Continuing Education Activity

Philadelphia orthopedic surgeon John Rhea Barton first described a Barton fracture. It is a fracture of the distal radius which extends through the dorsal aspect of the articular surface with associated dislocation of the radiocarpal joint; however, since there is no disruption of the radiocarpal ligaments, the articular surface of the fractured distal radius remains in contact with the proximal carpal row. This activity reviews the cause, pathophsiology and presenttaion of barton's fracture and highlights the role of the interprofessional team in the management of these patients.

Objectives:

• Describe the pathophysiology of Barton's fracture.
• Review the evaluation of a patient with suspected barton's fracture.
• Outline the treatment and management options available for barton's fracture.
• Explain interprofessional team strategies for improving care and outcomes in patients with barton's fracture.

Introduction

Philadelphia orthopedic surgeon John Rhea Barton first described a Barton fracture. It is a fracture of the distal radius which extends through the dorsal aspect of the articular surface with associated dislocation of the radiocarpal joint; however, since there is no disruption of the radiocarpal ligaments, the articular surface of the fractured distal radius remains in contact with the proximal carpal row. [1][2][3]This preserved relationship between the radius and carpus is what distinguishes the Barton fracture from other types of distal radius fracture/dislocations.

Etiology

The most common mechanisms of injury vary depending on patient population. In the pediatric and young adult population, most Barton fractures result from sporting activities and motor vehicle accidents. However, in the elderly, particularly women, decreased bone density from osteoporosis means that less force is needed to cause this injury. [1]Therefore, the majority of these fractures are a result of a fall while standing.

Epidemiology

The recent increase in distal radius fractures in patients of all ages is attributed to a variety of factors. Fractures in pediatric patients are most common around the time of puberty, with boys tending to suffer the injury more often than girls. The young adult population (ages 19 to 49) is the least affected by Barton fractures, with a greater predilection for males than females. In the elderly, women are more likely to be diagnosed with a Barton fracture than their male counterparts due to higher rates of osteoporosis.

Pathophysiology

A Barton fracture is a compression injury with a marginal shearing fracture of the distal radius. The most common cause of this injury is a fall on an outstretched, pronated wrist. The compressive force travels from the hand and wrist through the articular surface of the radius, resulting in a triangular portion of the distal radius being displaced dorsally along with the carpus. [4][5][6]Multiple stabilizing structures help to maintain the relationship between the radius and the carpal bones, including the extrinsic radiocarpal ligaments, the joint capsule, and the scaphoid and lunate fossa of the radius.

History and Physical

Patient’s with Barton fractures will typically present to the urgent care or emergency department with acute wrist pain and deformity following a recent trauma. A younger patient commonly will describe a sporting injury or motor vehicle accident while older patients may report a lower energy trauma such as fall from standing.

Evaluation

Initial evaluation of the Barton fracture begins with radiographs of the wrist, consisting of at least frontal and lateral views. Oblique views of the wrist often are obtained and may assist in the diagnosis. CT can be used to better evaluate anatomic detail or if radiographs are unclear. MRI may be utilized to evaluate for associated ligamentous or soft tissue injuries.

Treatment / Management

The overall goal in the evaluation and treatment of these patient presenting with Barton fractures is to obtain sufficient pain-free motion which will allow the patient to return to their usual activities while at the same time minimizing their risk for developing early-onset osteoarthritis that will lead to disability. Traditionally, the treatment of distal radius fractures is by closed reduction and immobilization in a splint or cast, this has been and remains the treatment of choice in nondisplaced and stable distal radial fractures. [7][8][9]Due to the nature of Barton fractures and the implied dorsal displacement of the fracture, in the general population, many fractures will fail conservative management; therefore, surgical treatment is the preferred option. 

The following key radiographic signs should alert the surgeon that the fracture is unstable and indicate closed reduction will be insufficient:

1. Dorsal comminution greater than 50% of the lateral width of the distal radius,
2. Palmar metaphyseal comminution,
3. Initial dorsal tilt greater than 20 degrees, initial fragment displacement greater than 1 cm,
4. Radial shortening of more than 5 mm,
5. Intra-articular disruption,
6. An associated ulna fracture, and
7. Severe osteoporosis. 

Most Barton fractures will be treated with closed reduction and application of external fixation device, followed by percutaneous pin insertion. However, it should be noted that recent studies have found little difference between conservative management and surgical treatment in the elderly. Those who elect to forgo surgery are treated with reduction and immobilization for at least six weeks. [10]When electing to treat these patients with either operative or nonoperative therapy, it is essential to include the patient in the management decision, clearly allowing them to establish and understand the pre-management expectations. The choice of treatment must be based on a two-way conversation with the patient that includes the understanding of the limitations of available data on the optimal treatment (surgical versus nonsurgical) and ultimately should rely on a combination of the treating surgeon’s experience and the patient’s preference.

Differential Diagnosis

Various distal radius fractures can have similar clinical presentations and may appear radiographically similar to the Barton fracture. 

• The reverse Barton fracture is an articular fracture of the distal radius with dislocation in which the articular surface of the radius remains in contact with the carpus; however, the reverse type involves the volar portion rather than the dorsal aspect of the radius.
• The Colles fracture is a fracture of the distal radius with dorsal angulation/displacement; the key differentiating finding is the lack of intraarticular extension.
• The Smith fracture can be thought of as a reverse Colles fracture with volar rather than dorsal angulation.
• The die-punch fracture is a fracture of the articular surface of the radius with depression of the lunate facet.
• The Chauffer’s fracture is an avulsion fracture of the radial styloid.

Prognosis

Intraarticular fractures of the distal radius, including the Barton fracture, have a higher risk of post-traumatic arthritis than extraarticular fractures. Any articular step-off of greater than 2 millimeters can increase the likelihood of post-traumatic arthritis by almost 100%. However, most studies indicate this does not significantly affect livelihood. The population with the worst prognosis is the elderly, who tend to have higher mortality than other patients due to the limitations to activities of daily living.

Complications

The treating/managing physician should be aware of the multiple injuries that can occur in association with Barton fractures and other fractures of the distal radius including tears of the triangular fibrocartilage (TFCC), traumatic acute carpal tunnel syndrome, development of compartment syndrome in the forearm at time of initial presentation, and development of complex regional pain syndrome (CRPS) in the subsequent weeks and months following the initial treatment.

Pearls and Other Issues

• The Barton fracture is a fracture of the distal radius which extends through the dorsal aspect of the articular surface with associated dislocation of the radiocarpal joint. However, since there is no disruption of the radiocarpal ligaments, the articular surface of the fractured distal radius remains in contact with the proximal carpal row. 
• Radiography is the primary imaging modality in diagnosis, although CT and MRI have a role as well.
• In the younger population, males suffer the injury more often than females, typically following high-energy trauma. 
• In the elderly, more women are diagnosed with Barton fractures after a fall from standing or other low-energy trauma. 
• Most Barton fractures are treated surgically, though recent studies have shown little significant difference in operative versus nonoperative management in the elderly.

Enhancing Healthcare Team Outcomes

Patients with a Barton fracture often first present to the emergency room; hence the emergency department physician and the nurse practitioner are often the first to make the diagnosis. It is important to know that Barton fracture is frequently associated with other injuries and hence a thorough physical exam is necessary. Because conservative treatment of Barton fracture is not always satisfactory, it is important to consult with the orthopedic surgeon. Most Barton fractures are treated surgically, though recent studies have shown little significant difference in operative versus nonoperative management in the elderly. After surgery, the outcomes in young patients are good but in elderly people, the recovery can be prolonged. All patients need some type of rehabilitation after the fracture has healed. [11][12](Level V)