When is surgery indicated for a volar Barton fracture?

Surgical Indications for Volar Barton Fracture

Surgery is indicated for virtually all volar Barton fractures due to their inherent instability and high risk of radiocarpal subluxation, with open reduction and internal fixation using a volar locking plate being the treatment of choice. 1

Understanding Volar Barton Fracture Characteristics

Volar Barton fractures are intra-articular distal radius fractures extending through the volar articular surface with associated radiocarpal joint dislocation or subluxation. 2 These fractures are:

• Extremely unstable by nature due to the shear forces and loss of volar cortical support 2, 3
• Prone to redisplacement with conservative management, leading to malunion, deformity, subluxation, instability, and early osteoarthritis 2

Primary Surgical Indications

Absolute indications for surgery include:

• Any intra-articular displacement of the volar fragment, as these fractures are inherently unstable and require anatomic reduction 1
• Articular step-off ≥2 mm, which correlates with significantly worse outcomes when treated non-operatively 4
• Radiocarpal subluxation or dislocation, which is characteristic of this fracture pattern 2
• Post-reduction radial shortening >3 mm, dorsal tilt >10°, or any intra-articular displacement per AAOS guidelines 1

Surgical Technique Recommendation

Volar locking plate fixation is the preferred surgical method:

• Provides superior wrist function recovery compared to anatomical plates, with excellent/good outcomes in 94.1% vs 75% of cases 5
• Enables immediate stability with anatomic reduction and early mobilization 3
• Allows shorter immobilization periods and faster return to function 2, 3
• Alternative techniques (external fixation with K-wires) show lower satisfaction rates (82% vs 100% with plating) 6

Conservative Management Limitations

Non-operative treatment is generally contraindicated because:

• Conservative therapy is often ineffective and associated with high complication rates including deformity, subluxation, instability, and early osteoarthritis 2
• Results are only acceptable if articular step-off is <2 mm, which is rarely achievable or maintainable with closed reduction 4
• The AAOS guidelines acknowledge they cannot recommend for or against casting as definitive treatment for unstable fractures, even when initially adequately reduced 1

Special Considerations

Age is not a contraindication:

• Patients >55 years may be considered for surgery, though evidence is inconclusive regarding superiority over casting in this age group 1
• Functional demands and medical fitness should guide decision-making in elderly patients rather than age alone 1

Delayed presentation (neglected fractures):

• Surgery remains indicated even in 3-week-old fractures if callus is immature and soft tissue shortening is minimal 2
• Standard volar locking plate fixation can still be used if anatomic reduction is achievable 2
• Prepare for potential difficulties with reduction by having K-wires and distraction equipment available 2

Common Pitfalls to Avoid

• Do not attempt prolonged conservative management hoping for acceptable alignment—these fractures will lose reduction 2, 4
• Do not accept articular step-off ≥2 mm—this threshold predicts poor functional outcomes 4
• Do not delay surgery in appropriate candidates, as this increases technical difficulty and may worsen outcomes 2