The wrist connects the hand to the forearm. It consists of the distal ends of the radius and ulna bones, eight carpal bones, and the proximal ends of five metacarpal bones. This arrangement of bones allows for a wide range of movement. The wrist can bend, straighten, move laterally, and rotate. Smith’s fracture is a specific type of injury to the forearm bone (the radius) near the wrist joint.
In this injury, there is a displacement of the bone such that the wrist joint rests in front of its regular anatomic position. The injury is most commonly located after falling on the back of the hand, or by falling with the hand planted on the ground with your body twisting around the hand. A Smith’s fracture is also sometimes referred to as a reverse Colles’ fracture. The Colles’ fracture is also a type of distal radius fracture, but the bone is pushed back rather than pushed forward.
As mentioned above, the wrist joint is the junction of the forearm with the hand. The joint is formed by the two forearm bones (the radius and the ulna) joining together with the small bones of the wrist. Generally, when someone is describing a wrist fracture, they are talking about an injury to the end of the radius bone. However, the term wrist fracture can be used to describe other fractures such as scaphoid fractures, distal ulna fractures, and other bone injuries around the wrist joint. There are several factors that can help physicians classify the type of fracture and determine the best course of treatment:
- Intra-articular vs extra-articular – These terms indicate whether the fracture extends into the radiocarpal joint (the joint between the radius and the first row of carpal bones in the wrist) or not. Fractures that involve the joint (intra-articular) are typically harder to treat and heal.
- Displaced vs non-displaced – These terms describe whether the bones or fragments have moved out of place or are still in place.
- Comminuted – A comminuted fracture is a break or splinter of the bone into more than two fragments.
- Compound – A compound fracture breaks the skin and will require a physician to repair close the wound. A compound fracture also raises the risk of infection.
Causes & Symptoms
The direct causes of a Smith fracture can be contributed to some of the most common factors, such as:
- Falls – the most common cause of a Smith fracture is a bad fall onto an outstretched arm. Such a fall can occur while completing daily activities or during the playing sports.
- Bone disorders – Patients who suffer from a bone disorder, such as Osteoporosis, are more likely to break their wrist in even a minor fall. This disorder weakens the bones in the body and makes them especially fragile which means an individual is susceptible to fractures of this nature. Medical studies and research have proven that a fracture to the wrist or a distal radius bone can be caused by a direct blow to the wrist. The impact of the blow can result in the displacement of the wrist bone even in someone who has otherwise healthy bones.
- Sports activities – Because falling onto an outstretched hand is the most common cause of a Smith fracture, those who participate in sports that involve potential falls, such as in-line skating, skiing, or snowboarding, are also at greater risk for this injury.
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, people 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 the 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, you may experience symptoms of acute carpal tunnel syndrome in the thumb, index, middle, and ring fingers.
In rare cases, you may have radial nerve compression, which may affect digits on the radial side of your 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. Lastly, you 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”.
Other symptoms linked to Smith fractures include:
- Sharp pain in the wrist
- Bruising around the affected area
- Inability to perform gripping or squeezing actions
Who gets a Smith Fracture?
Smith fractures (or other wrist fractures) are almost always the result of falling onto an outstretched hand. People of any age fall and attempt to catch themselves, but certain people are at higher risk for suffering a fracture as the result. There are two reasons these populations are more at risk:
- Growth spurts – For children ages 8-14 (8-11 for girls and 11-14 for boys), there is a period during which bones have grown longer because of growth spurts, but the bone mineral density has not yet caught up. This leaves the newly-grown bones more vulnerable to fracture, particularly during activities such as sports or play.
- Elderly age – Age can also be a contributing factor to injuries of this nature. People ages 60 years of age and older tend to experience Smith fractures more often than others. Fractures in the elderly are a result of weak bones or some other type of medical condition.
- Gender – Women’s risk for a Smith fracture begins to rise at age 50 and that risk doubles every 10 years. For men, the onset of age-related risk is much later, at age 80. Women may be able to lower their risk by taking measures to offset the bone loss through diet and exercise.
How does it affect you? How serious is it?
Proper treatment of a Smith fracture is important to make sure that your bones heal properly and help keep the full function of your wrist and hand. If you choose to avoid treating it, the bones may not heal together correctly.
