Smith's Fracture

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- See:
        - Barton's Fracture:
- Discussion:
      - extra - articular palmarly displaced distal radius frx;
      - volar angulation of frx is referred to as "Garden Spade" deformity
            (reversed Colles Fracture);
      - hand & wrist are displaced forward or volarly w/ respect to forearm;
      - frx may be extra articular, intra articular, or be part of frx dislocation of wrist;
- Mechanism:
      - backward fall on the palm of an outstreched hand causing pronation of
            upper extremity while the hand is fixed to the ground;
- Classification:
      - Type I:   extra articular;
      - Type II:   crosses into the dorsal articlar surface;
      - Type III: enters radiocarpal joint
            - Volar Barton's Fracture = Smith's type III
            - both involve volar dislocation of carpus assoc w/ intra articular
                    distal radius component;
- Reduction:
    - frx should be closed reduced by reversing frx deformity w/ longitudinal traction
          & applying as long arm cast w/ forearm in supination & wrist in neutral;
- Non Operative Rx:
      - if closed reduction is attempted, the wrist should remain in extension;
- Surgical Treatment:
    - ORIF (or External Fixators) is treatment of choice for volar displaced
          fractures, esp intra articular types II and III;
    - Ex fix for open Smith's frx is acceptable for wound considerations;
    - Reduction w/ flouro & supplementary K wires may be needed for Smith's
            type II frxs, to insure anatomic alignment of radiocarpal joint;
    - Smith's Type III: Barton's Fracture:
            - volarly displaced frx of Smith's or volar Barton's type is approached thru
                  volar incision and appication of a buttress plate;
            - displaced volar spike (Melone type III) may also require volar approach;
            - incision is made thru proximally extended carpal tunnel incision,
                  w/ reflection of pronator quadratus from radius;
            - plate is contoured to fit metaphyseal curvature, & distal frag screws are
                  rarely indicated;
            - during open reduction of distal radius, surgeon needs to examine
                  articular surface reduction of radioscaphoid, radiolunate, and
                  distal radioulnar joints, and treat each appropriately;
            - there is little indication for primary excision of distal ulna;