clinical Presentation

Patients with Smith’s fracture typically present with pain, swelling, and limited wrist motion.Volar displacement is not always obvious, but characteristic findings include:

• Swelling and visible deformity on the volar side

• Prominence of the ulna on the dorsal aspect

• Reduced active and passive motion

• Tenderness over the distal radius

Associated injuries are common and may involve:

• Distal radioulnar joint (DRUJ)• Triangular fibrocartilage complex (TFCC)• Ulnar styloid process

Neurovascular examination is essential since up to 15% of patients may develop acute carpal tunnel syndrome due to median nerve compression. Compression of the radial or ulnar nerves is less frequent but possible.Acute compartment syndrome of the forearm is a rare but potentially life-threatening complication¹.

Diagnosis

X-ray imaging (AP and lateral views) confirms the diagnosis and shows:

• A distal radius fracture with volar angulation

• Degree of displacement, angulation, and articular involvement

• Integrity of the radiolunate and radioscaphoid joints

Additional views (oblique or traction radiographs) may be helpful when soft-tissue injury is suspected.CT scanning is recommended for intra-articular or comminuted fractures to improve assessment and preoperative planning¹.

Differential Diagnoses

• Colles’ fracture: Dorsally displaced extra-articular fracture of the distal radius

• Barton’s fracture: Intra-articular fracture with dorsal displacement

• Reverse Barton’s fracture: Intra-articular fracture with volar displacement (Smith type II)

• Die-Punch fracture: Depressed lunate fossa fracture

• Chauffeur’s fracture: Avulsion of the radial styloid process

• DRUJ injury: Distal radioulnar joint instability

• TFCC tear

• Galeazzi fracture: Radius fracture with DRUJ instability¹

Functional Outcomes and Evaluation

Outcome measures combine objective and subjective parameters, including:

• Radiographic follow-up

• Range of motion (ROM)

• Grip and pinch strength

• Functional questionnaires

Validated assessment tools:

• DASH (Disabilities of the Arm, Shoulder and Hand): 30-item questionnaire; lower scores indicate better function

• Michigan Hand Questionnaire (MHQ): Evaluates six dimensions—function, ADL, pain, aesthetics, work, and satisfaction with hand function⁴

Complications of Smith’s Fracture

Malunion is common, with persistent volar tilt or shortening of the radius leading to a characteristic deformity known as “garden spade deformity.” This may also narrow the carpal tunnel and cause delayed-onset carpal tunnel syndrome.Elderly patients with low bone density are at higher risk of redisplacement despite proper immobilisation, and corrective osteotomy may be required for malunion¹.

Median nerve compression may develop either acutely or later, often due to improper or excessive mobilisation in flexion or extension¹.

EPL entrapment (Extensor Pollicis Longus) is a less frequent but documented complication following both conservative and surgical management. Late EPL tendon rupture may also occur¹.

Complex Regional Pain Syndrome (CRPS) is reported in up to 40% of cases, requiring early identification and preventive strategies¹.

Treatment

Conservative Management

For stable, non-displaced fractures, treatment involves closed reduction and casting or splinting. Reduction is performed by reversing the deformity through traction, followed by immobilisation in forearm supination and wrist neutral or slight extension⁵.

Reduction can be done under haematoma block, regional nerve block, or light sedation.The AAOS recommends weekly radiographs for the first three weeks post-reduction¹.

In two- or three-part fractures, percutaneous pinning (K-wires) can be a cost-effective alternative but is discouraged in patients with poor bone quality or comminution⁶.Risks include tendon or nerve injury, pin-site infection, and pin migration¹.

Surgical Management

Surgery is indicated when:

• Dorsal or volar comminution is present

• The fracture is intra-articular

• Instability persists after reduction

• Angulation >20° or >2 mm step-off

• Radial shortening >5 mm¹

ORIF with volar plating is recommended for unstable fractures.This provides rigid fixation, minimises the risk of extensor tendon rupture, and preserves metaphyseal blood supply.

Postoperative pain control may include transdermal buprenorphine or codeine/paracetamol, but opioids should be limited to the acute phase.

Physiotherapy Management

Immobilisation Phase (4–8 weeks for stable, 6–12 weeks for unstable fractures)

• Cryotherapy and elevation for pain and swelling control

• Finger exercises to maintain circulation and lymphatic drainage

• Active shoulder and elbow movements to prevent stiffness

After Cast Removal

• Heat therapy (hot packs or paraffin wax) combined with cold therapy for vascular and pain modulation

• Manual therapy (gentle massage and scar mobilisation)

• Mobility exercises: drawing, writing, buttoning, and picking up small objects

• Strength training: isometric exercises for wrist, grip, shoulder, and elbow

• Functional use in ADLs encouraged from early stages

Fall Prevention

Fall prevention is crucial, particularly in older adults.Measures include:

• Balance and gait training

• Assistive devices if needed

• Home adjustments (remove loose rugs, improve lighting)

Vitamin D supplementation is recommended by the AAOS to prevent CRPS in patients with distal radius fractures¹.

Prognosis

Closed reduction typically restores function within six weeks, though long-term outcomes depend on injury severity and treatment choice.For athletes, achieving stable fixation, rapid swelling control, early mobilisation, and functional retraining is key for safe return to activity.

Sources

1. Schroeder JD, Varacallo M. Smith's Fracture Review. InStatPearls [Internet] 2019 Oct 1. StatPearls Publishing.

2. Matsuura Y, Rokkaku T, Kuniyoshi K, Takahashi K, Suzuki T, Kanazuka A, Akasaka T, Hirosawa N, Iwase M, Yamazaki A, Orita S. Smith's fracture generally occurs after falling on the palm of the hand. Journal of Orthopaedic Research. 2017 Nov;35(11):2435-41.

3. Andrew Murphy. Assoc Prof Frank Gaillard et al.Smith fracture. Radiopedia.https://radiopaedia.org/articles/smith-fracture

4. Ikpeze TC, Smith HC, Lee DJ, Elfar JC. Distal radius fracture outcomes and rehabilitation. Geriatric orthopaedic surgery & rehabilitation. 2016 Dec;7(4):202-5.

5. Emergency Care South Wales Smiths.https://www.aci.health.nsw.gov.au/networks/eci/clinical/clinical-resources/clinical-tools/orthopaedic-and-musculoskeletal/musculoskeletal-orthopaedic-guide/smiths#:~:text=Most%20commonly%20an%20extra%2Darticular,falling%20on%20a%20flexed%20wrist.

6. Glickel SZ, Catalano LW, Raia FJ, Barron OA, Grabow R, Chia B. Long-term outcomes of closed reduction and percutaneous pinning for the treatment of distal radius fractures. The Journal of hand surgery. 2008 Dec 1;33(10):1700-5.