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Barton’s Fracture – Causes, Symptoms, Diagnosis, Treatment

Barton’s Fracture /A Barton’s fracture is an intra-articular rim fracture of the distal radius. It can be classified as either dorsal or volar. Dorsal rim fractures are more common and result from forced dorsiflexion and pronation. Volar rim fractures often occur with a fall onto a supinated hand/wrist. These forces disrupt the radiocarpal ligaments and subsequent avulsion fracture of the radial rim. In dorsal fractures, the avulsed fragment migrates dorsally. The opposite is true with volar fractures. These fractures are unstable and often present with a dislocation of the carpal bones. [rx][rx]

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. [rx][rx][rx]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.

Causes Of Barton Fracture

Barton’s Fracture

Sudden forceful fall down
Road traffic accident
Falls – Falling onto an outstretched hand is one of the most common causes of broken radial and causes Barton fracture
Sports injuries – Many Barton fractures occur during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
Motor vehicle crashes – Motor vehicle crashes can cause wrist bones to break, sometimes into many pieces, and often require surgical repair.
Have osteoporosis – a disease that weakens your bones
Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
Walk or do other activities in the snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing
Wave an inadequate intake of calcium or vitamin D
Football or soccer, especially on artificial turf
Rugby
Horseback riding
Hockey
Skiing
Snowboarding
In-line skating
Jumping on a trampoline

Symptoms Of Barton fracture

Common symptoms of Barton fracture include:

Severe pain that might worsen when gripping or squeezing or moving your hand or wrist
Swelling
Tenderness
Bruising
Obvious deformity, such as a bent wrist
Pain
The wrist hanging in a deformed way
Pain, especially when flexing the wrist
Deformity of the wrist, causing it to look crooked and bent.
Your wrist is in great pain.
Your wrist, arm, or hand is numb.
Your fingers are pale.

Diagnosis of Barton fracture

Plain Radiographs

Radiographic imaging is important in diagnosis, classification, treatment, and follow-up assessment of these fractures. The routine minimal evaluation for Barton fracture must include two views-a posteroanterior (PA) view and a lateral view.[rx]
The PA view should be obtained with the humerus abducted 90 degrees from the chest wall, so that the elbow is at the same level as the shoulder and flexed 90 degrees.[rx] The palm is maintained flat against the cassette

Computed Tomography

CT may be useful and can give significant information in comparison with that obtained with conventional radiography in the evaluation of complex or occult fractures, radial and ulnar shaft articular surface, distal radio-ulnar joint, ventromedial fracture fragment (as described by Melone),[rx] assessments of fracture healing as well as post-surgical evaluation.[rx]
CT may be indicated for the confirmation of occult fractures suspected on the basis of physical examination when plain films are normal.

Magnetic Resonance Imaging

Although this modality is not the first choice in evaluating acute distal radius fractures, it is a powerful diagnostic tool to assess bony, ligamentous, and soft tissue abnormalities associated with these fractures.
MRI has proved to be a very important diagnostic tool for delineating perforation of triangular fibrocartilage complex (TFCC),[rx] perforation of interosseous ligaments of the proximal carpal row, evaluating occult fractures, post-traumatic or avascular necrosis of carpal bones.

Treatment Of Barton fracture

Non-Surgical

Treatment available can be broadly

Get medical help immediately – If you fall on an outstretched arm, get into a car accident or are hit while playing a sport and feel intense pain in your shoulder area, then get medical care immediately. Barton fractures cause significant pain in the front part of your shoulder, closer to the base of your neck. You’ll innately know that something is seriously wrong because you won’t be able to lift your arm up. Other symptoms include immediate swelling and/or bruising near the fracture, grinding sounds with arm movements and potential numbness, and tingling in the arm/hand.
Apply ice to your fractured area – After you get home from the hospital Barton fracture (regardless if you had surgery or not), you should apply a bag of crushed ice (or something cold) to your injured in order to reduce the swelling and numb the pain. Ice therapy is effective for acute (recent) injuries that involve swelling because it reduces blood flow by constricting local blood vessels. Apply the crushed ice to your clavicle for 15 minutes three to five times daily until the soreness and inflammation eventually fades away

