Smith’s Fracture: What Is It

What Is It, Difference from Colles, and More

Author: Corinne Tarantino, MPH

Editor: Alyssa Haag

Editor: Emily Miao, PharmD

Illustrator: Jillian Dunbar

Copyeditor: David G. Walker

Modified: Jan 19, 2022

What is a Smith’s fracture?

A Smith’s fracture, or reverse Colles’ fracture, is a volar, or forward, displacement fracture of the distal (i.e., away from the body, towards the fingers) end of the radius (i.e., one of the two forearm bones, located on the lateral, or thumb side, of the forearm). The distal radius is the most common fracture site in the upper extremity and Smith’s fractures occur in about 5% of all radial and ulnar fractures. Smith’s fractures are often called Goyrand fractures in French literature, after the French Physician Jean-Gaspard-Blaise Goyrand.

There are three types of Smith’s fractures. Type I is the most common with a transverse break outside the wrist joint. Type II, also called a reverse Barton fracture, is an intra-articular fracture, or a fracture that occurs on the articular surface (i.e., joint surface) of the radial-ulnar joint. Lastly, a type III fracture is least common and involves a juxta-articular oblique fracture, or a fracture that occurs as a curved or angled break at the articular surface of the wrist joint.

What is the difference between a Smith’s and Colles fracture?

A Smith’s fracture is a volar displacement fracture where the fragment of the radius that has broken off projects towards the palm side of the hand, while a Colles fracture results in dorsal displacement, causing the bone fragment to bend towards the back of the hand. Colles fractures are the most common type of distal radius fracture.

What causes a Smith’s fracture?

Most Smith’s fractures are caused by a fall onto an outstretched hand (i.e., a FOOSH). Often the wrist is flexed upon falling or the dorsal sign is directly impacted, causing the volar angulation. However, it can also occur when an individual falls onto the palm of their hand. They most frequently occur from high radial impact falls in young males and low impact falls in elderly females with osteoporosis.

What are the signs and symptoms of a Smith’s fracture?

Smith’s fractures often appear as a deformity on the distal forearm; however, the direction of displacement may be difficult to assess without the use of radiographs. Typically, individuals with a Smith’s fracture may also present with swelling, pain, and decreased range of motion in the wrist.

Less commonly, the neurovascular system in the wrist and hand is compromised due to compression of one or more nerves from the fractured bone. If the neurovascular system is affected, the individual may experience symptoms such as tingling, numbness, or weakness in the specific areas of the wrist or the hand that is innervated by the affected nerve. When the median nerve is compressed, an individual may experience symptoms of acute carpal tunnel syndrome in the thumb, index, middle, and ring fingers. More rarely, an individual may have radial nerve compression, which may affect digits on the radial side of the hand, like the thumb or index finger. Ulnar nerve compression may also occur rarely, which affects digits on the ulnar side, like the pinky or ring fingers. A person may also experience acute compartment syndrome of the forearm, characterized by pain greater than expected and paresthesia, a tingling feeling sometimes described as “pins and needles.”

How is a Smith’s fracture diagnosed?

Diagnosis of a Smith’s fracture typically begins with a thorough medical examination of the individual, including a history of present illness, medical history, and evaluation of signs and symptoms, followed by conduction of a physical exam. Evaluation is often followed by AP and lateral X-rays to assist in distinguishing a Smith’s fracture from a Colles fracture. Other radiographs or advanced imaging may be used to assess for soft tissue injuries, such as a traction or oblique view on X-ray or a CT scan. A CT may also be used for diagnosis if there are extensive comminuted fractures (i.e., fractures in three or more pieces) or intra-articular fracture patterns.

How is a Smith’s fracture treated?

Smith’s fractures can be challenging to treat and often require surgery to successfully restore the radial alignment. The most conservative approach to surgical treatment is performing a closed reduction, which occurs when the bone is put back in place without surgery and, instead, by longitudinal traction while the individual is under sedation or given general anesthesia. When the fracture is unable to be reduced and is unstable (i.e., the bones continue shifting or become displaced despite attempts to reposition and stabilize), open reduction internal fixation (ORIF) is often performed. During ORIF, a plate and screws are implanted to stabilize the bones. Unstable fractures in an individual with good bone quality may be also treated by a closed reduction with percutaneous pinning (CRPP), which involves placing pins or wires, often Kirschner wires (K-wires), through the skin to hold the reset bones in place until the fracture has healed. External fixators may be used to stabilize an individual with lots of trauma before transferring them or for open fractures. However, external fixation is rarely used as pins may loosen or become infected.

