Smith's Fracture
Upper LimbOverview
Smith's fracture is a transverse fracture of the distal radius with volar (palmar) displacement of the distal fragment, often resulting from a fall onto a flexed wrist or direct blow to the dorsal forearm. It represents approximately 10-15% of all distal radius fractures and typically occurs in elderly patients with osteoporosis or younger patients following high-energy trauma. The condition requires prompt medical assessment and imaging, as proper alignment is critical for functional wrist recovery.
Pathophysiology
Smith’s fracture drives the distal radius fragment in a volar direction; it is classically attributed to a fall on a flexed wrist, although many patients report falling on the palm. This mechanism is opposite to Colles' fracture (dorsal displacement). The fracture may be simple (two-part) or complex (comminuted), with potential involvement of the lunate fossa and radial styloid process. Volar displacement can compromise the anterior interosseous nerve and radial artery, and may lead to carpal tunnel syndrome post-injury. Untreated or malpositioned fractures result in loss of wrist extension, grip strength, and forearm supination.
Patient Education
Proper immobilization, adherence to rehabilitation protocols, and gradual progressive loading are essential to restore wrist function and prevent chronic stiffness or arthritis.
Typical Presentation
Site
Distal radius, typically 2-3 cm proximal to wrist crease; pain may radiate into palm, thumb, and index finger
Quality
Acute sharp pain with associated numbness or tingling in radial nerve distribution; swelling and bruising typically pronounced on volar aspect
Intensity
Severe (8-10/10) at time of injury; moderate (5-7/10) during early healing phase
Aggravating
Wrist flexion, pronation/supination, gripping, weight-bearing through the wrist, direct pressure over fracture site
Relieving
Immobilization in cast or splint, elevation, ice application, anti-inflammatory medication, supported rest
Associated
Swelling and bruising (especially volar), visible deformity ('dinner fork' appearance in reverse), loss of wrist extension, reduced pronation/supination, potential anterior interosseous nerve compression signs
Orthopaedic Tests
Test descriptions are written with AI assistance from standard clinical texts. Where a test lists Sources, its description has been checked against them; those sources are independent and do not endorse OsteoKit. Accuracy figures and grades (A–D) appear only when checked against the published study; tests without one are marked “No accuracy study”.
Further reading: full test procedures are described in standard clinical examination texts, e.g. Magee & Manske, Orthopedic Physical Assessment (7th ed.), and Cook & Hegedus, Orthopedic Physical Examination Tests: An Evidence-Based Approach (2nd ed.).
Clinical Deformity Assessment (Garden Spade Deformity)
Procedure
Look at the injured wrist from the side and compare it with the other wrist.
Positive Finding
The hand and distal fragment sit palmar to the forearm (the 'garden spade' deformity, the reverse of the dinner fork seen with Colles' fractures), with swelling and bruising.
Interpretation
Suggests a palmar-displaced distal radius fracture (Smith's fracture). These fractures are often unstable and frequently need surgical fixation, so arrange an X-ray and orthopaedic review.
Wrist Range of Motion Testing
Procedure
Not for the acute phase of a suspected fracture. After imaging, and during rehabilitation, measure active wrist flexion and extension on both sides with a goniometer.
Positive Finding
Reduced range or pain at end of range compared with the other wrist.
Interpretation
Used to track recovery after the fracture has healed or been fixed. In the acute setting it adds nothing to imaging, and forcing movement risks displacing the fracture.
Palpation for Point Tenderness and Crepitus
Procedure
Gently palpate the distal radius on the palmar and dorsal sides, the radial styloid and the ulnar styloid. Do not try to produce crepitus.
Positive Finding
Localised bony tenderness over the distal radius.
Interpretation
Localised bony tenderness after a fall means X-ray. Deliberately producing crepitus is painful and unnecessary.
Pronation/Supination Assessment
Procedure
During rehabilitation: with the elbow at 90° by the side, measure active pronation and supination on both sides.