Lightly exercise after the pain fades – After a couple of weeks when the swelling has subsided and the pain has faded away, remove your arm sling for short periods and carefully move your arm and shoulder in all different directions. Don’t aggravate the Barton fracture so that it hurts, but gently reintroduce movements to the involved joints and muscles. Start cautiously, maybe starting with light calisthenics and then progress to holding light weights (five-pound weights to start). Your distal radius fractures need to move a little bit during the later phases of the injury to stimulate complete recovery.
Practice stretching and strengthening exercises – of the fingers, elbow, and shoulder if your doctor recommends them.
A splint – which you might use for a few days to a week while the swelling goes down; if a splint is used initially, a cast is usually put on about a week later.
A cast – which you might need for six to eight weeks or longer, depending on how bad the break is (you might need a second cast if the first one gets too loose after the swelling goes away.)
Get a supportive arm sling – Due to their anatomical position, Barton fracture can’t be cast like a broken limb can. Instead, a supportive arm sling or “figure-eight” splint is typically used for support and comfort, either immediately after the injury if it’s just a hairline fracture or following surgery, if it’s a complicated fracture. Sometimes a larger swath of material is wrapped around the sling to keep it closer to your body. You’ll need to wear the sling constantly until there is no pain with arm movements, which takes between two to four weeks for children or four to eight weeks for adults.
Get a referral to physical therapy – Once you’ve recovered and able to remove your arm sling splint for good, you’ll likely notice that the muscles surrounding your shoulder and upper chest look smaller and feel weaker. That’s because muscle tissue atrophies without movement. If this occurs, then you’ll need to get a referral for some physical rehabilitation. Rehab can start once you are cleared by your orthopedist, are pain-free, and can perform all the basic arm and shoulder movements. A physiotherapist or athletic trainer can show you specific rehabilitation exercises and stretches to restore your muscle strength, joint movements, and flexibility
Rigid fixation – osteosynthesis with locking plate, hook plate fixation, fixation with radial and styloid process locking plate, coracoclavicular screws, Knowles pin fixation.
Flexible fixation – simple k wire fixation, tension band wiring, suture anchors, vinyl tape, dacron arterial graft for styloid process ligament reconstruction.
A splint – which you might use for a few days to a week while the swelling goes down; if a splint is used initially, a cast is usually put on about a week later.
A cast – which you might need for six to eight weeks or longer, depending on how bad the break is (you might need a second cast if the first one gets too loose after the swelling goes away.)

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Rest Your Hand

Once you’re discharged from the hospital in an arm sling, your top priority is to rest your shoulder and not further inflame the injury. Of course, the arm sling not only provides support, but it also restricts movement, which is why you should keep it on even during sleep. Avoiding the temptation to move your shoulder and arm will help the bone mend quicker and the pain fades away sooner.

Depending on what you do for a living and if the injury is to your dominant side, you may need to take a couple of weeks off work to recuperate.
Healing takes between four to six weeks in younger people and up to 12 weeks in the elderly, but it depends on the severity of the radial and ulnar shaft fractures.
Athletes in good health are typically able to resume their sporting activities within two months of breaking they’re ulnar styloid depending on the severity of the break and the specific sport.
Sleeping on your back (with the sling on) is necessary to keep the pressure off your shoulder and prevent stressing the styloid process injury.

Eat Nutritiously During Your Recovery

All bones and tissues in the body need certain nutrients in order to heal properly and in a timely manner. Eating a nutritious and balanced diet that includes lots of minerals and vitamins is proven to help heal broken bones of all types, including ulnar styloid. Therefore, focus on eating lots of fresh produce (fruits and veggies), whole grains, lean meats, and fish to give your body the building blocks needed to properly repair your Barton fracture. In addition, drink plenty of purified water, milk, and other dairy-based beverages to augment what you eat.

