THE HAND SURGERY LANDSCAPE

Common Upper Extremity Fracture Eponyms:

A Look Into What They Really Mean
Ryan A. Caldwell, MD,* Peter L. Shorten, MD,* Nathan T. Morrell, MD*

Eponyms, whereas commonly used in hand surgery, are perhaps misused as often as they
are used correctly. Many commonly used eponyms, such as Colles fracture, Barton frac-
ture, Smith fracture, and Bennett fracture, were actually described decades before the
development of radiographs. The goal of this article is to revisit the original descriptions of
commonly used eponymous terms for distal radius and first metacarpal base fractures to
provide clarity and enhance understanding of what these eponyms actually mean. (J Hand
Surg Am. 2018;-(-):-e-. Copyright Ó 2018 by the American Society for Surgery of the
Hand. All rights reserved.)
Key words Colles fracture, Barton fracture, Smith fracture, Bennett fracture, Rolando fracture.

E
PONYMS ARE UBIQUITOUS IN MEDICINE, and their
use in orthopedics is as pervasive as in any
other field. Derived from the Greek words epi
and onyma, meaning upon and name, respectively,
eponyms are meant to serve 2 fundamental purposes:
(1) commemorate persons who have contributed
something of value; and (2) provide surrogate ter-
minology to represent a complex or specific disease
process, injury, or theory.1
Advances in our comprehension of pathoanatomy,
changes in technology, and the indefatigable influ-
ence of time seem to have weathered away the
nuances and details provided in the original descrip-
tion of many eponymous terms. Orthopedic surgeons
continue to use eponyms with regularity, assuming
that their interpretations of particular terms are
consistent with that of their peers. The presupposition
that users of eponyms have a grasp of the historical
From the *Department of Orthopaedics & Rehabilitation, University of Vermont, Burlington,
VT.
Received for publication January 1, 2018; accepted in revised form July 9, 2018.
No benefits in any form have been received or will be received related directly or
indirectly to the subject of this article.
Corresponding author: Nathan T. Morrell, MD, Department of Orthopaedics & Reha-
bilitation, University of Vermont, 192 Tilley Dr., South Burlington, VT 05403; e-mail:
Nathan.morrell@uvmhealth.org.
0363-5023/18/---0001$36.00/0
https://doi.org/10.1016/j.jhsa.2018.07.012
context from which the terms arose and an under-
standing of the original description is, unfortunately,
false.2,3
The purpose of this article is not to argue for or
against the use of eponyms in orthopedic surgery,
because there already exists a surfeit of impassioned
debate on the subject. Instead, it is to revisit the
original descriptions of commonly used eponymous
terms for distal radius and first metacarpal base
fractures, highlighting the fact that most of these
eponyms were actually developed decades before the
advent of the clinical radiograph (1896). In so doing,
we aim to provide clarity on the most common cur-
rent use of these terms as well as their original
definition and the historical context in which they
arose.
COLLES FRACTURE
Perhaps the most commonly used (or misused) upper
extremity eponym, Colles fracture, is typically
described as an extra-articular, dorsally angulated
fracture of the distal radius. Green’s Operative Hand
Surgery describes Colles fracture as “a distal radius
fracture with dorsal comminution, dorsal angulation,
dorsal displacement, radial shortening, and an asso-
ciated fracture of the ulnar styloid.”4 This description,
composed almost entirely of radiographic features,
references Colles original article5 (which predated
radiographs by about 80 years) as the sole source for

Ó 2018 ASSH r Published by Elsevier, Inc. All rights reserved. r 1

2 COMMON UPPER EXTREMITY FRACTURE EPONYMS
this definition. This definition, however, contrasts
starkly with the original description.
