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Barton's Fracture - Complete Clinical Guide

1. Definition and Historical Background

Barton's fracture is an oblique intra-articular fracture of the rim of the distal radius, with displacement and subluxation/dislocation of the radiocarpal joint - the carpus displaces along with the fracture fragment. It was first described by John Rhea Barton in 1838.

The key feature that distinguishes it from Colles and Smith fractures is that it is intra-articular and involves fracture-dislocation of the radiocarpal joint. As Grainger & Allison's diagnostic radiology states: "Barton fracture differs from the Colles and Smith fractures as there is subluxation of the carpus and a rim fracture at the radiocarpal interface. This is a shearing injury..."

2. Types of Barton's Fracture

There are two main variants:

Feature	Dorsal Barton (Classic)	Volar Barton (Reverse Barton)
Fracture site	Dorsal/posterior rim of distal radius	Volar/anterior rim of distal radius
Carpal displacement	Dorsal	Volar (palmar)
Mechanism	Dorsiflexion + pronation	Volar flexion / fall on flexed wrist in supination
Frequency	Less common	More common

As stated in ROSEN's Emergency Medicine: "the volar-anterior margin fracture is seen more often than the dorsal-posterior margin fracture."

Diagram: Left - Dorsal Barton fracture (dorsal rim shearing, carpus displaced dorsally). Right - Volar Barton fracture (volar rim fracture, carpus displaced palmarly).

3. Comparison with Other Distal Radius Fractures

Barton vs Colles vs Smith Fracture Comparison

Barton: Intra-articular, rim fracture, radiocarpal subluxation - no classic deformity name
Colles: Extra-articular, dorsally angulated - "dinner fork deformity"
Smith (reverse Colles): Extra-articular, volarly angulated - "garden spade deformity"

The key AO classification: Barton's fractures are classified as AO/OTA Type B (partial articular fractures) of the distal radius.

4. Etiology

Patient Population

Young adults / males: sporting injuries, motorcycle accidents, high-energy trauma - young male workers/motorcycle riders account for approximately 70% of Barton fracture cases
Elderly / women: low-energy falls from standing height; osteoporosis reduces the force threshold required
High-energy mechanisms: motor vehicle accidents, falls from height, direct trauma

Pathomechanics

The Barton fracture is a compression and shearing injury. Compressive force travels from the hand through the wrist, across the articular surface of the radius. This creates a shearing force at the radiocarpal interface, splitting off a triangular fragment from the radial rim. The carpal bones - tethered by strong extrinsic radiocarpal ligaments, the joint capsule, and the scaphoid/lunate fossa - are dragged along with the displaced fragment.

Stabilizing structures normally maintaining radiocarpal alignment include:

Extrinsic radiocarpal ligaments
Joint capsule
Scaphoid and lunate fossae of the radius

5. Mechanism of Injury

Dorsal Barton Fracture (Classic)

Fall on an outstretched, pronated wrist in dorsiflexion
Axial compressive force transmitted through the carpus strikes the dorsal rim of the articular surface
The dorsal rim is sheared off; the carpus subluxates dorsally

Volar Barton Fracture (Reverse Barton) - more common

Fall on a flexed wrist (volar flexion) or fall on outstretched hand in supination
Compressive shear force directed at the volar rim of the articular surface
The volar rim fractures; the carpus subluxates volarly/palmarly
Described in Tintinalli's EM: "less common volar rim fracture is produced by a fall on the outstretched hand in supination"

Force Transmission Pathway

Impact (ground) → Metacarpals → Carpus → Radiocarpal articular surface →
Shearing at the rim → Triangular rim fragment separates → Carpus displaced with fragment

6. Associated Injuries

Barton fractures rarely occur in isolation. Structures at risk include:

Associated Injury	Notes
TFCC tear (Triangular Fibrocartilage Complex)	Most common associated soft tissue injury
Distal Radioulnar Joint (DRUJ) disruption	Risk increased with coronal shift, >6 mm prereduction ulnar variance
Scapholunate ligament injury	Creates radiocarpal instability; may not be apparent acutely
Volar Intercalated Segment Instability (VISI)	Can result from ligamentous disruption
Ulnar styloid fracture	Common concomitant fracture
Median nerve compression	Acute carpal tunnel syndrome
Compartment syndrome	Forearm; must be excluded at initial presentation
Scaphoid fracture	Check with dedicated imaging if clinically suspected

From Miller's Review of Orthopaedics: "Concomitant injuries: scaphoid fracture, scapholunate (SL) injury, ulnar styloid fracture. Acute carpal tunnel syndrome (CTS): evolving paresthesias/pain requires emergent release."