Positive Finding
Reduced rotation or pain on rotation.
Interpretation
Forearm rotation is often limited after distal radius fractures and is a key rehabilitation target. Persistent loss or pain over the distal radioulnar joint needs review.
Swelling and Edema Assessment
Procedure
Compare the two wrists for swelling and bruising, and measure circumference at the same level on both sides with a tape measure.
Positive Finding
Visible or measurable swelling on the injured side.
Interpretation
Swelling tracks injury severity and the response to elevation. Rapidly increasing swelling with severe pain, tight skin or numbness is a warning sign of compartment syndrome or acute nerve compression and needs urgent medical review.
Grip Strength Testing (when appropriate)
Procedure
Only after fracture healing, or once cleared by the treating team: measure grip with a hand dynamometer on both sides, three trials each, and record the mean.
Positive Finding
Weaker grip on the injured side.
Interpretation
Tracks functional recovery. Do not test grip strength on an acute or unfixed fracture.
⚠ Red Flags
- •Acute severe trauma with neurovascular compromise (pale, pulseless, cold hand)
- •Signs of compartment syndrome (severe pain out of proportion, pain on passive stretch, paresthesia, pallor, paralysis)
- •Open fracture with wound contamination or exposed bone
- •Signs of anterior interosseous nerve injury (loss of thumb IP flexion and index finger DIP flexion)
- •Radial or ulnar artery compromise
- •Ipsilateral injuries requiring urgent management (polytrauma, head injury)
⚡ Yellow Flags
- •Fear-avoidance beliefs regarding wrist movement and re-injury
- •Low mood or anxiety related to functional loss and recovery uncertainty
- •Unrealistic expectations about healing timeline (typically 6-12 weeks for bone union)
- •Reluctance to engage in rehabilitation due to pain catastrophizing
- •Occupational or sports demands that may create psychological pressure for rapid return
Osteopathic Techniques
Refer first
A suspected Smith fracture needs X-ray and orthopaedic management. Most are not suited to closed reduction alone; intra-articular involvement, comminution, instability after reduction, more than 2 mm of articular step-off or marked angulation or shortening point to surgery. Refer before using manual techniques on the wrist.
- Reference bookSchroeder & Varacallo · StatPearls 2024
Rehabilitation Exercises
Wrist Pendulum Exercises
Passive Wrist Flexion and Extension (Supported)
Forearm Pronation and Supination (Gravity-Eliminated)
Wrist Extensor Stretch (Opposite Arm Assisted)
Wrist Flexor Stretch (Palm-Up)
Grip Strengthening with Soft Ball or Therapy Putty
Wrist Extension Resistance Band Exercise
Pronation and Supination with Light Dumbbell
Proprioceptive Weight Shifting (Two-Handed Neutral Wrist)
Shoulder Blade Stabilization Exercises (Rows and Scapular Squeezes)
Progressive Functional Activities (Reaching, Lifting, Writing)
Wrist Radial and Ulnar Deviation with Resistance
Referral Criteria
- •Any suspected Smith's fracture requires immediate referral to Emergency Department for imaging (X-ray) and orthopedic assessment
- •Neurovascular compromise (absent pulse, severe paresthesia, coolness, pallor) requires urgent vascular surgery consultation
- •Signs of compartment syndrome warrant immediate surgical decompression
- •Open fracture requires orthopedic and infection control management
- •Failed conservative management or loss of reduction during healing phase requires orthopedic review for possible surgical intervention (open reduction and internal fixation)
- •Persistent nerve symptoms (carpal tunnel syndrome, anterior interosseous nerve palsy) post-immobilization warrant neurology or hand surgery referral
- •Chronic complex regional pain syndrome symptoms warrant pain management specialist and physiotherapy
- •Work-related injury or occupational demands requiring early return warrant ergonomic consultation and occupational medicine input