Dorsal Barton Fracture Treatment
For dorsal Barton fractures of the distal radius, open reduction and internal fixation with dorsal plating is the definitive treatment, as these fractures are inherently unstable intra-articular injuries that cannot be adequately managed with conservative treatment alone.
Surgical Indication and Rationale
- Dorsal Barton fractures are unstable intra-articular fractures involving the dorsal articular rim with associated radiocarpal subluxation, requiring surgical stabilization 1
- The AAOS/ASSH guidelines recommend surgical fixation for fractures with intra-articular displacement, which applies to all Barton fractures by definition 2
- Conservative treatment is ineffective for these fractures and leads to complications including subluxation, instability, deformity, and early post-traumatic osteoarthritis 1
Optimal Fixation Method
Dorsal plating is the preferred approach for dorsal Barton fractures specifically, as it provides direct visualization, anatomic reduction, and buttressing of the dorsal articular fragment 3
- Dorsal plates allow direct fracture reduction and buttressing of the dorsal rim fragment, which is critical for this fracture pattern 3
- While volar plating has broad applicability for most distal radius fractures, dorsal plates are specifically advantageous for dorsal rim fractures where direct buttressing is needed 3
- The AAOS guidelines note no overall superiority of one fixation method over another for distal radius fractures in general, but this applies to mixed fracture patterns rather than specific subtypes like dorsal Barton 2
Surgical Technique Considerations
- Achieve anatomic reduction of the articular surface with restoration of joint congruity 1
- Use locking plate technology for stable fixation that allows early mobilization 2, 1
- Provisional fixation with K-wires may be helpful before definitive plate application 1
- Ensure adequate screw purchase both proximal and distal to the fracture site 4
Critical Pitfall: Tendon Complications
The major caveat with dorsal plating is the risk of extensor tendon irritation and rupture, which occurs more frequently than with volar approaches 3
- Dorsal plates can be prominent and cause tendon irritation, requiring careful plate positioning and potential hardware removal 3
- Despite this risk, the biomechanical advantage of direct buttressing for dorsal rim fractures outweighs the tendon complication risk 3
Postoperative Management
- Begin active finger motion exercises immediately after surgery to prevent stiffness, which is the most functionally disabling complication 2
- Early wrist motion is not routinely necessary following stable internal fixation 2
- Immobilization duration should be minimized—typically 2-3 weeks in a dorsal splint for soft tissue protection only 1
- Active assisted range of motion of the wrist should begin by 6 weeks postoperatively 1
Follow-up Protocol
- Obtain radiographs at 2 weeks (suture removal), 6 weeks (initiation of wrist motion), and 12 weeks to confirm healing 1
- Monitor for hardware prominence and tendon irritation symptoms throughout the healing period 3
- Plan for potential hardware removal if symptomatic tendon irritation develops after fracture union 3
Alternative Consideration for Complex Cases
- In cases with severe comminution or delayed presentation (>3 weeks), be prepared for potential need for distraction techniques or bone grafting, though this is rarely required 1
- For neglected cases with immature callus, standard reduction and plating techniques may still be successful if soft tissue shortening is minimal 1