Orthopaedic Emergencies 291INJURIES TO THE WRIST AND HAND(ii) Apply pressure with the heel of the hand to reduce the distal
fragment dorsally.
(iii) Place a long-arm plaster to hold the reduced fracture in position
(a) position the affected arm with the elbow in 90° flexion,
the forearm in full supination, and the wrist dorsiflexed
(extended)
(b) mould an anterior slab around the radius with a slot cut for
the thumb
(c) extend the plaster above the elbow, kept at a right angle.
(iv) Take a check X-ray to assess the adequacy of reduction before
terminating the anaesthetic. If reduction fails, internal fixation
may be necessary.3 Give the patient a sling and analgesics, and review in the next fracture clinic.
(i) As the fracture is often unstable, it is prone to slipping and
the patient usually requires weekly X-ray follow-up to ensure
continued fracture reduction.
BARTON’S FRACTURE–DISLOCATION
DIAGNOSIS1 This is an intra-articular fracture of the distal radius with an associated
subluxation of the carpus and wrist, which move in a volar or dorsal
direction.
2 The volar Barton’s fracture has a similar mechanism of injury to the Smith’s
fracture, and the intra-articular distal radius fracture is angulated in a
palmar direction.
3 The dorsal Barton’s fracture is caused by a fall onto the outstretched hand
with the wrist extended and forearm pronated. The axial load causes the
dorsa l rim of t he dista l radius to fracture wit h anterior displacement.
MANAGEMENT1 Refer the patient immediately to the orthopaedic team as this injury is
unstable and open reduction wit h interna l f i xation is required.
Radial styloid fracture
DIAGNOSIS
1 This is caused by a fall onto the outstretched hand causing an oblique intra-
articular fracture of the radial styloid. It used to be termed the ‘chauffeur’s
fracture’ when caused by an engine starting-handle kickback.
2 There is pain over the lateral aspect of the distal radius.
3 Displacement is usually slight, but look for an associated scapholunate
dissociation on X-ray.