Introduction
Smith's fracture is the fracture of the radial bone found at the distal end near the wrist of the hand. Smith’s fracture was named after an Irish surgeon, Robert William Smith, in 1847, while it was previously termed a Goyrand fracture from 1746 to 1814. Smith's fracture usually occurs as a fall injury where the arm is extended along with the wrist or outstretched. Based on the anatomy of the fracture line, Smith's fracture is also called reverse Colles fracture.
How Common Is Smith's Fracture?
Smith's fracture is the second most common fracture in adults, with an average incidence of almost 60 million cases annually. Nearly 16 percent of adults experience this, and 75 percent of hand fractures are Smith's fractures. This fracture is commonly termed a FOOSH (fall on an outstretched hand) injury, as the fracture occurs due to a fall with force applied on the wrist or palm. The high incidence rate of Smith's fracture occurs among young adult males and females. This fracture occurs near the volar side (side adjacently facing the palm) of the hand.
What Causes Smith's Fracture?
Smith's fracture is caused by the following:
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Fall accidents.
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Rotation of the wrist.
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Sports injuries.
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Vehicle accidents.
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Trauma due to abuse.
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Osteoporosis (a clinical condition seen as a weakening of the bones due to decreased bone density).
How Is It Clinically Seen?
The following clinical symptoms clinically appreciate Smith's fracture:
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Pain.
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Swelling.
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Decreased mobility or limited range of motion.
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Wrist deformity.
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Disruption of the cartilage presents distally and tissue complex.
How Is Smith's Fracture Evaluated?
The following methods can evaluate Smith's fracture:
Radiographic Imaging (X-Ray): Wrist radiographs are used to assess the fracture line to differentiate Smith's fracture from Colles fracture (Colles fracture is the wrist fracture in an upward direction, away from the body's midline). The radiographic images show the presence of three different types of fracture lines:
Type 1 - Most commonly seen in 80 percent of the clinical scenario.
Type 2 - 13 percent of the clinical cases.
Type 3 - Uncommon, with less than two percent clinical incidence.
Computed Tomography (CT): Computed tomography is an imaging technique of the entire body that uses computerized radiographic imaging techniques. CT scans assist normal radiographic imaging (X- rays) as it gives superior imaging quality. It is mainly done to differentiate and decide the pattern of fracture.
How Is Smith's Fracture Treated?
The presentation of Smith's fracture itself can be challenging for the doctor to fix it. However, fixing the fracture, restoring the fractured segment, and re-establishing the functional capacity are essential. Because of the fracture pattern, it is often not easy to fix it non-surgically. Treatment of Smith's fracture can be done in two types.
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Conservative Management: Smith's fracture can be conservatively managed by treating it non-surgically, also called a closed approach, as the skin lies intact. The fracture is reduced externally with the help of external splints, and the reduced segment is held without mobilization by using casts on the wrist. This external fixation and immobilization are done for three weeks.
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Surgical Management: There are specific criteria for performing surgery in the case of Smith's fracture. They are:
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When the arm is rotated.
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When there is any involvement of the bony joints.
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Instability even after reducing the fracture through a conservative approach.
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When the angular deformity is more than 20 degrees.
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Radial shortening is more than 5 mm (millimeter)
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The displacement of the articular surface is greater than 2 mm.
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The surgical approach is made by opening the fractured segment and fixing it by :
- Reduction - Open reduction is the treatment of choice for unstable fractures, even after closed reduction or conservative management.
- Fixation: This is achieved by placing the fractured segments using pins, screws, or plates.
- Immobilization: Immobilization is achieved using wrist braces, plaster casts, or splints for eight weeks.
Postoperative pain management is done by putting the patient on painkillers, elevation of the wrist position, and cryotherapy (managing pain with ice), followed by slow wrist movements and strengthening exercises.
What Are the Conditions Similar to Smith's Fracture?
The conditions which appear similar to Smith's fracture are:
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Colles Fracture: Fracture of the forearm with posterior displacement.
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Barton Fracture: Fracture of the wrist where the displaced side is opposite to the injured side.
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Reverse Barton's Fracture: Fracture involving the articular joint of the radial bone.
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Chauffeur's Fracture: Fracture of bone involving radial and styloid bone.
These clinical conditions are often misdiagnosed with Smith's fracture, and it is essential to rule out these.
What Are the Complications of Smith's Fracture?
The complications that might occur during the incidence of Smith's fracture when not diagnosed at the right time or not appropriately treated are:
Infection - The fractured area is more prone to infection when an open fracture (fracture exposing the bone due to the tear in the skin) or contamination during fracture reduction and fixation.
Compartment Syndrome: It occurs due to the pressure exerted due to the accumulation of blood within the interstitial cells of the injured area.
Nonunion of the Bones: These occur when the bone does not fuse in the desired position, and the cause can be wrist movement.
Injury to the Associated Vessels and Tissues: It happens due to the impingement of the bone to the adjacent soft tissue or impact on the tissues.
Carpal Tunnel Syndrome: The numbness felt in the wrist due to any nerve damage because of the broken bone or prolonged nerve compression. The characteristic features of carpal tunnel syndrome are:
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Numbness of the wrist.
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Tingling sensation in the palm.
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Pain and weakness in the hand.
Conclusion
Smith's fracture is the second most commonly occurring fracture of the distal part of the radial bone. It is an emergency condition because of the development of symptoms like carpal tunnel syndrome or compartment syndrome. Surgical management is done with internal fixation in case of significant wrist displacement. This fracture needs vigilant postoperative care with extensive rehabilitation to strengthen the muscles and tendons. Patients show a good prognosis after closed reduction and immobilization, followed by postoperative rehabilitation and care in six weeks.
