Journal of Orthopaedic Surgery 2004;12(2):230–234

Open reduction and internal fixation of volar

Barton’s fractures: A prospective study

AK Aggarwal, ON Nagi
Department of Orthopaedic Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India

radiographically after a mean follow-up duration of

ABSTRACT
Purpose. To assess the functional and clinical outcomes
of open reduction with internal fixation in the
treatment of Barton’s fracture of the wrist.
Methods. From January 1997 to July 2003, a total of 19
cases of volar Barton’s fracture were operated on by
open reduction and internal fixation at the Nehru
Hospital, Chandigarh, India. Records of 16 cases were
available for study. Special care was taken during
surgery to achieve articular congruity. The injury was
caused by motor vehicle accidents in 13 cases and by a
fall in 3. All cases were type-B3 fractures: 10 were of
the B3.3 subtype, 4 of the B3.2 subtype, and 2 of the
B3.1 subtype. Most (12) cases were operated on within
one week of injury, 3 in one to 2 weeks, and one in 2 to
3 weeks.
Results. All patients were assessed clinically and
32.4 months (range, 12.0–65.0 months). Fractures
healed after 7.0 to 10.0 weeks (mean, 8.8 weeks).
Results of evaluations according to functional criteria
were excellent in 9 cases, good in 5, and fair in 2.
Radiocarpal osteoarthrosis developed secondary to
trauma in 2 cases. There was no involvement of the
median nerve in any of the 16 cases.
Conclusion. Open reduction and internal fixation of
volar Barton’s fracture can restore articular congruity
and result in good to excellent function.
Key words: fracture fixation, internal; fractures
INTRODUCTION
Barton’s fracture, named after the American surgeon
John Rhea Barton,1 is a fracture of the distal end of