The accompanying ligamentous injuries create radiocarpal instability that may not be fully appreciated acutely but can lead to secondary carpal instability patterns and premature degenerative arthritis.

7. Signs and Symptoms

History

Acute onset wrist pain following trauma
Description of mechanism: fall on outstretched hand, sports injury, MVA
Young patients: high-energy mechanism; elderly patients: low-energy fall

Physical Examination

Inspection:

Wrist swelling and edema
Deformity of the wrist (less pronounced than Colles fracture but visible)
Ecchymosis (bruising) - may be delayed 24-48 hours
Skin integrity assessment (open fracture?)

Palpation:

Dorsal or volar wrist tenderness directly over the distal radius rim
Point tenderness at the radiocarpal joint
Bony crepitus may be palpable

Neurovascular Assessment (mandatory):

Median nerve: check sensation in the thumb, index, middle, and radial half of ring finger; thenar muscle strength
Radial nerve: dorsal web space sensation
Radial artery: capillary refill, radial pulse

Function:

Restricted range of motion of the wrist (flexion, extension, pronation, supination)
Grip strength reduced

Key exam feature: Unlike Colles (dinner fork) or Smith (garden spade), Barton's does not have a classic named deformity sign, but a subtle wrist deformity is present with the carpus shifted in the direction of the fracture.

8. Investigations and Evaluation

Imaging

Plain Radiographs (First-Line)

Request PA (posteroanterior) and lateral views of the wrist.

PA view:

May show a comminuted fracture of the distal radial metaphysis
Fracture line at the articular margin
Radial styloid fracture may coexist
Carpal shift visible

Lateral view (most important):

Shows the oblique intra-articular fracture of the volar or dorsal rim of the radius
Demonstrates the degree of articular surface involvement
Confirms the direction and magnitude of carpal subluxation/dislocation

From ROSEN's: "the lateral view best shows the degree of articular surface involvement and amount of associated fracture displacement."

Normal radiographic measurements to assess:

Radial height: 11 mm
Radial inclination: 22 degrees
Volar tilt: 11 degrees

Acceptable post-reduction parameters (Miller's Review):

Radial shortening < 3 mm
Dorsal tilt < 10 degrees
Intra-articular step-off < 2 mm

Volar Barton fracture - lateral X-ray:

$Volar Barton Fracture - Lateral radiograph showing oblique intra-articular volar rim fracture with carpal displacement (ROSEN's Emergency Medicine)$

Lateral radiograph of wrist showing typical oblique intra-articular fracture of the volar rim of the radius, with displacement of the distal radial fragment and carpal dislocation (ROSEN's Emergency Medicine)

Volar Barton - PA and lateral views (Tintinalli's):

PA view:

$Volar Barton's fracture - PA view (Tintinalli's EM)$

Lateral view:

$Volar Barton's fracture - Lateral view (Tintinalli's EM)$

FIGURE: Volar Barton's fracture PA (A) and lateral (B) views - Tintinalli's Emergency Medicine

CT Scan

Indicated when X-rays are inconclusive or show complex comminution
Best for assessing articular step-off, fragment size, and surgical planning
Evaluates intra-articular involvement in 3D
Useful to identify die-punch fragments or occult associated carpal fractures

MRI

Reserved for assessment of soft tissue injuries
Evaluates TFCC integrity
Identifies scapholunate ligament tears
Useful when carpal instability is suspected clinically but not confirmed radiographically
Not a first-line investigation in the acute setting

Other Studies

DRUJ assessment under fluoroscopy: pronation-supination stress test if DRUJ injury suspected
EMG/nerve conduction: if median nerve injury is present and persistent (not acute)
Bone density (DEXA): in elderly patients as part of osteoporosis workup (fragility fracture)
Doppler ultrasound: rarely needed; if vascular injury suspected

9. Treatment

The primary goal is to restore the articular surface of the distal radius and achieve a stable radiocarpal joint, to allow pain-free motion and prevent early onset osteoarthritis.

