What is Barton Fracture?
A Barton fracture was first identified by Philadelphia orthopedic surgeon, John Rhea Barton. This is a specific type of wrist fracture where the lower part of the radius (one of the forearm bones) breaks and extends through the back of the joint interacting with the wrist. Despite the break, the ligaments keeping the wrist bones and the radius together remain intact. What sets a Barton fracture apart is that despite the fracture, the broken radius and the wrist bones maintain contact.
Barton fractures can happen at either the front (volar) or the back (dorsal) of the wrist, and there are different subcategories for each type. In comparison to fractures at the back (dorsal) of the wrist, Barton fractures are most frequently seen on the front (volar).
The likelihood of a Barton fracture not healing is low, due to the nature of the broken bone area being rich in spongy bone. However, it’s important that the bone is set back in its correct position because poor healing and wrist arthritis are common issues if not treated properly. The wrist’s ability to hold tightly to something depends on the slope of the surface of the wrist-joint side of the radius bone. This side of the radius is relatively flat and the wrist’s ligaments, which control the wrist’s movements, originate from the edge of this side of the radius.
From a more complex perspective, there’s a 3mm vertical slope in a specific facet of the radius bone associated with a small bone in the wrist, making fixation challenging. If it isn’t properly supported, it can lead to instability in the wrist due to a weakened ligament. These details are critical to understand and address when treating a Barton fracture.
What Causes Barton Fracture?
How people get injured often depends on their age group. For young people, particularly kids and young adults, Barton fractures, which are wrist injuries, mostly occur from sports or car accidents. A severe traumatic wrist injury is usually the reason behind these fractures. In fact, young male workers or motorbike riders make up about 70% of all Barton’s fracture cases.
On the other hand, for older people, especially women, having weaker bones due to osteoporosis means it doesn’t take much to get injured. The majority of Barton’s fractures in older folks are caused by a simple fall from standing height.
Risk Factors and Frequency for Barton Fracture
There has been a recent increase in distal radius fractures, or breaks in the wrist bone, in people of all ages. Several factors contribute to this increase. These fractures in children are most frequently seen around puberty, and are more common in boys than girls.
Adults between the ages of 19 to 49 are less likely to experience a specific type of these fractures known as Barton fractures, and they’re more common in men than in women in this age group. However, in older adults, women are more prone to having a Barton fracture due to a higher instance of osteoporosis.
- Distal radius fractures are on the rise in all age groups.
- These fractures are most common in boys around puberty.
- Adults aged 19 to 49 are less likely to have Barton fractures, with males being more susceptible.
- Older women are more likely to have a Barton fracture than older men due to higher rates of osteoporosis.
- Volar Barton fractures account for about 1.3% of all distal radius fractures.
Signs and Symptoms of Barton Fracture
People with Barton fractures usually arrive at the emergency room or urgent care with wrist pain that came on suddenly, swelling, and a change in the shape of their wrist following a recent injury. They may have bruising, tender spots, and a swollen wrist joint. They may also find it difficult to move their wrist due to the pain. Doctors need to check the nervous system and blood supply at the end of the patient’s body during these exams to check for other injuries or complications. Younger patients often report sports injuries or car accidents, while older patients may report less severe injuries such as falls from a standing position. These patients generally recall falling and landing on an outstretched hand. The kind of fracture depends on the position of the wrist when it is injured; for instance, volar shear fractures happen when the wrist is bent towards the palm, whereas bending the wrist back leads to dorsal shear fractures.
Testing for Barton Fracture
The first step in examining a Barton’s fracture is to get X-rays of the affected wrist from at least two different angles – from the front and from the side. Additional angled views can also be taken and may help to make the diagnosis clearer. The X-ray can then be analyzed to measure key features like the height of the radius bone, its tilt, the distance to the ulna bone, and any effects on the joint surface.
These features provide important information, as the radius in a normal wrist is inclined about 23 degrees and has an 11 degree tilt. The usual height of the radius is about 11 mm and the variance in the length compared to the ulna ranges from -2 mm to +2 mm. By comparing these features to those on an X-ray of the unaffected wrist, doctors can assess how well the injured wrist is returning to normal.
Another important consideration in the long-term prognosis for the wrist — that is, whether it will develop arthritis or have full pain-free range of motion — is that the joint surface of the radius should align correctly.
If the X-rays aren’t clear or if more detailed information is needed, a CT scan may be used. The scan can give more insight about fracture detail, reveal hidden fractures, and evaluate how well the fracture is healing. Although an MRI is not typically the first imaging test used in acute cases, it can be useful in checking for damage to the ligaments or soft tissue.
Treatment Options for Barton Fracture
The ultimate goal when treating a patient with a Barton fracture is to manage the pain enough to allow normal activities to resume, while also minimizing the risk of early arthritis. Nonsurgical methods, such as using a splint or a cast to immobilize the hand, are usually the first-line approach for treating fractures in the lower part of the radius that are stable and haven’t moved out of place. However, because Barton fractures involve the back of the wrist moving out of place, they often don’t respond to this approach and usually need surgery.