Address correspondence and reprint requests to: Dr Aditya K Aggarwal, Assistant Professor, # 123-C Sector 24-A, Chandigarh
160023, India. E-mail: agg_aditya@hotmail.com
Vol. 12 No. 2, December 2004
the radius that involves the dorsal rim and extends
into the intra-articular region. Such intra-articular
fractures are uncommon, and they are usually
associated with high-velocity trauma. Conservative
treatment is usually unsuccessful, and it is also fraught
with complications, such as early osteoarthrosis,
deformity, subluxation, and instability. However, few
favourable studies have been reported on the
effectiveness of surgical treatment.2–4 In this article, we
present the results of a prospective study of open
reduction and internal fixation (ORIF) of Barton’s
fractures. The main purpose of the study was to assess
the functional results of ORIF in the treatment of volar
Barton’s fractures.
MATERIALS AND METHODS
From January 1997 to July 2003, a total of 19 cases of
volar Barton’s fracture were operated on by ORIF at
the Nehru Hospital, Chandigarh, India. Records of 16
cases were available for study. The mean age of the
11 men and 5 women was 29.5 years (range, 20.0–60.0
years). The mechanism of injury was high-energy
trauma (i.e. a motor vehicle accident) in 13 cases and
fall in 3 cases. Associated injuries were found in 10
patients and consisted of head injury (n=2), fracture
dislocation of the hip (n=1), fracture of the femoral
shaft (n=6), and fracture of the proximal humerus
(n=1). The Barton’s fractures were classified according
to a comprehensive classification system5 based on
radiographic and operative findings. All 16 cases were
type-B3 fractures. In terms of fracture subtype, 2 cases
were B3.1 fractures (characterised by a small volar
fragment and an intact sigmoid notch), 4 were B3.2
fractures (a large volar fragment that included
the sigmoid notch), and 10 were B3.3 fractures
(comminution of the volar fragment). In 6 of the
B3.3 fractures, the volar fragment was split into 2 parts;
in the other 4 cases, there were multiple fragments.
The majority of the cases (12) were operated on within
one week of the injury. Furthermore, 12 patients
received brachial plexus blocks. General anaesthesia
was administered to 4 patients.
SURGICAL TECHNIQUE
A pneumatic tourniquet was used in all cases in order
to provide bloodless field during surgery. The fracture
site was exposed through the distal part of the volar
approach of Henry. 6 Open reduction of all major
fragments was performed, focusing on restoring
articular congruity. A Kirschner wire was used to
Internal fixation of Barton’s fractures 231
provisionally fix the position of the fragments.
Definitive fixation was done with a 3.5-mm Ellis
T-plate. A below-elbow plaster-of-Paris slab was
applied for 3 weeks and then active movement of
wrist was started.
Postoperative radiographs were assessed by
measuring the volar angulation and ulnar angulation
of the distal-end radius and radioulnar index. Volar
and ulnar angles were angles of the articular surface
of the distal end of the radius in lateral and
anteroposterior views between the sagittal and coronal
planes, respectively. The radioulnar index was
determined by measuring (in millimetres) the distance
between the distal-most aspect of the sigmoid notch
of the radius and the distal-most part of the ulnar head.
Patients were followed up initially at 3-week
intervals up to 6 weeks, then every 6 weeks for 3
months, every 3 months for one year, and then every
6 months (Figs. 1–5). Results were evaluated using the
functional criteria proposed by Pattee and Thompson7
in 1988. Radiocarpal post-traumatic osteoarthrosis was
assessed radiographically.7
RESULTS
Fractures healed in 7 to 10 weeks (mean, 8.8 weeks)
postoperatively. The follow-up duration ranged from
12 to 65 months (mean, 32.4 months). Excellent results
were obtained for 9 of the 16 patients; results were good
for 5 patients and fair in the remaining 2. Postoperative
radiographic assessment revealed a mean volar angle
of 8.3Ο (range, -2.0Ο–14.0Ο) and a mean ulnar angle of
20.7Ο (range, 10.0Ο–28.0Ο). The radioulnar index ranged
from +2.00 to –1.00 (mean, 0.12).
Mild radiocarpal arthrosis developed secondary
to trauma in 2 patients (cases 6 and 11). In one of the
2 patients who had fair results (case 15), early signs of
Sudeck’s atrophy were observed, perhaps because
the patient was uncooperative regarding making
active movements of the fingers. The condition was
treated with active and passive movements of fingers,
analgesic anti-inflammatory drugs, and limb elevation.
The patient recovered after 4 weeks with some residual
stiffness of the wrist and fingers. No involvement of
the median nerve was seen, and no postoperative
infection was found in all 16 cases (Table 1).
DISCUSSION
Volar Barton’s fractures are not common injuries; they
constitute only 1.3% of distal-end radius fractures.7–10
Various forms of treatment have been described.
232 AK Aggarwal et al.
Figure 1 Anteroposterior and lateral radiographs of case 1,
showing volar Barton’s fracture of B3.3 type.
Figure 3 Anteroposterior and lateral radiographs of case 1
at 34-month follow-up showing complete union.
Figure 5 Follow-up radiographs of case 10 at 19 months
postoperatively, showing complete healing of fracture.
Journal of Orthopaedic Surgery
Figure 2 Immediate postoperative radiographs of the same
patient, demonstrating the reduction and internal fixation of
fractured fragments with Ellis T-plate.
Figure 4 Anteroposterior and lateral radiographs of case 10
demonstrating type-B3.3 volar Barton’s fracture with
dislocation.
They include closed reduction and plaster application,
percutaneous pinning, external fixation, ORIF with
Kirschner wires, and ORIF with a buttress plate.
Closed reduction is usually easy to achieve but
difficult to maintain. In an experimental study of the
pathomechanics of volar Barton’s fractures, King 8
observed that the stability of a reduction depended
on an intact radiocarpal ligament and concluded that
these fractures should be immobilised, keeping the
wrist in palmar flexion. Although King reported no
poor results, all patients had mild pain, weakness, and
some loss of motion at follow-up.
In our study, results were good to excellent in
14 cases. Our results are consistent with those studies
that supported the effectiveness of ORIF. 2–4,7,11 An
extensive review of the literature revealed only a
Vol. 12 No. 2, December 2004 Internal fixation of Barton’s fractures 233

