Barton Fracture: Symptoms, Types, Causes and Treatment

Barton fractures are a distinct and significant injury of the wrist, representing a subset of intra-articular distal radius fractures that are often accompanied by dislocation or subluxation of the radiocarpal joint. They are considered unstable and frequently demand surgical intervention to restore function and prevent long-term disability. In this comprehensive article, we will explore the symptoms, classification, underlying causes, and modern treatment options for Barton fractures, drawing from a range of clinical studies and expert literature.

Symptoms of Barton Fracture

When a Barton fracture occurs, the symptoms can be both dramatic and concerning. Because this injury involves the wrist joint and is often associated with a fragment of bone being displaced along with the carpal bones, immediate and sometimes severe symptoms can manifest.

Symptom	Description	Frequency/Context	Source(s)
Pain	Acute wrist pain, often severe	Present immediately post-injury	4, 7, 9
Swelling	Rapid swelling around the wrist joint	Common	4, 9
Deformity	Visible wrist deformity or angulation	More apparent with displacement	5, 7
Loss of Motion	Reduced or painful wrist movement	Limits daily activities	4, 9

Table 1: Key Symptoms

Immediate Presentation

Most individuals with a Barton fracture experience a sudden onset of intense pain immediately following trauma. This pain is typically localized to the wrist and can be exacerbated by any attempt to move the joint. Swelling develops rapidly as the body responds to the injury, and in more severe cases, there can be a visible deformity—often a bump or angulation due to the displacement of the bone fragment and associated joint dislocation 4, 5, 7.

Functional Impairment and Further Signs

Movement of the wrist is usually significantly restricted. Even small motions can cause sharp or throbbing pain, making it difficult for affected individuals to use their hand or grip objects. In some cases, the wrist may appear misaligned, and there may be associated bruising as the soft tissues are damaged during the injury 4, 9.

Complications and Additional Symptoms

While nerve injuries are rare, severe displacement can occasionally affect nerves or blood vessels, leading to numbness, tingling, or coolness in the hand. However, studies show that median nerve involvement is uncommon in these fractures 4.

Types of Barton Fracture

Barton fractures are not a single entity but encompass a spectrum of injuries, primarily differentiated by the direction and location of the fracture. Correct classification is essential for diagnosis, management, and predicting outcomes.

Type	Description	Prevalence/Key Feature	Source(s)
Volar Barton	Fracture of volar (palm side) distal radius	Most common (~69%)	1, 3, 4, 8
Dorsal Barton	Fracture of dorsal (back side) distal radius	Less common	2, 3, 5
Comminuted	Multiple fragments, complex displacement	~19% of Barton fractures	3
Marginal/Other	Involvement of ulnar or radial margin	Ulna: ~7%, Radial: ~5%	3

Table 2: Barton Fracture Types

Volar Barton Fracture

The volar (anterior) Barton fracture involves the palmar aspect of the distal radius. It is the most prevalent type and is characterized by a shearing injury that causes the volar rim of the radius to fracture, typically accompanied by dislocation or subluxation of the radiocarpal joint. These injuries are inherently unstable and often require surgical intervention to restore joint congruity 1, 3, 4, 8.

Dorsal Barton Fracture

The dorsal (posterior) Barton fracture affects the dorsal rim of the distal radius. Though less common, it follows a similar mechanism but in the opposite direction. There is debate in the literature about eponymous naming, with some advocating for more anatomically descriptive terms such as "anterior" and "posterior marginal fracture-dislocations" 2, 3, 5.

Comminuted and Marginal Variants

Some Barton fractures are comminuted, meaning the bone is shattered into several pieces, making surgical reconstruction more complex. Additionally, variants can affect the ulnar or radial margins of the distal radius, though these are relatively rare 3.

Grading and Morphological Classification

Recent studies have proposed grading Barton fractures based on morphology:

• Simple split: Single fracture line without depression.
• Split-depression: Fracture with depressed articular surface.

Understanding the precise fracture type and grade is crucial for selecting the optimal treatment strategy and predicting prognosis 3.

Causes of Barton Fracture

Barton fractures are typically the result of significant trauma, but the precise mechanism and patient demographics can vary.

