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

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

Address correspondence and reprint requests to: Dr Aditya K Aggarwal, Assistant Professor, # 123-C Sector 24-A, Chandigarh 160023, India. E-mail: [email protected]

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.

Journal of Orthopaedic Surgery

Figure 1 Anteroposterior and lateral radiographs of case 1, showing volar Barton’s fracture of B3.3 type.

Figure 2 Immediate postoperative radiographs of the same patient, demonstrating the reduction and internal fixation of fractured fragments with Ellis T-plate.

Figure 3 Anteroposterior and lateral radiographs of case 1 at 34-month follow-up showing complete union.

Figure 4 Anteroposterior and lateral radiographs of case 10 demonstrating type-B3.3 volar Barton’s fracture with dislocation.

Figure 5 Follow-up radiographs of case 10 at 19 months postoperatively, showing complete healing of fracture.

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 (years)/ involved of fracture sex injury

†

Associated injuries

Duration between injury and ORIF * (days)

Implant used Follow-up duration (months)

Result

Complications

Head injury Fracture of the femoral shaft None

24 25

Ellis T-plate Ellis T-plate

34 46

Excellent Good

None None

23

28

Excellent

None

28

Ellis T-plate, Kirschner wire Ellis T-plate

32

Good

None

25

Ellis T-plate

41

Excellent

None

25 23

Ellis T-plate Ellis T-plate, Kirschner wire Ellis T-plate, Kirschner wire

20 52

Fair Excellent

Mild RC OA None

22

Good

None

29 24

Ellis T-plate Ellis T-plate

31 19

Excellent Excellent

None None

22 28 24

65 39 17

Good Excellent Excellent

Mild RC OA None None

36

Good

None

12

Fair

24

Excellent

Sudeck’ s atrophy None

11 12

20/M 34/M

Right Right

MVA MVA

B3.3 B3.1

13

54/M

Left

MVA

B3.3

14

38/F

Right

Fall

B3.2

15

44/M

Right

MVA

B3.3

16 17

25/F 46/M

Left Right

MVA MVA

B3.3 B3.3

18

60/M

Left

MVA

B3.3

19 10

28/M 32/F

Right Left

MVA MVA

B3.2 B3.3

11 12 13

36/M 27/M 34/F

Right Right Left

Fall MVA Fall

B3.2 B3.1 B3.2

14

22/M

Right

MVA

B3.3

Fracture of the femoral shaft Fracture of the proximal humerus None Fracture of the femoral shaft Fracture dislocation of the hip None Fracture of the femoral shaft None Head injury Fracture of the femoral shaft None

15

45/F

Right

MVA

B3.3

None

26

Ellis T-plate Ellis T-plate Ellis T-plate, Kirschner wire Ellis T-plate, Kirschner wire Ellis T-plate

16

30/M

Left

MVA

B3.3

Fracture of the femoral shaft

22

Ellis T-plate

ORIF MVA RC OA

20

25

‡

open reduction and internal fixation motor vehicle accident radiocarpal osteoarthrosis

few studies making use of ORIF in displaced, volar Barton’s fracture (Table 2). 2–4,7,11 As with all intraarticular fractures, anatomical reduction and internal 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.

Journal of Orthopaedic Surgery

234 AK Aggarwal et al. Table 2 Review of the literature Study

Total No. of cases

Type of treatment (No.)

Good to excellent results (%)

de Oliveira,11 1973 Pattee and Thompson,7 1988

26 20

77% 85%

Not available Mild post-traumatic arthritis (13)

Mehara et al.,4 1993

78

ORIF*Lwith buttress plate (26) Closed reduction (11) ORIF (9) Buttress plate (3) Kirschner wires (5) Screw (1) ORIF or closed reduction (78)

90%

Jupiter et al.,2 1996

49

ORIF (49)

83.7%

Zoubos et al.,3 1997 Present report

35 16

ORIF with Ellis T-plate (35) ORIF with Ellis T-plate (16)

94% 87.5%

Mild osteoarthrosis (10) Moderate osteoarthrosis (2) 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) Not available Radiocarpal osteoarthrosis (2) Sudeck’ s atrophy (1)

*

ORIF

Complications (No.)

open reduction and internal fixation

REFERENCES 1. Barton JR. Views and treatment of an important injury to the wrist. Philadelphia Med Exam 1838;1:365–8. 2. Jupiter JB, Fernandez DL, Toh CL, Fellman T, Ring D. Operative treatment of volar intra-articular fractures of the distal end of the radius. J Bone Joint Surg Am 1996;78:1817–28. 3. Zoubos AB, Babis GC, Korres DS, Pantazopoulos T. Surgical treatment of 35 volar Barton fractures. No need for routine decompression of the median nerve. Acta Orthop Scand Suppl 1997;275:65–8. 4. Mehara AK, Rastogi S, Bhan S, Dave PK. Classification and treatment of volar Barton fractures. Injury 1993;24:55–9. 5. Muller ME, Nazarian S, Koch P, Schatzker J. The comprehensive classification of fractures of long bones. New York: Springer; 1990. 6. Henry AK. Extensile exposures. 2nd ed. Baltimore: Williams and Wilkins; 1957:67. 7. Pattee GA, Thompson GH. Anterior and posterior marginal fracture-dislocations of the distal radius. An analysis of the results of treatment. Clin Orthop 1988;231:183–95. 8. King RE. Barton’s fracture-dislocation of the wrist. Curr Pract Orthop Surg 1975;6:133–44. 9. Thompson GH, Grant TT. Barton’s fractures-reverse Barton’s fractures. Confusing eponyms. Clin Orthop 1977;122:210–21. 10. Bohler L. Treatment of fractures. Bristol, England: John Wright & Sons; 1943. 11. de Oliveira JC. Barton’s fractures. J Bone Joint Surg Am 1973;55:586–94.