# Upper Limb Orthotics/Smith's Fracture
## Describe your case study

The patient is a 24 year old male who suffered an injury playing AFL. He is a professional AFL Footballer fighting for his position in the squad, the injury occurred in a match when he was unexpectedly pushed in the back, he fell on top of his right hand in a flexed position which resulted in a distal radius fracture with volar displacement of the distal fragment (Smith’s Fracture). There is a significant ulnar protrusion and the normal anterior curve of the distal radius head is extremely exaggerated. The patient has undergone current reduction and is in a cast however, the fracture is unstable and has become unaligned. Using the modified Thomas classification system, the client has a type 2 Smith’s fracture. The patient would like to get back to training and playing football as quick as possible to be able to maintain his position in the squad.

## Written information
### Evidence

Anatomy & Pathology: A Smith fracture is a distal radius fracture, commonly referred to as a reverse Colles’ fracture, which has volar displacement of the distal fragment. Distal radius fracture are the most common upper limb fracture and constitute 8% to 15% of all bone injuries (Hanker,2001).
A smith’s fracture occurs at the distal radius, it can have an impact on the wrist joint stability, involving the proximal row of carpals and articular surfaces of the radius, and surrounding tendons such as extensor pollicis longus. The distal radius has “two articular surfaces, the radiocarpal joint with the scaphoid and lunate facets, and the sigmoid notch that articulates with the distal ulna.” (Capo, Swan & tan, 2006). The smith fracture can include these articular surfaces and can lead to further complications. Both these articular surfaces need to be realigned to allow for optimal function (Capo,Swan & Tan, 2006). Involvement of these articular surfaces in the fracture can lead to instability of the fracture and a likely chance of displacement to reoccur after reduction.
The fracture can have an impact of our mobility of our fingers especially our thumb. In the literature it has been well documented that “tendon damage may occur as a complication of distal radius fractures”(Murakami & Todani, 1981). The position of the fracture being at the distal end of the radius allows it to become a problem when reduction occurs with a chance of “entrapment of the extensor pollicis longus” (Itoh et al., 1987). This complication can cause stiffness and pain (Kelly & Kumar, 2002) for the client and can lead to further surgery.
This specific type of distal radius fracture is quite rare compared to the Colles’ fracture as it is uncommon for an individual to fall on their flexed hand. The fracture can occur in multiple different ways; it is usually a result from “a fall on the dorsum of the hand” (Jacobs & Austin, 2013) however another concept of how the fracture can occur, as stated by Flandreau, Sweeney and O'Sullivan (1962), is the individual falling backwards on their outstretched supinated hand causing volar displacement of the distal fragment as the proximal fragment is forcibly pronated while the hand is locked in a supinated position on the ground combined with compressive forces. Picture here in fig 14 & 15
Smith fractures can be categorized using a modified Thomas classification system (Woodyard, 1969):
Type 1) extra-articular.
Type 2) Fracture line crosses into the dorsal articular surface.
Type 3) Fracture line enters the carpal joint.
To see examples here in fig 2.17

### Orthotic treatment options

(this may include post-surgery)
The best treatment of a fracture is one that “should restore and maintain anatomy, allow early mobilisation and have minimal risk of complications” (Fang, Kwan & Leung, 2013). The type of orthotic treatment of a Smith’s fracture is dependent on the severity, classification type, of the fracture and whether the fracture is going to be operated on or not.
If surgery is not going to be under taken for the client, a below elbow cast will be placed on the client after closed reduction. This immobilisation technique will “hold the wrist in slight extension, the forearm in full supination, and the elbow at 90 degrees of flexion” (Fernandez & Jupiter, 2002) with a below elbow sugar tong cast. If the fracture is extra-articular the hand will be placed in 20 to 30 degree extension as mentioned above, if it is an intra-articular fracture and non-operative treatment is attempted it is recommended to be placed in slight flexion to “maintain congruity between the proximal row of the carpus and the intact part of the lower end of the radius.” (Thomas, 1957). Picture of this concept here in fig 16 and 17. The cast should remain on for 6 weeks (Fernandez & Jupiter, 2002). With a removable splint used for the following weeks.
Dependent on the surgery undertaken, different post-surgery orthotic interventions can be used. The different types of surgery involve non-bridging external fixation, bridging external fixation, Kirschner-wires or internal fixation with volar placed buttress plate. According to Fernandez & Jupiter percutaneous k-wires used for an intra-articular compression fracture should use a thumb spica splint for post-surgical recovery. Whereas Michlovitz, Lestayo, Alzner and Watson (2001) states that a splint that allows all metacarpal and intercarpal range of motion of the digits is recommended for a quicker recovery, such as a keyhole wrist hand orthoses.

### Comparison of orthotic treatment options

(or orthotic treatment vs surgical intervention)
As mentioned before there are multiple surgical interventions. These surgical interventions should be used only when the joint is unstable and a high risk of displacement. According to Nazar,Mansingh, Bassi and Waseem (2008) there is not a set management technique used for distal radius fractures like a smiths fracture, a magnitude of different treatment plans are utilised and are chosen upon dependent on the individual’s needs, goals and severity of injury. However, Jacobs and Austin (2013) believe there is an increase of incidence of volar plated management of distal radius fractures due to improvement of the plating designs.
In a randomly controlled trial of distal radius fractures in 56 individuals comparing volar plates and k-wires treatment success conducted by Mcfadyen et al. (2011) the volar plate had a quicker return to functionality and posted better scores then k-wires in DASH tests. The volar plates created no complications however, 28% of the clients treated with K-wires contracted a complication of sort, such as pin site infection or carpal tunnel syndrome occurring. In relation to the previous literature it seems the volar plate internal fixation leads to a quicker return from injury, a low risk of complications and re-displacement and further surgical requirements in the future in relation to the fracture and k-wire treatment. In agreement, Shyamalan, Theokli, Pearse and Tennent (2009) mention “volar locked plat fixation provides a more stable fixation and allows an earlier range of wrist motion then percutaneous fixation”.
External fixation is a well-known treatment for distal radius fractures like the smith’s fracture. Although, in a study comparing external fixation and volar plating conducted by Koshkin, Sergeev, Matveev and Grishanin (2008) the results show volar plating being a greater treatment option than a bridging external fixation such as the motube triax device (stryker) that was used in the study. The plating treatment resulted in 15 out of 22 patients ending in a good result compared to 11 out of 32 in the external fixation group, results recorded using E. R. Mattis' score system. In agreement, Murray and Trigg (2002) state sustained longitudinal traction created by external fixation can lead to increased rates of complications.

### Summary

As the client has had “redisplacement in [a] plaster support, [that] defines the fracture as being unstable, and that an alternative approach to maintain the reduction should be considered” (Fernendaz & Jupiter, 2002) it is therefore in the clients best interests to undertake surgery for his fracture. With limited literature on the post operational orthotic devices recommended for Smith fracture treatment, it is recommended for the client to undertake the surgery that allows for a quick recovery and allow for early mobilisation and has a low risk of complications. In review of the literature the client shall undertake a volar plate internal fixation, resulting in an above elbow cast with the hand in neutral position for two weeks and then replaced with a removable keyhole wrist hand orthosis with the hand only being used in daily living activities for the first 6 to 8 weeks (Fernandez & Jupiter, 2002) this treatment is allowing for early movement, non-contact training to be undertaken and extremely light hand skills such as handballing and short kicking. In case of swelling and sensitivity over the surgical site, volar distal radius surface, pressur is released from that area. After 12 weeks the client should be back playing competitively.