Smith Fracture Review

What is Smith Fracture Review?

A Smith fracture is a medical term for a break in the end of the radius bone in the wrist, where the broken piece is displaced or angled towards the palm. This is sometimes called a reverse Colles fracture, as the more common Colles fracture has the broken piece angled towards the back of the hand.

The wrist joint is a type of complex joint that includes the end of the radius bone and a special cartilage disc in the joint between the radius and ulna bones. This joint also includes the closest wrist bones, except for one tiny bone called the pisiform. A group of tissues known as the triangular fibrocartilage complex (TFCC) makes the joint stable and acts as a shock absorber for the wrist. The TFCC is made up of several parts including different ligaments and a part of a tendon for one of the forearm muscles.

The ulna bone is attached narrowly to one of the ligaments but doesn’t directly connect to any wrist bone. Still, it plays a vital role when twisting the forearm and wrist. Most of the movement of bending and stretching the wrist happens at the joint between the radius and the wrist bones.

A Smith fracture can cause a specific type of deformity that looks like a reversed ‘dinner fork’. The break can also harm the median nerve and a bone called the scaphoid. The median nerve travels through a space at the front of the wrist and helps with feeling and movement in the hand. Injuries to this nerve can decrease these functions. The scaphoid bone has a poor blood supply, which makes healing slower and can result in improper healing or failure to heal. Parts of the joint between the radius and ulna and the stabilizing TFCC can also get damaged when the end of the radius moves towards the palm. This can lead to pain and weakness on the side of the forearm and wrist near the little finger.

What Causes Smith Fracture Review?

Fractures in the area near the wrist, termed distal radial fractures, are usually caused by falling onto an outstretched hand. This type of fall is often responsible for a fracture known as a Colles fracture. Conversely, Smith fractures typically happen either from falling onto a bent wrist or from getting hit directly on the back of the wrist. When you fall onto your palm, the part of your wrist near your thumb, known as the distal radius, can move toward the palm as well.

Risk Factors and Frequency for Smith Fracture Review

Fractures of the distal radius, the end part of the largest bone in the forearm, are quite common. Every year in the United States, over 600,000 cases are reported, making up more than 16% of all adult fractures and 75% of forearm fractures. These types of breaks are the second most common in older adults, after hip fractures.

Interestingly, different types of distal radius fractures are more common in certain age groups. Colles fractures, a specific type of break in the distal radius, commonly occur in the elderly. Smith fractures, another type, make up about 5% of all radial and ulnar bone breaks and are more likely to happen in young men and older women.

• Fractures of the distal radius mostly occur in children who have high-energy falls or in seniors with weak bones due to osteoporosis, who suffer low-impact falls.
• Women between the ages of 64 and 94 are six times more likely than men of the same age to have a distal radial fracture.
• There is evidence to suggest that if a person has low bone strength and suffers a distal radius fracture due to minor trauma, this could predict decreased bone mineral density.

Interestingly, hospital data from Denmark showed a 31% increase in adult males’ fractures from 1997 to 2018. This could be due to the growing number of older men. Also, more surgeries to treat these fractures have been noticed in this period, also likely due to more older patients.

Signs and Symptoms of Smith Fracture Review

A Smith fracture is usually caused by a traumatic injury typically from a fall on a flexed hand, resulting in pain, swelling, deformation, and limited joint mobility. Numbness or weakness in the hand might also be present, suggesting nerve damage.

During a physical examination, the doctor may observe a warm, tender deformation in the forearm along the wrists’ palm (volar) side and a prominent bone on the back (dorsum) of the wrist. However, it might be tricky to determine on visual inspection alone whether the deformation is towards the back (Colles) or the palm (Smith). The wrist’s movement might also be restricted.

Examination of the arm’s nerve and blood supply (neurovascular status) is crucial. Some people with Smith fractures, up to 15% may show signs of Acute Carpal Tunnel Syndrome (ACTS) from compression of the median nerve. It’s less common, but the radial and ulnar nerves may also be compressed after a fracture towards the wrist’s end. Signs of damage in these nerves can be found during the examination. An acute compartment syndrome may also develop, which can present as:

• Pain
• Pallor
• Absence of a pulse (pulselessness)
• Abnormal skin sensations such as tingling or pricking (paresthesia)
• Paralysis or severe loss of muscle function

It’s important to note that any compromise in the neurovascular status calls for immediate surgical treatment.

Testing for Smith Fracture Review

If you hurt your wrist and your doctor suspects a fracture, the first thing they might do is have a set of X-rays taken from the front and side of your wrist. These X-rays can show if the lower part of the radius (a bone in the forearm), is broken and if it’s leaning towards the palm. This type of fracture is called a Smith fracture.