Cause	Mechanism/Context	Demographics	Source(s)
High-energy	Motor vehicle accidents, falls from height	Younger males	2, 4
Low-energy	Simple falls, especially onto outstretched hand	Older females	2, 5
Shearing Force	Forced wrist extension/flexion	Any age; mechanism-dependent	1, 3, 5

Table 3: Common Causes

High-Energy Trauma

In younger adults, particularly males, Barton fractures most frequently occur following high-velocity incidents such as motor vehicle accidents or falls from a significant height. The force required to produce this type of intra-articular fracture is substantial and often results in additional injuries 2, 4.

Low-Energy Trauma in Elderly

Older adults—most often women—can sustain a Barton fracture after a simple fall, usually onto an outstretched hand. This reflects the increased fragility of bones with age and the higher prevalence of osteoporosis in this demographic 2, 5.

Biomechanics of Injury

The key mechanism in a Barton fracture is a shearing force applied to the distal radius, usually with the wrist in either extreme extension or flexion. This causes a fragment of the articular surface to be displaced along with the carpal bones, leading to the characteristic fracture-dislocation pattern 1, 3, 5.

Treatment of Barton Fracture

The approach to treating a Barton fracture is driven by the instability and intra-articular involvement characteristic of this injury. Modern management prioritizes the restoration of joint congruity and early mobilization.

Treatment Method	Approach/Technique	Outcomes/Considerations	Source(s)
Open Reduction & Internal Fixation (ORIF)	Surgical, buttress/locking plate	Excellent/good results, preferred for unstable fractures	1, 4, 7, 8, 9
Closed Reduction	Manipulation, casting	Acceptable only if articular step <2mm, less favorable	1, 7
Volar Plate Fixation	Locking compression or T plate	Satisfactory function, cost-effective	8, 9
Non-operative	Splinting, immobilization	Rarely indicated, only in select cases	1, 7

Table 4: Treatment Options

Open Reduction and Internal Fixation (ORIF)

ORIF is considered the gold standard for most Barton fractures, especially those with displacement or instability. Surgery involves realigning the bone fragments and securing them with plates and screws—often a volar buttress or locking plate. Studies have shown that this approach leads to excellent or good functional outcomes in the majority of patients, with a high rate of return to previous activities 1, 4, 7, 8, 9.

• Volar Plate Fixation: The use of locking compression plates or T-plates is especially effective for volar Barton fractures. These implants offer stable fixation, allowing for early mobilization and reducing the risk of complications. The technique is also cost-effective and has a relatively short learning curve 8, 9.

Closed Reduction and Casting

For non-displaced or minimally displaced fractures (articular step <2 mm), closed reduction followed by immobilization in a cast may be considered. However, these cases are rare, and the functional results are generally inferior to surgical management due to the risk of late displacement and joint incongruity 1, 7.

Considerations in Surgical Technique

• Articular Congruity: Achieving precise alignment of the joint surface is critical to minimize the risk of post-traumatic osteoarthritis and maximize wrist function 4.
• Comminuted/Dorsal Involvement: In complex or comminuted fractures, or when there is concomitant dorsal cortex involvement, surgical planning must be meticulous. Undetected dorsal fractures can lead to poor alignment if not properly addressed during fixation 5.

Rehabilitation and Recovery

Early mobilization following stable surgical fixation is encouraged to restore wrist function and prevent stiffness. Most fractures heal within 7-10 weeks, and the majority of patients regain near-normal motion and strength, though some may experience mild limitations or post-traumatic arthritis 4, 8, 9.

Conclusion

Barton fractures are a distinctive and challenging injury of the distal radius, requiring prompt recognition and tailored management to optimize outcomes. Key points covered in this article include:

• Symptoms: Acute pain, swelling, deformity, and reduced wrist motion are hallmark features.
• Types: Volar Barton is most common, but dorsal, comminuted, and marginal variants exist.
• Causes: High-energy trauma in younger adults and low-energy falls in older adults are the primary mechanisms.
• Treatment: Surgical fixation (ORIF) using a volar buttress or locking plate is the preferred and most effective approach for most cases, with conservative management reserved for rare, minimally displaced fractures.

A multidisciplinary approach, accurate diagnosis, and individualized rehabilitation are essential to restore function and minimize complications for patients with Barton fractures.