A. Emergency Department Management (Immediate)

Analgesia: NSAIDs (ibuprofen), acetaminophen/paracetamol; IV/IM analgesia if severe
Neurovascular documentation: before and after any manipulation
Splinting: Sugar-tong splint or volar slab for temporary immobilization
Emergent orthopedic consultation: required for all Barton fractures (unstable by nature)

B. Conservative (Non-Operative) Treatment

Indications:

Minimally displaced fractures
Fragments involving < 50% of the radial articular surface
No associated carpal subluxation

Method:

Closed reduction under fluoroscopy (attempted under sedation/haematoma block)
Sugar-tong splint immobilization
Followed by cast application once swelling subsides
Urgent orthopedic follow-up within 2-3 days

Limitation: Barton fractures are inherently unstable. The radiocarpal ligaments tethered to the displaced fragment mean that muscle forces continually displace the fragment. Most fractures fail conservative management.

C. Operative Treatment

Indications (from Tintinalli's):

Fracture involving > 50% of the radial articular surface
Accompanying carpal subluxation
Failed closed reduction
Irreducible fracture
Open fracture
Associated neurovascular compromise

Open Reduction and Internal Fixation (ORIF) - Standard of Care

Most Barton fractures require ORIF
Volar Barton: volar plating approach (Henry approach to volar surface of distal radius)
Dorsal Barton: dorsal plating (direct visualization of articular surface)

From Miller's Review: "ORIF (volar) for volarly displaced fractures (Smith and volar Barton); also become standard for dorsally displaced fractures (Colles)."

ORIF Steps:

Open reduction - direct visualization of articular surface
Reduction and anatomic alignment of the rim fragment
Internal fixation - typically a volar locking plate (for volar Barton) or dorsal buttress plate
Intraoperative fluoroscopy to confirm reduction
Address associated ligamentous injuries (TFCC, scapholunate) if needed

Percutaneous Pinning

An option when closed reduction under fluoroscopy is successful but fracture is at risk of re-displacement
K-wires used to hold reduction
Less commonly used than plate fixation

External Fixation

Used in highly comminuted fractures or when soft tissue condition precludes plating
Can be used as a bridging procedure

D. Post-operative Rehabilitation

Early range-of-motion exercises for wrist and fingers started as soon as possible to prevent stiffness
Progressive strengthening at 6-8 weeks
Full return to activity at 3-6 months depending on fracture type and fixation

10. Complications

Complication	Timing	Notes
Post-traumatic arthritis (radiocarpal OA)	Late	Most common long-term complication; related to quality of articular reduction
Carpal instability	Delayed	From ligamentous injury; may not be apparent acutely
Median nerve dysfunction	Early or late	Most common nerve complication; acute CTS needs emergent release
TFCC tear	Early	May require arthroscopic repair if DRUJ unstable
Complex Regional Pain Syndrome (CRPS)	Late (weeks-months)	Vitamin C 500 mg/day x 50 days prescribed postoperatively to reduce risk
EPL tendon rupture	Late	After ORIF due to long screws, or attritional wear at Lister's tubercle
FPL rupture	Late	Most common flexor injury after volar plating (watershed line issue)
Compartment syndrome	Early	Must be excluded at initial presentation
Malunion / loss of reduction	Early	Particularly with conservative management
Infection / hardware failure	Post-op	Standard surgical risks

11. Prognosis

Outcomes are most favorable when anatomic reduction of the articular surface is achieved and maintained
The overall goal is sufficient pain-free motion to allow return to usual activities while minimizing early-onset osteoarthritis
Young patients with high-energy injuries have higher complication rates due to concomitant soft tissue disruption
Elderly patients with osteoporotic bone may have poorer fixation quality

Quick Reference Summary

BARTON'S FRACTURE AT A GLANCE
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Definition:   Intra-articular rim fracture of distal radius
              + radiocarpal fracture-dislocation

Types:        Dorsal (classic) | Volar (reverse, more common)

Mechanism:    Dorsal = fall on dorsiflexed pronated wrist
              Volar  = fall on flexed/supinated wrist

Key feature:  Carpus displaced WITH the fragment

Investigation: X-ray (PA + lateral) → CT if complex
              Lateral view is MOST diagnostic

Treatment:    Emergent ortho consult
              Minimally displaced → splint + urgent f/u
              Displaced/unstable → ORIF (standard of care)

Complications: Post-traumatic arthritis, TFCC tear, CTS,
              CRPS, carpal instability
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Sources:

ROSEN's Emergency Medicine: Concepts and Clinical Practice (9th ed.)
Tintinalli's Emergency Medicine: A Comprehensive Study (8th ed.)
Rockwood and Green's Fractures in Adults (10th ed., 2025)
Miller's Review of Orthopaedics (9th ed.)
Campbell's Operative Orthopaedics (15th ed., 2026)
StatPearls - Barton Fracture (NCBI Bookshelf)

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