Summary

Smith's fracture is a distal radius fracture with volar (palmar) displacement and angulation — the opposite of the more common Colles' fracture. Sometimes called a "reverse Colles'", it results from a fall onto a flexed wrist or a direct blow to the dorsal forearm. These fractures are inherently unstable due to the volar displacement and the pull of wrist flexor muscles. Most require surgical fixation with a volar locking plate, which has become the gold standard treatment.

Key Facts

• Definition: Distal radius fracture with volar angulation/displacement
• Eponym: Robert William Smith (Dublin, 1847)
• Mechanism: Fall onto flexed wrist OR direct dorsal blow
• Key Difference: Colles' = dorsal angulation; Smith's = volar angulation
• Stability: Inherently unstable — high redisplacement rate with cast alone
• Treatment: Volar locking plate ORIF is gold standard for most adults

Clinical Pearls

"Garden Spade" vs "Dinner Fork": Smith's creates a "garden spade" deformity (volar prominence of distal radius), while Colles' creates the classic "dinner fork" deformity (dorsal angulation). Examine from the side.

Median Nerve Alert: Acute carpal tunnel syndrome is a significant risk due to volar displacement compressing the carpal tunnel. Check sensation and motor function — urgent decompression if symptomatic.

Casts Often Fail: Unlike Colles' fractures, Smith's fractures are notoriously difficult to maintain in a cast. Operative fixation has much better outcomes.

Why This Matters Clinically

Smith's fractures, though less common than Colles' fractures, have important management differences. Their inherent instability means conservative treatment often fails. Recognition of the volar displacement pattern and understanding that surgery is often required leads to better patient outcomes.

Structured Approach

General:

• Expose entire forearm and hand
• Compare to contralateral side
• Assess patient comfort level

Specific Examination:

• Inspect for deformity (volar prominence on lateral view)
• Palpate for tenderness, crepitus
• Check DRUJ stability
• Full neurovascular assessment

Special Tests

Natural History

Without treatment, Smith's fractures would heal in a malunited position with volar angulation, significantly affecting wrist biomechanics, grip strength, and forearm rotation. Modern surgical treatment provides excellent outcomes.

Outcomes with Treatment

Prognostic Factors

Good Prognosis:

• Young patient
• Extra-articular fracture
• Anatomic surgical reduction
• Early mobilisation

Poor Prognosis:

• Intra-articular involvement
• Comminution
• Late presentation
• Associated DRUJ injury
• Non-compliance with rehabilitation

Key Guidelines

1. BOAST 12: Distal Radius Fractures (2017) — British Orthopaedic Association Standards. Recommends surgical fixation for unstable fractures including Smith's type.

2. NICE NG177: Fractures (Non-complex) — Supports early mobilisation and appropriate surgical intervention for displaced/unstable fractures.

Landmark Trials

DRAFFT (2014) — Distal Radius Acute Fracture Fixation Trial

• Compared K-wire vs volar locking plate for displaced DRFs
• Key finding: No significant difference at 12 months for dorsal fractures
• Clinical Impact: However, volar locking remains preferred for Smith's due to instability pattern

Arora et al. (2011) — Volar locking plate outcomes

• Prospective study of volar plate for volar DRFs
• Key finding: Excellent functional outcomes with low complication rate
• Clinical Impact: Established volar plate as gold standard for Smith's fractures

Evidence Strength

What is a Smith's Fracture?

A Smith's fracture is a break in the wrist bone (radius) where the broken end tilts toward the palm side of your wrist. It's sometimes called a "reverse Colles' fracture" because it's the opposite of the more common Colles' fracture where the bone tilts the other way.

Why does it matter?

This type of fracture is harder to treat with just a cast because the muscles in your forearm keep pulling the broken bone out of position. That's why surgery is usually needed to fix it properly. Without proper treatment, the wrist may heal in the wrong position, causing lasting problems with grip and movement.

How is it treated?

1. Most cases need surgery: A small plate and screws are placed on the front of the wrist bone to hold it in place. This is done through a small incision and has very good results.

2. Occasionally a cast is tried: If the fracture hardly moved at all, a cast may be tried, but X-rays are needed weekly to make sure it stays in position.

3. Physiotherapy: After surgery, you'll start exercises quickly to regain movement and strength.

What to expect

• Surgery usually done within a few days of injury
• Most people go home the same day as surgery
• Wrist exercises start within the first week
• Return to office work: 2-4 weeks
• Return to manual work: 8-12 weeks
• Full recovery: 3-6 months

When to seek help

See a doctor urgently if you notice:

• Numbness or tingling in your thumb, index, or middle fingers
• Fingers becoming cold, pale, or blue
• Increasing pain despite medication
• Wound problems (redness, discharge, opening)