Once reduction is complete, a cast or splint is usually placed in an extended position, where the wrist is flat, for about four to eight weeks. Weekly radiographs are often performed for at least three weeks before allowing complete wrist movement. After cast removal, physical therapy and splinting is typically prescribed for six to eight weeks until movement is painless and strength is restored. Non-steroidal inflammatories (NSAIDs) (e.g., ibuprofen, aspirin) or opioid analgesics (e.g., oxycodone, hydrocodone) may be prescribed to control pain during recovery.

What are possible complications of a Smith’s fracture?

Smith’s fractures may result in complications. A primary concern is malunion, which is where the bone healed improperly, either with continued volar displacement or distal radius shortening. A residual volar displacement is commonly referred to as a garden spade deformity since it has a similar curvature to a garden spade. A malunion may also lead to delayed carpal tunnel syndrome if the carpal tunnel becomes consistently narrowed. Malunion occurs more commonly in older adults with low bone density as they may have trouble maintaining the closed reduction.

Many people may also experience complex regional pain syndrome (CRPS), characterized by chronic pain in the hand and wrist often associated with sensory, motor, or vasomotor issues. When the wrist is splinted at an angle greater than 15 degrees, there is an increased risk of acute CRPS. CRPS is typically treated by physical and occupational therapy. Any continuing neuropathic pain may be treated with NSAIDs and adjunctive agents like gabapentin. Despite appropriate treatment, many individuals have some prolonged disability.

Less commonly, the extensor pollicis longus (EPL) may be entrapped or ruptured, resulting in an inability to extend the thumb. Typically, this occurs within seven weeks of the injury and is diagnosed after the EPL ruptures, at which point surgical treatment is necessary.

What are the most important facts to know about a Smith’s fracture?

A Smith’s fracture is a fracture of the distal radius where the fractured fragment is displaced ventrally. A Smith’s fracture is the reverse of a Colles fracture where the fragment has dorsal displacement. Smith fractures are often caused by falls on the dorsal side of the wrist or from a hard hit. Symptoms typically include a visibly displaced fragment, pain, swelling, and loss of movement. Diagnosis is based upon a medical evaluation and X-rays. Treatment typically involves closed reduction, several weeks in a splint or cast, and physical therapy. Complications of Smith’s fractures include malunion, leading to a garden spade deformity or carpal tunnel syndrome, as well as complex regional pain syndrome or extensor pollicis longus rupture.

Breed, M., & Fitch, R. (2021). Fractures of the distal radius. In Knoop, K.J., Stack, L.B., Storrow, A.B., & Thurman, R. (Eds.), The Atlas of Emergency Medicine (5th ed.). McGraw Hill.

Chumley, H.S., & Usatine, R.P. (2019). Distal radius fracture. In Usatine, R.P., Smith, M.A., Mayeaux Jr., E.J., & Chumley, H.S.(Eds.), The Color Atlas and Synopsis of Family Medicine (3rd ed.). McGraw Hill.

Erhart, S., Toth, S., Kaiser, P., Kastenberger, T., Deml, C., & Arora, R. (2018). Comparison of volarly and dorsally displaced distal radius fracture treated by volar locking plate fixation. Archives of Orthopaedic and Trauma Surgery, 138(6), 879–885. DOI: 10.1007/s00402-018-2925-x

Grewal, R., MacDermid, J. C., King, G. J., & Faber, K. J. (2011). Open reduction internal fixation versus percutaneous pinning with external fixation of distal radius fractures: A prospective, randomized clinical trial. The Journal of Hand Surgery, 36(12), 1899–1906. DOI: 10.1016/j.jhsa.2011.09.015

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Breed, M., & Fitch, R. (2021). Fractures of the distal radius. In Knoop, K.J., Stack, L.B., Storrow, A.B., & Thurman, R. (Eds.), The Atlas of Emergency Medicine, (5th ed.). McGraw Hill.

Schroeder, J. D., & Varacallo, M. (2021). Smith's Fracture Review. In StatPearls. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK547714/

Smith’s Fracture

What Is It, Difference from Colles, and More

What is a Smith’s fracture?

What is the difference between a Smith’s and Colles fracture?

What causes a Smith’s fracture?

What are the signs and symptoms of a Smith’s fracture?

How is a Smith’s fracture diagnosed?

How is a Smith’s fracture treated?

What are possible complications of a Smith’s fracture?

What are the most important facts to know about a Smith’s fracture?

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