Journal of Orthopaedic Surgery 2009;17(1):28-30
Ligamentotaxis for Barton’s and paediatric
distal radial fractures
P Lakshmanan, MK Sayana, B Purushothaman, JL Sher
Wansbeck General Hospital, Ashington, United Kingdom
ABSTRACT
Purpose. To establish a consensus regarding
immobilisation of the wrist following reduction of
Barton’s and paediatric distal radial fractures.
Methods. Questionnaires were distributed to
orthopaedic surgeons at the European Federation
of National Associations of Orthopaedics and
Traumatology meeting in Lisbon in 2005. Questions
included the surgeon’s country of practice, hospital,
professional grade, years of experience, sub-specialty,
and preferred position of wrist immobilisation after
(1) a volar Barton’s fracture, (2) a dorsal Barton’s
fracture, (3) a paediatric Salter-Harris type-II injury
to the distal radius with volar displacement, and (4)
the same injury but with dorsal displacement.
Results. Of 148 questionnaires distributed, 118
were returned. The specialist-to-trainee ratio was
45:73. In volar Barton’s fractures, only 20% (29%
specialists and 15% trainees) would immobilise the
wrist in palmar flexion, as per recommendations. In
dorsal Barton’s fractures, only 25% (33% specialists
and 21% trainees) would immobilise the wrist in
dorsiflexion, as per recommendation. In paediatric
Salter Harris type-II injury to the distal radius with
volar displacement, 87% (100% specialists and 79%
trainees) would immobilise the wrist in dorsiflexion
or in a neutral position, as per recommendation. In
the same injury but with dorsal displacement, 84%
(89% specialists and 81% trainees) would immobilise
the wrist in palmar flexion or in a neutral position, as
Address correspondence and reprint requests to: Mr Palaniappan Lakshmanan, 36, Greenhills, Killingworth, Newcastle-Upon-
Tyne, NE12 5BB, United Kingdom. E-mail: lakunns@gmail.com
per recommendation. In all 4 types of fractures, 26%
to 30% of respondents would immobilise the wrist in
a neutral position.
Conclusion. Most respondents deviate from the
recommended immobilisation positions in treating
Barton’s fractures. Understanding of the anatomy
or biomechanics of ligamentotaxis are crucial for
conservative treatments.
Key words: fractures, bone; immobilization; ligaments;
wrist joint
INTRODUCTION
Ligamentotaxis involves moulding fracture fragments
into alignment by applying tension across the fracture
using surrounding intact soft tissues.1 This forms the
basis for external fixation and plaster immobilisation
using 3 points to hold the reduction. Knowledge of
ligamentotaxis and the anatomy of ligaments around
a fracture are crucial in conservative treatments.
Barton’s fractures are intra-articular and involve
the distal radius and the radiocarpal joint. They are
classified as volar or dorsal based on the involvement
of the anterior or posterior cortex, with the volar
variety being more common. They should be treated
surgically because of inherent instability. When
conservative treatment is indicated, it is important
to understand the concept of closed reduction,
immobilisation, and ligamentotaxis. We aimed to
establish a consensus among orthopaedic surgeons
regarding immobilisation of Barton’s and paediatric
Vol. 17 No. 1, April 2009 Ligamentotaxis for Barton’s and paediatric distal radial fractures 29

Table
Immobilisation positions reported by respondents for different wrist fractures

Fracture No. (%) of respondents

Dorsiflexion Palmar flexion Neutral
Specialists Trainees Specialists Trainees Specialists Trainees
(n=45) (n=73) (n=45) (n=73) (n=45) (n=73)
Volar Barton’s fracture 19 (42) 51 (70) 13 (29) 11 (15) 13 (29) 11 (15)
Dorsal Barton’s fracture 15 (33) 15 (21) 19 (42) 43 (59) 11 (24) 15 (21)
Salter Harris injury with volar displacement 32 (71) 43 (59) 0 (0) 20 (27) 13 (29) 10 (14)
Salter Harris injury with dorsal displacement 5 (11) 18 (25) 29 (64) 44 (60) 11 (24) 11 (15)

distal radial fractures following reduction. (a) Dorsal carpal ligament

MATERIALS AND METHODS

Questionnaires were distributed to orthopaedic Volar carpal ligament

surgeons at the European Federation of National (b)
Associations of Orthopaedics and Traumatology Taut dorsal carpal ligament
meeting in Lisbon in 2005. Questions included the
surgeon’s country of practice, hospital, professional
grade, years of experience, sub-specialty, and
preferred position of wrist immobilisation after (1) a Lax volar carpal ligament
volar Barton’s fracture, (2) a dorsal Barton’s fracture,
(3) a paediatric Salter-Harris type-II injury to the
distal radius with volar displacement, and (4) the (c) Lax dorsal carpal ligament
same injury but with dorsal displacement.

