Barton's Fractures

Barton's is one of several eponyms for the same bone end, and they are not interchangeable: the parent account of the injury, its classification and the non-eponymous patterns is distal radius fractures. Of the eponyms, Smith's is the extra-articular volar-angulated pattern most often confused with a volar Barton's, chauffeur's is the radial styloid shear, and die-punch is the impacted lunate facet — which matters here, because a depressed lunate facet and a volar lunate facet shear fragment are different problems needing different implants.

The injury. A Barton's fracture is a fracture-dislocation of the distal radius: a fracture of the volar or dorsal articular rim with subluxation of the carpus. The carpus subluxates with the fractured rim fragment, and that single feature separates Barton's from every other distal radius fracture. A Barton's is intra-articular by definition.

Terminology. The names overlap:

• Volar Barton: volar rim fracture with volar carpal subluxation, the more common type
• Dorsal Barton: dorsal rim fracture with dorsal carpal subluxation, the less common type, and the pattern Barton originally described
• Reverse Barton: the volar Barton, the "reverse" of the dorsal pattern Barton described, and not the other way round
• Thomas Type II Smith fracture: the intra-articular variant in the Thomas classification of Smith fractures, which is identical to a volar Barton

Who. Barton's fractures account for 5-10% of distal radius fractures, and the volar type is about three times as common as the dorsal. Peak incidence is in young adults aged 20-40 after high-energy trauma (falls from height, motor vehicle accidents, sports injuries); the pattern is also seen in the elderly with osteoporosis after a simple low-energy fall. There is no significant gender predominance.

The two rims. The distal radius has two distinct articular rims. The volar rim is the stronger and carries the attachment of the volar radiocarpal ligaments; the dorsal rim is thinner and carries the dorsal radiocarpal ligaments.

The ligaments. The volar radiocarpal ligaments are the stronger set:

• Radioscaphocapitate ligament
• Long radiolunate ligament
• Short radiolunate ligament
• Radioscapholunate ligament

The dorsal set is weaker:

• Dorsal radiocarpal ligament
• Dorsal intercarpal ligament

Mechanism. The load is axial, and the position of the wrist decides which rim breaks. With the wrist in flexion the shear force concentrates at the volar rim, which fractures along an oblique line, and the volar radiocarpal ligaments pull the carpus volarly with the fragment. With the wrist in extension the shear concentrates at the dorsal rim, and the dorsal ligaments carry the carpus dorsally with the fragment.

The classification is straightforward: identify which rim is fractured and confirm carpal subluxation in the same direction.

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History. Ask about the mechanism and the position of the wrist at impact, the energy involved, hand dominance, occupation and functional demands, previous wrist injuries and medical comorbidities.

Examination. The deformity, swelling and tenderness sit on the side of the fractured rim, and the carpus is displaced in the same direction as the rim fracture. That carpal displacement is the defining finding, and it must be confirmed on the lateral radiograph.

Neurovascular assessment. The median nerve is the one most at risk in a volar Barton's: test sensation over the palmar surface of the thumb, index and middle fingers and the power of abductor pollicis brevis (opposition weakness), and remember that an acute carpal tunnel syndrome may develop. Assess the ulnar nerve if there is medial displacement, palpate the radial artery at the wrist and check capillary refill in every digit.

Associated injuries. Assess for:

• DRUJ instability (piano key sign after reduction)
• TFCC injury
• Scapholunate ligament injury
• Ulnar styloid fracture
• Carpal fractures

Radiographs. Three views, and the lateral is the critical one:

• PA view: the rim fragment, radial shortening and articular involvement
• Lateral view: the direction of subluxation and which rim is involved
• Oblique views: additional fragment detail

What to look for. In a volar Barton's the volar rim fragment is visible on the lateral, the carpus sits anterior to the radius shaft, the lunate may appear tilted volarly, and the PA shows disruption of the volar cortex. A dorsal Barton's is the mirror image: a dorsal rim fragment on the lateral, the carpus posterior to the shaft, the lunate tilted dorsally, and dorsal cortical disruption on the PA.