In 1814, Abraham Colles, working at the Royal
College of Surgeons in Dublin, described a fracture
of the distal radius, an injury that was previously
thought of as a radiocarpal dislocation. He
described the fracture as located “about an inch
and a half above the carpal extremity of the radius”
with a “considerable deformity” including dorsal
angulation of the hand and a visible “depression”
in the dorsal forearm.5 Any reduction, he warned,
would not be maintained, and “at the expiration of
a few weeks, that the deformity still exists in its
fullest extent.”5 He also specified that “the end of
the ulna admits of being readily moved backward
and forward.”5 His definition is clinically based
and necessarily lacks any radiographic description
such as loss of radial inclination or articular
involvement.
BARTON FRACTURE
In clinical practice, Barton fracture has been used to
denote a variety of dorsally and volarly displaced
intra-articular distal radius fractures. This has led
some to insist that there is “no such thing as a Bar-
ton’s fracture.”6 In reality, his description is one of
the clearest of all injuries described by eponyms.
In 1838, John Rhea Barton, working at Penn-
sylvania Hospital in Philadelphia, described a new
fracture pattern of the distal radius. Many previous
descriptions described similar injuries as frank dis-
locations (luxations). In contrast, Barton described
an injury that appeared not as a dislocation, but
rather as a “sub-luxation of the wrist, consequent to
a fracture through the articular surface of the carpal
extremity of the radius.”7 He goes on to describe the
mechanism:
In the act of falling, for example, the hand is thus
instinctively thrown out, and the force of the fall
is first met by the palm of the hand, which is
violently bent backward until the bones of the
wrist are driven against the dorsal edge of the
articulating surface of the radius, which, being
unable to resist, it gives way. A fragment
[emphasis added] is thus broken off from the
margin of the articular surface of this bone.
The moment the cartilaginous extremity of the
radius is deprived of its concave form, the
united force of the carpal and digital flexors is
exerted to create a complete luxation; but as the
ligaments are only stretched, or but partially
torn, this cannot take place.7
J Hand Surg Am.
Barton went on to clarify that, although he
considered the dorsal variety much more common,
[i]t sometimes happens also, although rarely,
that the fracture of a similar character.occurs
on the palmar side of the radius, from the
application of force to the back of the hand
while it is bent forward to its ultimate degree.
thus reversing the deformity of the arm.7
Thus, Barton actually clarified what is commonly
confused today: a “volar Barton fracture” is indeed
a type of Barton fracture, even though it is often
classified as a “type II Smith fracture.”
SMITH FRACTURE
In 1847, Robert Williams Smith, while working at
Trinity College in Dublin, first described the fracture
that bears his name in his lengthy tome, A Treatise on
Fractures in the Vicinity of Joints and on Certain
Forms of Accidental and Congenital Dislocations.8
He was meticulous to a fault but it was this that
made him a renowned physician. Abraham Colles
requested that Smith perform his autopsy because of
his famous attention to detail. A portion of his
description follows:
This is an injury of exceedingly rare occurrence,
and one which presents characters closely
resembling those of dislocation of the carpus
forwards. It generally occurs in consequence of
a fall upon the back of the hand, and the situ-
ation of the fracture is from half an inch to an
inch above the articulation; it is accompanied by
great deformity, the principal features of which
are a dorsal and a palmar tumour, and a striking
projection of the head of the ulna at the poste-
rior and inner part of the forearm; the dorsal
tumour occupies the entire breadth of the fore-
arm, but is most conspicuous internally, where
it is constituted by the lower extremity of the
ulna displaced backwards.8
Like Colles and Barton, Smith did not have the
advantage of x-rays for medical uses, so he regret-
fully conveyed:
I cannot speak with accuracy as to the
anatomical characters of the injury, having
never had an opportunity of examining after
death the skeleton of the forearm. but still I
feel satisfied that the injury. is a fracture of the
lower end of the radius, with displacement of
the lower fragment along with the carpus for-
wards, and of the head of the ulna backwards.8
r Vol. -, - 2018
 COMMON UPPER EXTREMITY FRACTURE EPONYMS
Smith fracture was largely absent from the ortho-
pedic literature for the better part of a century. That
changed when F. Brian Thomas published his article,
“Reduction of Smith’s Fracture” in 1957, wherein he
notes, “no attempt appears to have been made to
classify the different varieties of Smith’s fracture” and
goes on to define three types that are differentiated
radiographically.9 Thomas’s description of a type II
Smith fracture—“an anterior marginal fracture of the
lower articular end of the radius, with forward and
proximal dislocation of the entire carpus”—is, in fact, a
volar Barton fracture, as described by Barton himself.
