Neglected volar Barton fracture in adult managed in a rural setting: a case report

Barton fractures are distal radius fractures that extend through the dorsal aspect of the articular surface, with associated dislocation of the radiocarpal joint. They are extremely unstable and require open reduction and internal fixation (ORIF). Delayed presentation is often encountered with difficulty in achieving reduction, and more extensive surgery may be needed. Here, we present a case of a 3-week-old neglected volar Barton fracture of the right wrist treated with the conventional method in a rural setting.

A 32-year-old gentleman was initially denied surgical intervention for a distal radius fracture he sustained after a motor vehicle accident and was discharged with a long arm slab plus analgesics represented in the outpatient department and agreed upon surgical intervention after his condition did not improve with conservative treatment. The trans-FCR (flexor carpi radialis) approach was used for surgery under the brachial plexus block. The fragment was reduced by applying pressure volarly into the distal radius and was confirmed with imaging. A K-wire (Kirschner) was used to temporarily hold the fragment. A volar distal radius locking plate was used to buttress the distal fragment. Final fixation was made using altogether six screws. The wrist was splinted in a short dorsal slab. Skin sutures were removed after 2 weeks, and an active assisted range of motion of the wrist was begun after 6 postoperative weeks.

Volar Barton is an uncommon subset of intra-articular fractures and typically results from damage sustained at high speeds. The general agreement for neglected fractures is that 'fractures that are not handled or mishandled resulting in treatment delay, worsening of the fracture and even a disability' are to be considered neglected fractures. Rebuilding the damaged anatomy properly and enabling a prompt, problem-free recovery of hand function are the main objectives of treatment. As conservative therapy is often ineffective and rife with side effects, including early osteoarthrosis, deformity, subluxation, and instability, stabilization and anatomic reduction by surgery is the key to managing these fractures. Plating is one of the therapeutic modalities among various therapeutic modalities depicted in the literature that enables shorter time of immobilization and early restoration of wrist function through direct anatomic repair and stable internal fixation. In our case, the callus was relatively immature, and the original fracture site could easily be cleared. Also, there was no significant soft tissue shortening, and the volar fragment had not migrated proximally, in contrast to what is expected in prolonged neglected cases. Hence, the intraoperative reduction was possible, and the fracture was fixed with a volar locking plate as usual.

Given the modest tissue shortening and young callus, such cases may be treated as conventional Barton's fractures and managed using conventional means of fixation with locking buttress plates. However, it makes sense to prepare for potential malreduction by carrying K wires and wrist distractions. To restore complete function to the injured wrist, adequate physiotherapy and postoperative splinting are essential components of postoperative rehabilitation.