A possible complication of a Smith fracture (or any other serious injury to a limb) is something called complex regional pain syndrome. This is a chronic pain condition that affects a limb after an injury. It is thought to be caused by damage to the nervous system. Therefore, it is important to seek medical attention if you are experiencing unrelenting pain and numbness after your injury.
Recommended Treatment & Rehabilitation
Diagnosis of a Smith fracture usually begins with a thorough medical examination, 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 fracture from a Colles fracture. Other radiographs or advanced imaging may be used to assess for soft tissue injuries, such as traction or oblique view on X-ray or a computed tomography (CT) scan. A CT may also be used for diagnosis if there are extensive comminuted fractures or intra-articular fracture patterns.
After a diagnosis has been done by your physician, a physiotherapist will be able to work with you following a Smith fracture to help you regain regular wrist motion, strength, and function, and will provide education and training to help you prevent future fractures. While your bone heals, your arm will be in a cast or a sling to keep it still and promote healing. During that time, it is important to ensure that the arm does not get too stiff, weak, or swollen. Depending on the amount of activity that is allowed for your type of fracture, your physiotherapist will prescribe gentle exercises to keep your shoulder, elbow, and fingers moving while you are in the cast or sling.
After your cast or sling is removed, your wrist will most likely be stiff, and your arm will feel weak. Your physiotherapist will examine your wrist and select treatments to improve its function and restore strength to your arm. Therefore, your rehabilitation will include treatments to help:
Your physiotherapist might use either warm or cold therapeutic treatments, or electrical stimulation, to help manage pain or swelling in your wrist, hand, or arm.
Your physiotherapist may use skilled hands-on techniques (manual therapy) to enable your joints and muscles to move more freely with less pain.
Increase your strength
Your physiotherapist may help you begin to gently move your elbow, using passive range-of-motion exercises. As your arm gets stronger, you can exercise it yourself without weights. Once the bone is well-healed, you can begin to perform resistance exercises, using weights or elastic bands. In addition to prescribing range-of-motion and strengthening exercises, your physiotherapist can help you retrain your muscles.
Return to regular activities
Your therapist will help you remain independent by teaching you how to perform your daily activities even while wearing a cast or a sling. Once you can move your arm freely without pain, your physiotherapist may begin adding more-demanding activities that you were doing before your injury, such as using your arm for dressing, grooming, and housekeeping.
Below are some exercise examples for you to try. It is recommended to begin each exercise slowly:
Wrist flexion and extension
Place your forearm on a table, with your hand and affected wrist extended beyond the table, palm down. Next, bend your wrist to move your hand upward and allow your hand to close into a fist, then lower your hand and allow your fingers to relax. Hold each position for about 6 seconds, then repeat 8-12 times a day.
While seated, place your forearm and affected wrist on your thigh, palm down. Flip your hand over so the back of your hand rests on your thigh and your palm is up. Alternate between palm up and palm down while keeping your forearm on your thigh. Repeat this method 8-12 times a day.
Wrist radial and ulnar deviation
Hold your affected hand out in front of you, palm down. Slowly bend your wrist as far as you can from side to side. Finally, hold each position for about 6 seconds before repeating the same procedure 8-12 times a day.
Place your good hand on a table, palm up. Next, put the hand with the affected wrist on top of your good hand with your fingers wrapped around the thumb of your good hand as if you are forming a closed fist. Slowly uncurl the joints of the hand with the affected wrist where your fingers connect to your hand so that only the top two joints of your fingers are bent. Hold this position for 6 seconds, then repeat 8-12 times a day.
Alternative & Homeopathic Treatment
If your wrist pain is manageable or there is no obvious sign of deformity, you may choose to treat the wrist at home, and then see a physician in the next day or two if symptoms do not subside. Some of these treatments may include:
- Elevation – Elevate your wrist on a pillow or the back of a chair above the level of your heart for the first few days. This will ease pain and swelling.
- Ice application – Ice the wrist for every 15-20 minutes during the day; however, be careful to keep the splint or cast dry while icing.
- Non-steroidal anti-inflammatory medications (NSAIDs) – Taking NSAIDs can help with pain and swelling. However, these drugs may contain side effects, such as the increased risk of bleeding and ulcers. They should be used only occasionally unless your doctor specifically says otherwise, as this can delay healing.