This redundancy is confusing, but has nonetheless
persisted in the literature. Green’s Operative Hand
Surgery defines Smith fractures as “fractures of the
distal radius with volar displacement, classified as
Smith’s types I, II and III,” and later says that a
Barton fracture “may be either dorsal or volar, and
may also be classified as a Smith type II variant.”4
In reality, Smith fracture is best described as extra-
articular, considering that he speaks of the displace-
ment of a singular “distal fragment along with the
carpus forward.”9 In attempting to classify Smith
fractures into subtypes, Thomas wrongly extended
the definition to include intra-articular fractures (volar
Barton fractures), which is a distinctive fracture
pattern with a different treatment algorithm. As Dean
Louis suggests, “It is unfortunate that Thomas chose
to disregard [Smith’s original] description, as the
treatment of this fracture is relatively simple when the
term ‘Smith’s Fracture’ is properly used.”10 Smith
fracture can usually be managed with closed reduc-
tion and immobilization, whereas a volar Barton
fracture often requires open reduction and internal
fixation to restore articular congruity. This highlights
an important motivation of this article: proper use of
eponyms matters.
BENNETT AND ROLANDO FRACTURES
A partial articular fracture at the volar-ulnar base of
the first metacarpal is commonly called a Bennett
fracture. This has remained consistent with the orig-
inal description. In 1882, Edward Hallaran Bennett,
also from Trinity College in Dublin, described the
fracture, stating that the fracture detaches “the greater
part of the articular facette with that piece of the bone
supporting it, which projects into the palm” and that
“the dorsal surface of the bone is free from any
implication in the fracture.”11,12
The term Rolando fracture is also commonly used,
although with less consistency and less fidelity to the
original meaning. Green’s Operative Hand Surgery
J Hand Surg Am.
3
summarizes modern usage of the term as “any
comminuted articular fracture of the base of the thumb
metacarpal.”4 This is not exactly what the Italian sur-
geon described in 1910. Silvio Rolando knew what a
Bennett fracture was, although recognized a different
pattern that “[could not] be distinguished from a
Bennett’s fracture without radiographic studies.”13,14
He wrote of “a Y shaped fracture.divided into 3
fragments of which 2 parallel the base, dorsal and
palmar respectively, and the other corresponds to the
body of the bone.”13,14 The volar process fractures
obliquely in the pattern described by Bennett. How-
ever, if the metacarpal continues to be forcefully
compressed in the same manner, a fracture will also
occur in “the more resistant joint process, that is to say,
the dorsal process.”13,14 It is, therefore, this fracture
pattern that is properly described as a Rolando fracture:
a Y-shaped fracture at the base of the first metacarpal,
with 2 articular fragments, 1 dorsal and 1 volar. In
describing this fracture that later carried his name,
Rolando became the third Milanese surgeon to have a
fracture named after him, following in the footsteps of
the famed Giovanni Battista Monteggia and Ricardo
Galeazzi.15
DISCUSSION
Critics of eponyms argue their use should cease for a
multitude of reasons, not the least of which is the fact
that inconsistency in the use of an eponym creates
confusion based on differing meanings of the term.
