aka Bone and Joint Bamboozler 003
A 50 year-old woman tripped down the last 5 steps of a flight of stairs. Her left forearm bore the brunt of the impact. Fortunately, she sustained no other significant injuries.The radiographs of her painful and swollen left wrist are shown below:
Describe the fracture?
- There is a fracture of the volar lip of the distal radius articular surface, with volar subluxation of the radiocarpal joint along with volar displacement of the fracture fragment.
What is the eponymous name for this fracture?
- This is a volar Barton fracture.
- The volar Barton fracture is equivalent to a Smith’s fracture that enters the radiocarpal joint.
- Dorsal Barton fractures are less common than volar fractures – and both are rare (<4% of distal radius fractures).
- John Rhea Barton (1794-1871) was an ambidextrous surgeon who was born, worked, and died in Pennsylvania. He spent time as a student of John Hunter in London and was renowned as a daring surgeon who could perform an osteostomy of an ankylosed hip in just seven minutes.
What the typical mechanism of injury?
- Barton fractures result from high-energy impact transmitted to the articular surface of the radiocarpal joint (e.g. FOOSH – ‘fall no outstretched hand‘).
- The volar or dorsal rim fractures depending on whether the wrist is in volar flexion or dorsiflexion, respectively.
- Alternatively, a volar rim fracture may result from tension failure and avulsion due to the pull of the strong radiocarpal ligaments when the wrist is forecfully dorsiflexed on impact.
What imaging and views are best for this assessing this injury?
- Lateral wrist radiographs best demonstrate the degree of articular involvement and displacement.
- The fracture is also easily seen on a PA radiograph of the wrist.
What specific associated injuries and complications should be considered?
Early complications and associated injuries:
- Carpal bone fracture or dislocation
- Nerve Injuries to:
- sensory branches of the radial nerve
- median nerve
- ulnar nerve
- Radiocarpal joint arthritis and chronic pain
What is the management of this injury?
- Treatment of a Barton’s fracture may depend on the size of the fracture fragment and the degree of displacement.
- Get an orthopedics review early as operative repair is often necessary.
Non-displaced Barton’s fracture:
- consider sugar-tong splint with wrist in neutral position
Displaced Barton’s fracture:
- closed reduction under procedural sedation
- if stable, consider sugar-tong splint with wrist in neutral position
- if unstable or inadequately reduced, open reduction and internal fixation
Although closed reduction is sometimes successful, many experts advocate early operative intervention for all Barton fractures.