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What is the diagnosis?

Reverse Barton fracture (also known as volar type Barton fracture) is an intra-articular distal radial fracture with volar displacement and associated dislocation of the radiocarpal joint. Reverse Barton fracture is a type of Smith fracture (volar displaced distal radial fracture with no intra-articular involvement) that is an intra-articular fracture.  The differential diagnosis includes Smith fracture, Colles fracture, die-punch fracture (fracture of articular surface of radius w/ depression of lunate facet), and Chauffeur's fracture (avulsion fracture of radial styloid) [1].

What is the mechanism of injury?

What physical exam findings are expected?

Acute wrist pain with swelling and deformity with volar fullness/swelling. Flexion and extension of wrist limited by pain. 

Which imaging modalities can be used?

AP and lateral radiographs. Oblique view is also helpful. 

CT scan w/o contrast for surgical planning if complex fracture and to help determine if more ulnar or radial sided comminution.  MRI can be used outpatient to evaluate for ligamentous injuries [1]. 

Image 2. Illustrations of reverse (volar) Barton fracture, dorsal Barton fracture, Smith fracture, and Chauffeur fracture:  Case courtesy of F Gaillard, Radiopaedia.org, rID:2059

What is the management in the ED/when should you consult orthopedics?

Ensure normal neurovascular status and provide pain management. Depending on institutional preference, urgently consult orthopedics for reduction and fixation due to intra-articular involvement. If possible, reduce fracture fragment and splint in extension if significantly displaced or evidence of neurovascular compromise while awaiting orthopedic evaluation. 

• Pearl: Splint with forearm supinated and wrist in neutral. Either volar short arm or sugar-tong splint.