A 55-year-old man from Mumbai falls backward while stepping off a bus and lands on his palm with the wrist flexed forward. He presents with severe pain, swelling, and a deformity described as 'reverse dinner fork' on the volar aspect of the wrist. X-ray confirms a fracture of the distal radius with volar angulation and volar displacement of the distal fragment. Which of the following is the most appropriate initial management for this fracture?

Explanation

## Smith Fracture: Diagnosis and Management **Key Point:** Smith fracture (reverse Colles) is a distal radius fracture with volar (palmar) displacement and angulation. It accounts for approximately 10% of distal radius fractures and requires specific management considerations. ### Clinical Presentation of Smith Fracture | Feature | Smith Fracture | |---------|------------------| | **Deformity** | 'Reverse dinner fork' (volar prominence) | | **Mechanism** | Fall on flexed wrist with pronation | | **Displacement** | Volar and radial | | **Angulation** | Volar angulation | | **Age group** | Younger patients (high-energy); also osteoporotic elderly | | **Associated injuries** | Higher rate of soft tissue injury, volar wrist structures at risk | ### Management Algorithm ```mermaid flowchart TD A[Smith Fracture Diagnosed]:::outcome --> B{Displacement & Angulation?}:::decision B -->|Minimal/Acceptable| C[Closed Reduction]:::action B -->|Severe/Unstable| D[Consider ORIF]:::action C --> E[Volar Slab or Cast]:::action E --> F[Immobilize 4-6 weeks]:::action D --> G[Volar Plate ORIF]:::action F --> H[Serial X-rays to monitor]:::action G --> H H --> I[Early mobilization post-healing]:::action ``` ### Closed Reduction Technique **High-Yield:** The reduction maneuver for Smith fracture: 1. Apply longitudinal traction to the wrist 2. Correct volar displacement by **extending the wrist** (dorsiflexion) 3. Supinate the forearm to restore anatomical alignment 4. Maintain reduction in a **volar slab or volar cast** (not dorsal) **Clinical Pearl:** Unlike Colles fracture (which is immobilized in dorsal slab with wrist flexion), Smith fracture requires **volar immobilization with wrist extension** to maintain reduction against the volar angulation. ### Why Volar Immobilization? - The fracture has volar displacement and angulation - Volar slab or cast supports the volar cortex and prevents re-displacement - Dorsal slab would allow the fragment to re-angulate volarly - Immobilization duration: typically 4–6 weeks for uncomplicated cases **Mnemonic:** **Smith = Slab Volar** (remember: Smith fracture → volar displacement → volar slab immobilization). ### Indications for Open Reduction and Internal Fixation (ORIF) - Severe displacement or comminution - Unstable fracture pattern - Intra-articular involvement with step-off > 2 mm - Associated soft tissue injury (volar structures, tendons) - Failure of closed reduction - Multiple trauma requiring early mobilization **Warning:** Smith fractures have a higher risk of volar soft tissue injury (flexor tendons, median nerve) compared to Colles fractures. Careful neurovascular examination is mandatory before and after reduction. [cite:Rockwood and Green's Fractures in Adults Ch 13; Campbell's Operative Orthopaedics 13e Ch 57]