Stairs versus Wrist

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.

This is a volar Barton fracture.

Described by John Rhea Barton (1794-1871) in 1838

Barton 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.

The volar Barton fracture is equivalent to a Smith fracture that enters the radiocarpal joint (Robert William Smith (1807 – 1873).

Dorsal Barton fractures are less common than volar fractures – and both are rare (<4% of distal radius fractures).

Barton fractures result from high-energy impact transmitted to the articular surface of the radiocarpal joint (e.g. FOOSH – ‘fall onto 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 forcefully dorsiflexed on impact.

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.

Early complications and associated injuries:

• Carpal bone fracture or dislocation
• Nerve Injuries to the  sensory branches of the radial nerve, median nerve and/or ulnar nerve

Late complications:

•  Radiocarpal joint arthritis and chronic pain

Treatment of a Barton fracture may depend on the size of the fracture fragment and the degree of displacement.

Request an orthopedic review early, as operative repair is often required.

Non-displaced Barton fracture:

•  consider sugar-tong splint with wrist in neutral position

Displaced Barton 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.

• Howard J. John Rhea Barton (1794–1871). LITFL 2018
• Fulford D. Robert William Smith (1807 – 1873)
• Purcell D. Minor Injuries A Clinical Guide 3e
• Sherman S. Simon’s Emergency Orthopedics 7e