Mark Ravitch encapsulated the frustration of medical
historians when he wrote, “Given an eponym one
may be sure (1) that the man so honored was not the
first to describe the disease, the operation, or the in-
strument, or (2) that he misunderstood the situation,
or (3) that he is generally misquoted, or (4) that (1),
(2), and (3) are all simultaneously true.”16
Some have advocated the complete abolition of
eponyms in favor of more precise language.17 How-
ever, as several authors have pointed out, eponyms
serve as a reminder of our professional heritage and
of the great minds who helped shape the history of
orthopedic surgery.18,19 A less drastic remedy, and
one that preserves the history and convenience
embedded in this nomenclature, is to clarify the terms
as they were first described and how they are
commonly used. Such is our goal.
Eponyms serve as a valuable communication
tool in orthopedic surgery, a shorthand that enables
efficient communication of complex ideas. An un-
derstanding of the history and original meaning of
eponyms, therefore, enhances a surgeon’s ability to
r Vol. -, - 2018
4 COMMON UPPER EXTREMITY FRACTURE EPONYMS
converse with peers as well as his or her appreciation
of the history of orthopedics.
REFERENCES
1. Garfield E. What’s in a name? The eponymic route to immortality.
Essays Inf Sci. 1983;6:384e395.
2. Somford MP, Nieuwe Weme RA, van Dijk CN, IJpma FF,
Eygendaal D. Are eponyms used correctly or not? A literature review
with a focus on shoulder and elbow surgery. Evid Based Med.
2016;21(5):163e171.
3. Waseem M, Khan M, Hussain N, Giannoudia PV, Fischer J,
Smith RM. Eponyms: errors in clinical practice and scientific writing.
Acta Orthop Belg. 2005;71(1):1e8.
4. Wolfe SW, Pederson WC, Kozin SH, eds. Green’s Operative Hand
Surgery. 6th ed. Philadelphia: Elsevier; 2011.
5. Colles A. On the fracture of the carpal extremity of the radius. Edinb
Med Surg J. 1814;10:182e186.
6. Helferich H. Atlas and Epitome of Traumatic Fractures and Dislo-
cations. 5th ed. Philadelphia: WB Saunders; 1902.
7. Barton JR. Views and treatment of an important injury to the wrist.
The Medical Examiner (Philadelphia, Pa). 1838;1:365e368.
8. Smith R. A Treatise on Fractures in the Vicinity of Joints and on
Certain Forms of Accidental and Congenital Dislocations. Dublin:
Hodges and Smith; 1847.
J Hand Surg Am.
9. Thomas FB. Reduction of Smith’s fracture. J Bone Joint Surg Br.
1957;39-B(3):463e470.
10. Louis DS. Barton’s and Smith’s fractures. Hand Clin. 1988;4(3):
399e402.
11. Bennett EH. Fractures of the metacarpal bones. Dublin J Med Sci.
1882;73:72e75.
12. Bennett EH. On fracture of the metacarpal bone of the thumb.
Br Med J. 1886;2(1331):12e13.
13. Rolando S. Fracture of the base of the first metacarpal and principally
on a variation not yet been described [in French]. Presse Med.
1910;33:303e304.
14. Rolando S. Fracture of the base of the first metacarpal and a variation
that has not yet been described: 1910. (Translated by Roy A. Meals).
Clin Orthop Relat Res. 2006;445:15e18.
15. Mahoney M, Marsland D, Garagnani L, Sauve P. Rolando and his
fracture. Trauma. 2015;17(1):24e28.
16. Ravitch MM. Dupuytren’s invention of the Mikulicz enterotome
with a note on eponyms. Perspect Biol Med. 1979;22(2 Pt 1):
170e184.
17. Woywodt A, Matteson E. Should eponyms be abandoned? Yes. BMJ.
2007;335(7617):424.
18. Whitworth JA. Should eponyms be abandoned? No. BMJ.
2007;335(7617):425.
19. Hunter TB, Peltier LF, Lund PJ. Radiologic history exhibit.
Musculoskeletal eponyms: who are those guys? Radiographics.
2000;20(3):819e836.
r Vol. -, - 2018