Smith's fracture, or "reverse Colles' fracture," is a volar angulated fracture of the distal radius. These injuries result from a fall or direct blow on the dorsum of the hand and wrist or from falls on the outstretched hand in supination that then shifts into a pronated position. The hand is displaced palmar in a "garden-spade deformity." The anteroposterior radiograph looks much like the Colles' fracture, with a distal metaphyseal radius fracture that may be shortened and comminuted. The lateral radiograph shows the volar angulated and displaced fracture ( Fig.262-13).
The treatment objectives and complications are much like those seen with Colles' fracture. In this case, however, the angulation is in the opposite direction. Barton's Fracture
Barton's fractures are dorsal or volar rim fractures of the distal radius. The dorsal rim fractures result from a dorsiflexion and pronation force, whereas the less common volar rim fracture is produced by a fall on the outstretched hand in supination. These injuries are often fracture dislocations or subluxations, because the carpus or hand is frequently displaced in the direction of the fracture. Accompanying ligamentous injuries create radiocarpal instability. This is often not fully appreciated in the acute setting but can lead to various secondary carpal instability patterns and premature degenerative arthritis.
The anteroposterior radiograph often shows a comminuted fracture of the distal radial metaphysis. The lateral view reveals an intra-articular fracture of the volar or dorsal rim of the radius, which may be accompanied by carpal subluxation in the same direction ( Fig 262.:1M, Fig:...,2.62.zii§).
FIG. 262-14. Volar Barton's fracture. A. AP view. B. Lateral view. (With permission from Chin HW, Visotsky J: Wrist fractures. Em Med Clin North Am 11:3, 1993.)
Minimally displaced fractures can be treated acutely with closed reduction and a splint or cast until they can be reevaluated by the orthopedist. Unstable fractures involve more than 50 percent of the radial articular surface or have accompanying carpal subluxation and require reduction and immobilization by the orthopedist. These injuries often require open reduction and fixation with pins or a buttress plate.
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