In certain cases, your doctor might want to look at your wrist from different angles to gain extra information about the break. These additional X-rays can help them see how well your wrist bones are lined up, how stable two particular bones are (the lunate and scaphoid), and if there are any other bone fractures or foreign bodies present.

If the fracture is complex, or if the break extends into the joint, your doctor might also order a special type of X-ray called a computed tomography (CT) scan. This can give them a better view of the fracture and help them plan for surgery if it’s required.

Treatment Options for Smith Fracture Review

The aim of treating Smith fractures, a type of wrist fracture, is to realign the bones and prevent any further complications. These injuries usually can’t be treated through a simple realignment without surgery. There are several factors, such as extensive misalignment, conditions that involve the joints or shattering, instability after realignment, extreme angling, and shortening of the radius bone which can indicate that a surgical approach might be necessary. If these factors aren’t present, a non-invasive treatment can be tried.

Non-invasive treatment involves adjusting the bones back into place and then immobilizing the wrist. This is the leading way to treat wrist fractures that are still stable and haven’t moved out of place. For Smith fractures specifically, the wrist is readjusted and then put in a splint. Different ways to manage pain during this procedure include general anesthesia, regional nerve blocks, or medications that numb only the affected area.

Research hasn’t shown any differences in results based on the method used in splinting stable wrist fractures. However, it doesn’t support the use of certain types of splints on fresh wrist fractures. The American Academy of Orthopaedic Surgeons recommends rechecking the fracture every week for the first three weeks after realignment, and before removing the splint or cast.

Previous case reviews indicate that a second realignment attempt doesn’t necessarily improve the position of the bones or decrease the need for surgery. In fact, re-realignment might increase the need for an operation. Therefore, different treatment options should be considered before trying to readjust a Smith fracture again. A study showed that immobilizing the wrist for 4 weeks adequately readjusted most types of these fractures.

Surgery may be considered if non-invasive treatment isn’t enough to correct a Smith fracture. Several factors influence the choice of surgical approach including the severity of the injury, the amount of bone movement, the patient’s age, their job, and general health state.

The first option is a procedure where the bones are moved back into place and then secured with Kirschner wires. This method is minimally invasive, cost-effective, and usually results in good functional outcomes with two or three-segment fractures. Yet, this technique is not recommended in cases of more complex fractures, particularly when the bones are weak, such as in osteoporosis.

The second option is external fixation. This technique uses tension applied to the soft tissues surrounding the fracture to realign the bone fragments. This technique is especially useful when dealing with multiple injuries at once or major open fractures. However, it is generally more challenging to use this method for Smith fractures, and it carries potential complications such as infection and complex regional pain syndrome.

The third option, and currently the most commonly performed procedure, is open reduction and internal fixation (ORIF) surgery. This is the best choice for a Smith fracture that is unstable or can’t be realigned non-invasively. This method can be applied from different directions. However, professional bodies have not recommended one method over the others, but placing the locking plates from the palm side appears to be best for Smith fractures. It reduces the risk of the tendons tearing and preserves blood flow to the bone.

Sometimes, carpal tunnel syndrome can also develop as a complication of a Smith fracture. In some cases, a carpal tunnel release procedure may be necessary during the fracture-fixing operation. Finally, fractures can also occur to the ulnar styloid process associated with wrist fractures. Both nonoperative and surgical management have been found to be similarly effective in these cases, although non-invasive treatment is linked to a higher risk of the fracture not healing correctly.

What else can Smith Fracture Review be?

When a person experiences pain and deformity in their forearm due to an injury, there can be a number of different causes. These might include:

• A Colles fracture, which is a particular type of break in the bone of the wrist
• A Barton fracture, another type of wrist injury, is also possible
• A reverse Barton fracture is similar but presents in a slightly different way
• A Die-punch fracture relates to a specific part of the wrist, the radial surface, being affected
• The Chauffer’s fracture – a specific break in the radial bone of the wrist
• DRUJ disruption refers to an injury to specific parts of the wrist
• TFCC tear is when damage has been done to a specific area of cartilage in the wrist
• A Galeazzi fracture is when a specific part of the radius bone in the arm, near the wrist, has been broken

To successfully tell the difference between these conditions and a Smith fracture, a thorough physical examination and x-rays are needed. Good logical conclusions based upon these results are also necessary. In some cases, help from a specialist in bone health may be required to arrive at the correct diagnosis and the best course of action for treatment.

