Open reduction and internal fixation of volar Barton's fractures: A prospective study

Journal of Orthopaedic Surgery, Dec 2004 by Aggarwal, A K, Nagi, O N

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 radiographically after a mean follow-up duration of 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 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 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 8.3� (range, -2.0�-14.0�) and a mean ulnar angle of 20.7� (range, 10.0�-28.0�). The radioulnar index ranged from 2.00 to -1.00 (mean, 0.12).