A 55-year-old man from Mumbai falls directly onto the dorsum of his wrist while trying to break his fall. He presents with wrist pain, swelling, and a characteristic 'reverse dinner fork' deformity visible on the lateral wrist X-ray. The distal radius fragment is displaced volarly with volar angulation. Associated with this fracture is a volar displacement of the carpus. What is the most appropriate initial management?

Explanation

## Management of Smith Fracture **Key Point:** Smith fracture (volar Colles) requires closed reduction under anesthesia followed by immobilization in a FLEXED position to maintain the reduction and counteract the volar displacement. ### Diagnosis: Smith Fracture **High-Yield:** Smith fracture is a distal radius fracture with VOLAR displacement and volar angulation of the distal fragment, producing a 'reverse dinner fork' deformity on lateral X-ray. ### Mechanism and Epidemiology - **Mechanism:** Direct blow to dorsum of wrist or FOOSH with wrist in flexion - **More common in:** Elderly patients (osteoporosis), falls from height - **Associated injuries:** Volar displacement of carpus, anterior radiocarpal dislocation (in severe cases) ### Comparison: Colles vs. Smith Fractures | Parameter | Colles | Smith | |-----------|--------|-------| | **Displacement** | Dorsal | Volar | | **Angulation** | Dorsal | Volar | | **Deformity** | Dinner fork | Reverse dinner fork | | **Mechanism** | FOOSH in extension | FOOSH in flexion / direct blow | | **Immobilization position** | Neutral to slight extension | Flexion (supination) | | **Complication risk** | Posterior interosseous nerve | Anterior interosseous nerve, median nerve | ### Management Algorithm ```mermaid flowchart TD A[Smith Fracture Diagnosed]:::outcome --> B{Fracture Stability?}:::decision B -->|Stable, Extra-articular| C[Closed Reduction]:::action B -->|Unstable, Intra-articular| D[Consider ORIF]:::action C --> E[Immobilize in Flexion]:::action E --> F[Above-elbow cast for 4-6 weeks]:::action D --> G[Volar plate or percutaneous pinning]:::action F --> H[Serial X-rays to monitor reduction]:::action G --> I[Early mobilization after union]:::action H --> J[Physiotherapy]:::action ``` ### Closed Reduction Technique 1. **Anesthesia:** Hematoma block or procedural sedation 2. **Traction:** Apply longitudinal traction to disimpact the fracture 3. **Reduction:** Flex the wrist and forearm to reduce volar displacement 4. **Immobilization:** Apply above-elbow plaster cast with wrist in **flexion and supination** (position of comfort) 5. **Monitoring:** X-rays at 1 week, 2 weeks, and 4 weeks to assess for loss of reduction **Clinical Pearl:** The key difference from Colles management is the immobilization position — Smith fractures are immobilized in FLEXION to maintain reduction, whereas Colles fractures are immobilized in neutral or slight extension. **Warning:** Anterior interosseous nerve (AIN) injury is a recognized complication; assess for loss of thumb IP flexion and index finger DIP flexion postoperatively. ### Indications for Operative Management - Unstable fractures with >20° volar angulation - Intra-articular involvement with displacement >2 mm - Loss of reduction during conservative treatment - Barton variant (fracture-dislocation) - Multiple trauma or polytrauma **High-Yield:** Modern preference for unstable Smith fractures is **volar plate fixation** (rather than dorsal plating) because it directly addresses the volar displacement and provides better functional outcomes. [cite:Rockwood and Green's Fractures in Adults Ch 8]