A 55-year-old woman is brought to the emergency department after falling on her outstretched hand while trying to break her fall during a slip on wet floor. On examination, the wrist shows a 'garden spade' deformity with volar prominence and volar angulation of the distal wrist. The dorsal aspect of the wrist appears relatively flat. Plain radiographs reveal a fracture of the distal radius with volar displacement of the distal fragment and angulation toward the volar aspect. What is the most appropriate classification for this fracture?

Explanation

## Diagnosis: Smith Fracture ### Clinical Presentation and Deformity The 'garden spade' deformity is the characteristic clinical sign of a Smith fracture. This deformity results from **volar (palmar) displacement and volar angulation** of the distal radius fragment, creating a prominence on the volar aspect of the wrist while the dorsal surface appears relatively flat. ### Comparative Analysis: Colles vs. Smith | Characteristic | Colles Fracture | Smith Fracture | |---|---|---| | **Deformity** | Dinner fork (dorsal) | Garden spade (volar) | | **Displacement** | Dorsal and radial | Volar (palmar) | | **Angulation** | Dorsal | Volar | | **Mechanism** | FOOSH with wrist **extension** | FOOSH with wrist **flexion** | | **Frequency** | ~90% of distal radius fractures | ~10% of distal radius fractures | | **Age group** | Elderly (osteoporotic bone) | Younger patients, high-energy trauma | | **Intra-articular** | Common (50%) | Less common | **Key Point:** Smith fracture = volar displacement + garden spade deformity + flexion-type FOOSH. It is sometimes called a "reverse Colles" fracture because the displacement is opposite to that of a Colles fracture. ### Mechanism of Injury Smith fractures occur when the wrist is in **flexion** at the time of impact. The volar force drives the distal fragment in a volar direction. This mechanism is less common than the extension-type FOOSH that produces Colles fractures, making Smith fractures account for only ~10% of distal radius fractures. ### Subtypes of Smith Fractures 1. **Type I (Extra-articular):** Transverse fracture distal to the wrist joint 2. **Type II (Intra-articular):** Fracture extends into the radiocarpal joint 3. **Type III (Intra-articular):** Fracture involves the dorsal lip of the radius (reverse Barton fracture) **High-Yield:** Smith fracture Type III (reverse Barton) is an intra-articular fracture-dislocation and requires surgical intervention, unlike simple extra-articular Smith fractures which may be managed conservatively. ### Treatment Approach - **Extra-articular (Type I & II):** Closed reduction and immobilization in a volar slab or cast with the wrist in **extension** (to reduce the volar displacement) - **Intra-articular (Type III/Reverse Barton):** Usually requires **open reduction and internal fixation (ORIF)** with volar plating **Clinical Pearl:** Smith fractures are more common in younger patients and high-energy trauma, whereas Colles fractures predominate in elderly osteoporotic patients. Always assess for associated injuries and neurovascular compromise, particularly median nerve compression due to volar swelling. ### Why This Is Not a Colles Fracture The volar displacement and garden spade deformity are the opposite of what is seen in Colles fractures. The mechanism (flexion-type FOOSH) also differs from the extension-type mechanism typical of Colles fractures.