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What to measure. These guide surgical planning and implant selection:

• Size of the rim fragment as a percentage of the articular surface
• Degree of subluxation, in mm of carpal translation
• Articular step-off, in mm
• Comminution of the fragment
• Radial height loss and radial inclination
• Associated injuries (ulnar styloid, TFCC)

MRI. MRI is not routine for an acute Barton's fracture. Consider it for persistent pain after healing, when it evaluates the TFCC and ligamentous injuries.

Tendon complications. On the dorsal side EPL rupture is the most common, with EDC irritation; the prevention is appropriate plate position, a low-profile implant and EPL transposition. On the volar side the tendon at risk is FPL, and the reason is where the plate sits relative to the watershed line, set out in the pearl below.

Carpal instability. Instability follows either an associated ligament injury that was not addressed or an inadequate reduction that allowed chronic subluxation. If symptomatic it requires ligament reconstruction.

Stiffness. Stiffness is more common after prolonged immobilisation, an early motion protocol reduces the risk, and hand therapy is essential for the best outcome.

The principle. Stable internal fixation is what permits early wrist motion, within the first 1-2 weeks, and that early motion reduces stiffness, improves the outcome, and is the key advantage of operative management over casting. The protocol balances protection against mobilisation, hand therapy optimises the result, and every review looks for pain, weakness or numbness as the signs of a complication.

What to expect. Surgical treatment of a Barton's fracture produces good to excellent results in the majority of patients. The determinants of that outcome are these.

Favourable factors

• Anatomic articular reduction (less than 2mm step)
• Stable fixation achieved
• Early motion protocol
• Young age
• Single fragment pattern
• No associated carpal injury

Unfavourable factors

• Articular incongruity (greater than 2mm step)
• Comminuted fragment
• Associated carpal ligament injury
• Elderly with poor bone quality
• Delayed treatment

Function. Most patients achieve a functional range of motion, within 20-30 degrees of normal, and grip strength typically recovers to 70-80% of the contralateral side. Return to work takes 4-8 weeks for desk work and 8-12 weeks for manual work; return to sport takes 3-4 months.

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In the long term. The risk of post-traumatic arthritis correlates with the quality of the reduction, and symptomatic arthritis may require a salvage procedure, fusion or arthroplasty. Hardware removal is needed in 15-20% for irritation.

Global epidemiology

Barton's fracture is an uncommon pattern, accounting for a small proportion of the very large global burden of distal radius fractures (one of the most common fractures worldwide, with a characteristic bimodal distribution: younger patients sustaining high-energy injuries and older patients with osteoporotic fragility falls). Volar Barton's is encountered more frequently than the dorsal (reverse) variant, which is genuinely rare, with the largest published surgical series numbering only ~20 cases (Lozano-Calderón et al., PMID 16818974). The defining articular-rim-plus-subluxation pattern is consistent across populations; resource setting affects access to CT and to low-profile fragment-specific implants rather than the injury itself.

Major guidelines, side by side

The dedicated evidence base for Barton's fractures is limited to retrospective series, so guidance is largely extrapolated from the wider distal radius and partial-articular fracture literature. The strongest unifying recommendation across bodies is that displaced partial articular (rim) fractures with carpal subluxation are surgical and that fixation should be driven by fracture pattern.

Registry evidence

Major arthroplasty registries (NJR, AJRR, AOANJRR, SHAR, Norwegian, NZJR) do not track fracture-fixation implants such as distal radius plates, so there is no registry-level survivorship data specific to Barton's fixation; the evidence base is therefore confined to single-centre series and comparative cohorts (e.g. Tang et al., PMID 22868605).

Global practice variation

• Implant choice: volar locking plates are the default for volar Barton's worldwide; in limited-resource settings, non-locking buttress plates or K-wire/external-fixation constructs remain in use and still achieve union, though with modestly lower functional scores (Tang et al., PMID 22868605).
• Dorsal Barton's: managed by dorsal buttress plating where low-profile implants are available; fragment-specific or wire fixation is substituted where they are not.
• Imaging: CT for pre-operative planning is routine in high-resource centres but selectively used elsewhere; the lateral radiograph remains the universal diagnostic view.