Broken bones need ample minerals (calcium, phosphorus, magnesium, boron) and protein to become strong and healthy again.
Excellent sources of minerals/protein include dairy products, tofu, beans, broccoli, nuts and seeds, sardines and salmon.
Important vitamins that are needed for bone healing include vitamin C (needed to make collagen), vitamin D (crucial for mineral absorption), and vitamin K (binds calcium to bones and triggers collagen formation).
Conversely, don’t consume food or drink that is known to impair bone/tissue healing, such as alcoholic beverages, sodas, most fast food items and foods made with lots of refined sugars and preservatives.

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Physical Therapy

Although there will be some pain, it is important to maintain arm motion to prevent stiffness. Often, patients will begin doing exercises for elbow motion immediately after the injury. After a fracture, it is common to lose some shoulder and arm strength. Once the bone begins to heal, your pain will decrease and your doctor may start gentle shoulder exercises. These exercises will help prevent stiffness and weakness. More strenuous exercises will be started gradually once the fracture is completely healed.

Follow-Up Care

You will need to see your doctor regularly until your fracture heals. During these visits, he or will take x-rays to make sure the bone is healing in a good position. After the bone has healed, you will be able to gradually return to your normal activities.

Breathing Exercise

To elevate breathing problems or remove lung congestion if needed.

Medication

Antibiotic – Cefuroxime or Azithromycin, or Flucloxacillin or any others cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema
Antidepressants – A Drugs that block pain messages from your brain and boost the effects of endorphins (your body’s natural painkillers).
Corticosteroids – Also known as oral steroids, these medications reduce inflammation.
Muscle Relaxants – These medications provide relief from associated muscle spasms.
Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include and Ketorolac, Aceclofenac, naproxen
Calcium & vitamin D3 – to improve bones health and healing fracture.
Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerate cartilage or inhabit the further degeneration of cartilage, ligament
Corticosteroid- to healing the nerve inflammation and clotted blood in the joints.
Dietary supplement -to remove general weakness & improved health.

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

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

Most Barton fractures will be treated with closed reduction and application of external fixation devices, 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. [rx]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.

Complications Of Radial Styloid Process Fractures

There were no major complications such as neurovascular injury, infection, or impaired wound healing. Surgery-related complication at 2-year follow-up included nonunion in 3 patients (11%),

DRUJ subluxation in 3 patients (11%),
Implant migration in 4 patients (14%),
Radiographic resorption of the ulnar styloid in 4 patients (14%).
Radiographic nonunion was noted in 1 patient in group A (8%) and 2 in group B (13%). Residual DRUJ subluxation was noted in 3 patients; all were in group B (20%).
Partial or complete radiographic resorption of the ulna was found in 1 patient in group A (8%) and 3 in group B (20%).
Implant migration was noted in 1 patient in group A (8%), and 2 in group B (13%).
Subsequent removal surgery due to implant irritation occurred in 13 patients (46%), with 4 in group A (31%) and 8 in group B (53%).
A total of 11 patients (39%) with surgery-related complications included 5 (38%) in group A and 12 (80%) in group B, with a significant difference

There are risks associated with any type of surgery. These include

Nonunion (1-5%)
Infection (~4.8%)
4% in the surgical group develop adhesive capsulitis requiring surgical intervention
Bleeding
Problems with wound healing
Blood clots
Damage to blood vessels or nerves
Reaction to anesthesia
Hardware prominence
Malunion with cosmetic deformity
Restriction of ROM
The difficulty with bone healing
Hardware irritation
Fracture comminution (Z deformity)
Fracture displacement
Increased fatigue with overhead activities
Dissatisfaction with appearance
The difficulty with shoulder straps, backpacks and the like
~30% of patient request plate removal
Superior plates associated with increased irritation
Superior plates associated with increased risk of subclavian artery or vein penetration