What to expect with Smith Fracture Review

Patients who get proper treatment through a procedure called closed reduction typically have good results, and generally heal functionally around 6 weeks. While there’s no evidence that suggests moving around early can help improve long-term outcomes after surgery, several other things are crucial for athletes who want to get back to their sports activities early. These include having a secure fixation, managing swelling, starting movement early with rehab, and using functional braces.

Possible Complications When Diagnosed with Smith Fracture Review

Smith fractures, or breaks in the wrist, can lead to complications if they are not treated properly. These complications might affect the wrist’s appearance and its ability to function. One common complication is malunion. This occurs when the wrist does not set back into place properly, leading to a shift or shortening of the bone in the wrist. This may result in the wrist looking odd – a condition referred to as the “garden spade” deformity.

A malunion might narrow the space in the wrist where the median nerve travels (known as carpal tunnel), leading to delayed carpal tunnel syndrome. Older individuals with lower bone density are at a higher risk for malunion because their bones are harder to reset. It’s reported that up to 50% of elderly patients might have a malunion after their wrist bone has been reset. Surgery to correct the direction of the malunion can improve the function and appearance of the wrist.

The compression of the median nerve can occur from the lower arm bone angulating towards the palm, which might occur from both normal healing or treatment using excessive bending. Another less common complication after a wrist injury is the entrapment or tearing of a long thumb tendon with malunion. This can happen after both conservative treatment and surgery.

De Quervain synovitis, a painful condition caused by inflammation of the tendons on the thumb side of the wrist, is another possible complication of Smith fractures. Risk factors include higher impact fracture patterns, lack of response to corticosteroid injections, and patients who have had their wrist fractures treated without surgery. People who’ve had a Smith fracture have a higher risk of developing this condition than the general population.

Complex Regional Pain Syndrome (CRPS), a condition of persistent severe pain, has been reported in up to 40% of people with wrist fractures. Risk factors for developing CRPS include fractures with greater complexity or associated tissue damage, being female, having a high Body Mass Index (BMI), and having psychiatric disorders.

Possible complications of Smith fractures are:

• Malunion
• Garden spade deformity
• Delayed carpal tunnel syndrome
• Compression or possible damage to the median nerve
• Entrapment or rupture of the long thumb tendon
• De Quervain synovitis
• Complex Regional Pain Syndrome (CRPS)

Recovery from Smith Fracture Review

For stable fractures, the usual treatment is immobilization for a period of 4 to 8 weeks. After this, the patient undergoes a further 4 to 6 weeks of rehabilitation and bracing until they regain pain-free movement and their usual muscle strength. In contrast, unstable fractures are usually immobilized for a longer period ranging from 6 to 12 weeks, with rehabilitation following until normal movement and strength return.

Managing pain after surgery is always important. One particular study found that a combination of transdermal buprenorphine (a patch applied to the skin) and codeine-acetaminophen (a common pain reliever) was more effective at controlling pain after surgery than celecoxib (a type of non-steroidal anti-inflammatory drug). This helped to increase the patient’s adherence to their treatment plan and speed up their recovery. However, health professionals should strive to minimize the use of opioids once the initial post-surgery period is over. Both the surgical team and the primary care physician should work together to manage pain following an operation. The American Academy of Orthopaedic Surgeons (AAOS) also recommends vitamin D supplements to prevent Complex Regional Pain Syndrome (CRPS), a severe pain condition, in patients with a specific type of fracture called a distal radial fracture.

Preventing Smith Fracture Review

To prevent a Smith fracture, which is a type of wrist injury, it’s important to do everything possible to lower the chances of experiencing traumatic events, like falls that could lead to the fracture. While accidents can’t always be avoided, there are steps a person can take to reduce the risk.

One strategy is to make homes safer, especially in terms of preventing falls. This could involve adding handrails on stairs, using flooring that is particularly non-slippery, ensuring that there’s sufficient lighting, getting rid of things that one could trip over, and advising everyone in the household to wear suitable footwear.

Another way to stay safe is to comply with safety measures at work. This includes wearing necessary protective gear, steering clear of dangerous areas, and understanding and following safety protocols designed for operating machinery. Additionally, those who participate in high-risk sports should be extra careful while playing and improve their physical preparedness off the field.

Keeping bones healthy is also key. Eating a balanced diet and engaging in weight-bearing exercises can help enhance bone strength. It is also sensible to think about the risk factor of your immediate environment and refrain from any activities or places that could be risky.

Lastly, if injuries do occur, seek immediate treatment to reduce the risk of further complications. This is a type of secondary prevention aiming at minimizing the potential consequences of an injury after occurrence.