If you’re a surgeon looking at a patient’s X-rays, there are several signs that would suggest the fracture is not stable and will need more than just a cast:
1. Over half of the side of the lower radius is broken into smaller pieces.
2. There are broken pieces of bone on the inner side of the wrist.
3. The back of the wrist is tilted more than 20 degrees or the broken fragment has moved more than 1 cm out of place.
4. The radius is shorter by more than 5 mm.
5. There’s a suspect Barton’s fracture or the joint is disrupted.
6. The ulna – the other bone in your arm, situated next to the radius – is also fractured.
7. The patient has severe osteoporosis, or fragile bones.
Given that most Barton fractures are unstable, surgery is usually required. However, if the fracture hasn’t moved out of place, it can potentially be treated with a cast. When doing this, the cast is put on in a way that bends the wrist forward slightly for volar Barton fractures and bends back for dorsal Barton fractures. Even these fractures should be monitored regularly with X-rays until they heal because they can easily move out of place within the cast. Patients who opt not to have surgery are treated with a cast for at least six weeks. It’s important for patients to understand the expected outcomes before choosing a treatment option.
There are different surgical approaches for volar and dorsal Barton’s fractures. For volar Barton’s fractures, a special supporting plate is used to fix the break. The plate is placed on the inner surface of the wrist. For a dorsal Barton’s fracture, a CT scan is done before surgery to assess the specifics of the fracture, and the surgery is done through the back of the wrist.
Following surgery, the wrist is immobile in a splint for 5 to 10 days before movement is started. There are other surgical methods possible, with success rates ranging from 80 to 90 percent, but they can also have drawbacks, including infections at the pin site and misalignment of the bones.
If the fracture does not show that the carpal bones have moved out of place, treatment with a cast might be sufficient. However, if the surface of the joint is uneven by 2mm or more, surgery is typically needed.
What else can Barton Fracture be?
There are several types of wrist injuries that might look similar to the Barton fracture on X-rays, and can also lead to similar symptoms.
- The reverse Barton fracture also affects the distal radius (end part of the forearm bone near the wrist), but the injury is to the interior side of the forearm (volar) rather than the back of the hand (dorsal).
- The Colles fracture is a break in the distal radius that leans toward the back of the hand (dorsal displacement), but it doesn’t extend into the wrist joint.
- A Smith fracture is similar to a Colles fracture, but the break causes the wrist to tilt toward the palm of the hand. In a way, you can think of it as a reverse Colles fracture.
- A die-punch fracture is when there’s a depression in the lunate facet – a part of the radius that’s near the wrist.
- Lastly, the Chauffeur’s fracture refers to a fracture of the radial styloid, which is when a specific part on the outer edge of the wrist bone is pulled off.
These fractures are all different and it’s crucial to distinguish between them to ensure the appropriate care and treatment.
What to expect with Barton Fracture
Fractures within the joint at the end of the radius, like Barton fractures, have a greater risk of developing arthritis after the trauma compared to fractures outside of the joint. If the break in the joint’s surface is more than 2 millimeters, it can almost double the chances of developing arthritis after the injury. Despite this, most research suggests that it doesn’t majorly impact a person’s day-to-day life.
The group that fares the worst is the elderly. They often face more serious consequences because of the impact these fractures have on their daily activities, which can lead to a higher death rate compared to other patients.
Possible Complications When Diagnosed with Barton Fracture
Doctors need to know about the variety of injuries that can happen alongside Barton fractures and other fractures at the end of the radius – the bigger bone in your forearm. These include triangular fibrocartilage (TFCC) tears, suddenly developing carpal tunnel syndrome, compartment syndrome starting early on, and complex regional pain syndrome (CRPS) arising weeks or months after initial treatment. To prevent the wrist becoming stiff, it’s important to do motion exercises for the wrist and fingers as soon as possible.
These are some of the complications that can occur from a Barton’s fracture:
- Carpal tunnel syndrome
- Radial nerve compression
- Ulnar nerve injury
- Complex regional pain syndrome (CRPS)
- Post-traumatic arthritis
- Instability in the wrist joint
- Badly healed fractures
- Instability in the joint between the two bones in the forearm
- Adhesions in the flexor tendon
- Tendon rupture
- Tendinitis
- Tenosynovitis
- Trigger finger
- Dupuytren’s contracture
- Compartment syndrome
After an operation, the following complications are common:
- Infections at the surgery site
- Loss of the fracture’s reduction
- Fracture caused by the treatment itself
- Tendon injuries
- Danger to nerves and blood vessels
- Compartment syndrome
- Painful surgical implants
- Stiff wrists
Recovery from Barton Fracture
The main aim of rehabilitation is to regain full movement of the wrist without any pain. This involves three stages: splinting, mobilization, and endurance training, all under the supervision of physiotherapists. Even while the wrist is in a splint, it’s advised to get the fingers, elbow, and shoulder moving to stop them from becoming stiff. The splint is generally worn for between three to six weeks.
Splinting for a shorter period, like three weeks, can lead to better short-term progress, though the long-term results are similar to wearing a splint for six weeks. During the mobilization phase, the focus remains on managing pain and swelling, as well as improving the flexibility of the wrist. If the wrist is not immobilized in time, it can lead to added stiffness and more visits to the therapist.
After exercises that work both the passive and active range of motion, strength-building exercises are then initiated by the therapist.