RESULTS
Of 148 questionnaires distributed, 118 were returned.
The specialist-to-trainee ratio was 45:73. The
respondents’ countries of practice were the United
Kingdom (n=75), Italy (n=11), Germany (n=7), Serbia
and Montenegro (n=6), Hungary (n=6), Denmark
(n=5), the Czech Republic (n=5), and Belgium (n=3).
In volar Barton’s fractures, 53% (42% specialists
and 70% trainees) would immobilise the wrist in
dorsiflexion; only 20% (29% specialists and 15%
trainees) would immobilise the wrist in palmar flexion,
as recommended. In dorsal Barton’s fractures, 48%
(42% specialists and 59% trainees) would immobilise
the wrist in palmar flexion; only 25% (33% specialists
and 21% trainees) would immobilise the wrist in
dorsiflexion, as recommended. In paediatric Salter
Harris type-II injury to the distal radius with volar
displacement, 87% (100% specialists and 73% trainees)
would immobilise the wrist in dorsiflexion or in a
neutral position, as recommended. In the same injury
but with dorsal displacement, 84% (89% specialists and
Taut volar carpal ligament
Figure 1 Wrist in (a) neutral, (b) palmar flexion, and (c)
dorsiflexion positions.
75% trainees) would immobilise the wrist in palmar
flexion or in a neutral position, as recommended. In
all 4 types of fractures, 20% to 23% would immobilise
the wrist in a neutral position (Table).
DISCUSSION
The dorsal carpal ligament is a strong, fibrous band
attached medially to the styloid process of the ulna,
triquetral, and pisiform bones, laterally to the lateral
margin of the radius and to the ridges on the dorsal
surface of the radius. The volar carpal ligament is the
thickened band of antibrachial fascia that extends
30 P Lakshmanan et al. Journal of Orthopaedic Surgery

(a) Dorsal carpal ligament (a) Dorsal carpal

ligament

Volar carpal ligament Volar carpal ligament

(b) Dorsal carpal ligament Dorsal carpal ligament

(b)

Volar carpal ligament Volar carpal ligament

Figure 2 Volar Barton’s fracture: (a) subluxation of the
carpus along with the fractured distal radius in dorsiflexion
with the force along the wrist pushing the whole wrist further
towards the palmar side. (b) The intact long dorsal carpal
ligaments maintain the carpus onto the distal radius in volar
flexion.
Figure 3 Dorsal Barton’s fracture: (a) subluxation of the
carpus along with the fractured distal radius in palmarflexion
with the force along the wrist pushing the whole wrist further
towards the dorsal side. (b) The intact long volar carpal
ligaments maintain the carpus onto the distal radius in
dorsiflexion.

from the radius to the ulna over the flexor tendons as
they enter the wrist. These ligaments are responsible
for positioning the carpal bones in relation to the
distal radius and provide stability to the wrist. The
volar carpal ligaments become taut in dorsiflexion
and lax in palmar flexion; the converse applies to the
dorsal carpal ligaments (Fig. 1).
Reduction should focus on the subluxed
radiocarpal joint.2 In volar and dorsal Barton’s
fractures, the carpal surface of the distal radius
is associated with radiocarpal joint subluxation/
dislocation; the wrist should thus be immobilised in
palmar flexion and dorsiflexion, respectively. Thereby,
the respective dorsal and volar carpal ligaments are
made taut to maintain the reduction of the subluxed
carpal bones. Otherwise, the wrist joint may sublux
along with the fractured volar/dosal lip of the distal
radial fragment, as the intact dorsal/volar carpal
ligaments relax (Fig. 2).
In volar Barton’s fractures, although the volar
carpal ligaments are intact, they do not contribute to
stability as they are attached to the fractured distal
radial fragment. Additionally, the dorsal carpal
ligaments may be strained, while the long dorsal
carpal ligaments are intact, with tears involving only
the short dorsal carpal ligament.2 Thus, intact long
dorsal carpal ligaments provide joint stability in volar
flexion by tipping the lunate away from the fractured
surface of the distal radius. Similarly in a dorsal
Barton’s fracture, a volar flexed wrist relaxes the intact
volar carpal ligaments, resulting in subluxation of the
wrist with the fractured dorsal lip of the distal radius
(Fig. 3). Hence a dorsal Barton’s fracture should be
immobilised in dorsiflexion.2,3
In paediatric distal radial physeal fractures with
dorsal angulation or displaced fractures, the wrist
should be immobilised in palmar flexion. Whereas,
when such fractures have volar angulation, the wrist
should be immobilised in dorsiflexion, as the intact
periosteum acts as the hinge for ligamentotaxis.
Immobilisation in a neutral position is also
appropriate.4

REFERENCES

1. Agee JM. Distal radius fractures. Multiplanar ligamentotaxis. Hand Clin 1993;9:577–85.
2. Crenshaw AH Jr. Fractures of shoulder girdle, arm and forearm. In: Canale ST, editor. Campbell’s operative orthopaedics. St
Louis: Mosby; 1998;3:2355–6.
3. Thomas FB. Reduction of Smith’s fracture. J Bone Joint Surg Br 1957;39:463–70.
4. Wilkins KE, O’Brien E. Fractures of distal radius and ulna. In: Rockwood CA Jr, Wilkins KE, Beaty JH, editors. Fractures in
children. Philadelphia: Lippincott-Raven; 1996;4:463.