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Smith Fracture – Causes, Symptoms and Treatment

A Smith fracture is a break of the distal radius (forearm bone) in which the bone fragment tilts toward the palm. It is considered the reverse of a Colles fracture.

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Things worth knowing about "Smith Fracture"

A Smith fracture is a break of the distal radius (forearm bone) in which the bone fragment tilts toward the palm. It is considered the reverse of a Colles fracture.

What Is a Smith Fracture?

A Smith fracture is a fracture of the distal radius -- the lower end of the radius bone near the wrist. The broken fragment tilts toward the palmar side (inner surface of the hand), which is why it is also known as a reverse Colles fracture. The condition was first described by Irish surgeon Robert William Smith in the 19th century and remains one of the most common wrist fractures seen in emergency medicine.

Causes and Mechanism

Smith fractures typically result from a fall or direct impact on the wrist. Common mechanisms include:

Falling onto the back of a flexed (bent) hand
Direct blow to the back of the wrist
Road traffic accidents or sports injuries

The fracture is more common in younger, active individuals as well as older people with osteoporosis, a condition that reduces bone density and increases fracture risk.

Classification (Thomas Classification)

Smith fractures are classified into three types according to the Thomas classification:

Type I: Extra-articular fracture (does not involve the joint surface)
Type II: Intra-articular fracture (involves the joint surface)
Type III: Intra-articular fracture with a palmarly displaced joint fragment (also referred to as a Barton fracture)

Symptoms

Common symptoms of a Smith fracture include:

Severe pain in the wrist area
Swelling and bruising around the wrist
Visible deformity with the hand displaced toward the palm (garden spade deformity)
Restricted range of motion in the wrist
Numbness or tingling in the fingers (if nerves are involved)

Diagnosis

Diagnosis is established through:

Clinical examination: Assessment of pain, swelling, and deformity
X-ray: Standard anteroposterior and lateral views confirm palmar angulation of the distal fragment
CT scan (Computed Tomography): Used for complex or intra-articular fractures to evaluate joint surface involvement in detail

Treatment

Conservative Treatment

Stable, non-displaced fractures may be managed conservatively with a below-elbow plaster cast for approximately 4 to 6 weeks. Regular X-ray check-ups are essential to detect any secondary displacement of the fragment.

Surgical Treatment

Displaced, unstable, or intra-articular fractures usually require surgical fixation. Common techniques include:

Volar plate fixation: Stabilization using an angle-stable plate and screws applied to the palmar side of the radius
Kirschner wire fixation: Used for simpler fracture patterns
External fixator: Indicated for highly comminuted fractures or significant soft tissue injury

Rehabilitation

Following immobilization or surgery, structured physiotherapy is essential to restore wrist mobility, strength, and function. Full recovery may take several months depending on fracture severity and the age of the patient.

Complications

Potential complications associated with a Smith fracture include:

Carpal tunnel syndrome due to compression of the median nerve
Chronic wrist pain
Reduced range of motion and functional impairment
Post-traumatic wrist osteoarthritis
Malunion if the fracture is not adequately stabilized

References

Wolfe S.W. et al. (eds.): Green's Operative Hand Surgery, 7th edition, Elsevier, 2017.
Egol K.A., Koval K.J., Zuckerman J.D.: Handbook of Fractures, 5th edition, Wolters Kluwer, 2014.
Netter F.H.: Atlas of Human Anatomy, 7th edition, Elsevier, 2018.

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