Table 1
Characteristics and clinical details of 16 cases

Case Age Side Mode Type of Associated Duration Implant used Follow-up Result Complications
(years)/ involved of fracture injuries between duration
sex injury injury (months)
and
ORIF *
(days)
†
11 20/M Right MVA B3.3 Head injury 24 Ellis T-plate 34 Excellent None
12 34/M Right MVA B3.1 Fracture of the 25 Ellis T-plate 46 Good None
femoral shaft
13 54/M Left MVA B3.3 None 23 Ellis T-plate, 28 Excellent None
Kirschner wire
14 38/F Right Fall B3.2 Fracture of the 28 Ellis T-plate 32 Good None
femoral shaft
15 44/M Right MVA B3.3 Fracture of the 25 Ellis T-plate 41 Excellent None
proximal
humerus ‡
16 25/F Left MVA B3.3 None 25 Ellis T-plate 20 Fair Mild RC OA
17 46/M Right MVA B3.3 Fracture of the 23 Ellis T-plate, 52 Excellent None
femoral shaft Kirschner wire
18 60/M Left MVA B3.3 Fracture 20 Ellis T-plate, 22 Good None
dislocation of Kirschner wire
the hip
19 28/M Right MVA B3.2 None 29 Ellis T-plate 31 Excellent None
10 32/F Left MVA B3.3 Fracture of the 24 Ellis T-plate 19 Excellent None
femoral shaft
11 36/M Right Fall B3.2 None 22 Ellis T-plate 65 Good Mild RC OA
12 27/M Right MVA B3.1 Head injury 28 Ellis T-plate 39 Excellent None
13 34/F Left Fall B3.2 Fracture of the 24 Ellis T-plate, 17 Excellent None
femoral shaft Kirschner wire
14 22/M Right MVA B3.3 None 25 Ellis T-plate, 36 Good None
Kirschner wire
15 45/F Right MVA B3.3 None 26 Ellis T-plate 12 Fair Sudeck’ s
atrophy
16 30/M Left MVA B3.3 Fracture of the 22 Ellis T-plate 24 Excellent None
femoral shaft
* ORIF open reduction and internal fixation
†
MVA motor vehicle accident
‡
RC OA radiocarpal osteoarthrosis

few studies making use of ORIF in displaced, volar
Barton’s fracture (Table 2). 2–4,7,11 As with all intra-
articular fractures, anatomical reduction and in-
ternal fixation are the ultimate goals of treatment
for these injuries. This point has been very well
emphasised by the few authors in their studies on
Barton’s fractures.4,9
Mild radiocarpal osteoarthrosis, seen in 2 patients
in this study, did not affect their functional outcome.
One case of Sudeck’s atrophy (in a non-cooperative
patient) did affect the functional result (which was
graded as fair). Postoperatively, median nerve function
was not affected. This finding is consistent with that
in the study of Zoubos et al.3 in 1997. Hence, we suggest
that the release of the median nerve is not necessary
in ORIF of volar Barton’s fractures. In all displaced
Barton’s fractures, we suggest that ORIF can result in
a satisfactory functional outcome.
234 AK Aggarwal et al. Journal of Orthopaedic Surgery

Table 2
Review of the literature

Study Total Type of treatment (No.) Good to Complications (No.)

No. of excellent
cases results (%)
de Oliveira,11 1973 26 ORIF*Lwith buttress plate (26) 77% Not available
Pattee and Thompson,7 1988 20 Closed reduction (11) 85% Mild post-traumatic arthritis (13)
ORIF (9)
Buttress plate (3)
Kirschner wires (5)
Screw (1)
Mehara et al.,4 1993 78 ORIF or closed reduction (78) 90% Mild osteoarthrosis (10)
Moderate osteoarthrosis (2)
Jupiter et al.,2 1996 49 ORIF (49) 83.7% Early (6):
LIDeep vein thrombosis (1)
LISympathetic-maintained pain (3)
LILoss of reduction (1)
LIScapholunate dissociation (1)
Late (14):
LIPain (5)
LIMedian nerve compression (3)
LITenosynovitis (2)
LISubluxation of distal radioulnar joint (2)
ISevere post-traumatic arthritis (1)
LIRupture extensor pollicis longus (1)
Zoubos et al.,3 1997 35 ORIF with Ellis T-plate (35) 94% Not available
Present report 16 ORIF with Ellis T-plate (16) 87.5% Radiocarpal osteoarthrosis (2)
Sudeck’ s atrophy (1)
* ORIF open reduction and internal fixation

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