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Year : 2017  |  Volume : 9  |  Issue : 2  |  Page : 78-80

Fixation of choice for transverse fractures of medial malleolus of ankle

Department of Orthopaedics, Maharajah's Institute of Medical Sciences, Vizianagaram, Andhra Pradesh, India

Date of Web Publication14-Dec-2017

Correspondence Address:
Dr. Meesala Vijayabhushanam
Maharajah's Institute of Medical Sciences, Nellimarla, Vizianagaram - 535 217, Andhra Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jotr.jotr_37_17

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Background: Fixation of choice for transverse fractures of medial malleoli has always been a debate as most of the times the fragment is too small to achieve placement of two screw heads. Absolute stability of the medial malleolar fragment with a single screw is difficult in comminuted and osteoporotic fragments. Materials and Methods: This is a prospective study conducted in our centre from November 2013 to May 2017 in 97 cases. Results: There was a failure of 3 cases of fixation with single screw out of 16 cases of primary fixation with single screw, contributing to 18.75% of cases of failure with primary single screw fixation. Conclusion: We advise to fix two screws of 4.0mm cannulated cancellous screws crossing the fracture site if the fragment is large enough to support screw heads. If the fragments are small we prefer to do a tension band wiring with two K-wires and a transverse screw which we had done in 55.7% of cases as a primary procedure. All three failure cases in our series achieved union with tension band wiring.

Keywords: Bioabsorbable screws, cannulated cancellous screws, comminuted fracture, medial malleoli, osteoporotic fracture, tension band wiring

How to cite this article:
Appalaraju S, Vijayabhushanam M. Fixation of choice for transverse fractures of medial malleolus of ankle. J Orthop Traumatol Rehabil 2017;9:78-80

How to cite this URL:
Appalaraju S, Vijayabhushanam M. Fixation of choice for transverse fractures of medial malleolus of ankle. J Orthop Traumatol Rehabil [serial online] 2017 [cited 2021 Feb 25];9:78-80. Available from: https://www.jotr.in/text.asp?2017/9/2/78/220769

  Introduction Top

Open reduction and internal fixation of transverse fracture of medial malleolus fragment to tibia can be done with various devices as operation is imperative.[1],[2],[3] The hardware devices include cancellous screws, K-wires, tension band, bioabsorbable screws, or a combination of all the above.[4],[5],[6],[7] The failure of a fixation device can be due to the improper support of fractured bone, support at a single point of fixation, shortening and rotation of malleoli and comminution.[5] This failure is more if the fragment of medial malleolus is small or osteoporotic and AO-ASIF recommends tension band wiring for those medial malleolar fragments as screw fixation is unacceptable.[5]

The purpose of the study is to evaluate the reasons for the failure of fracture fixation of medial malleoli and to evaluate the choice of fixation for the troublesome small osteoporotic medial malleolar fragments.

  Materials and Methods Top

This study was done in Maharajah's Institute of Medical Sciences, Nellimarla, by the two authors from November 2013 to May 2017. All transverse fractures of medial malleoli are included in the study, i.e., (simple transverse fracture, bimalleolar, and trimalleolar fractures).

Total number of cases observed is 97. Out of which, 56 are males and 41 are female patients.

Operative procedure

The surgery is performed in the supine position with tourniquet control under image guidance. The medial malleolus is approached through a gently curved anteromedial incision. The dissection of skin and subcutaneous tissue is done carefully to prevent saphenous vein and nerve. Dissection is carried out sharply to the bone, and the interposed periosteum is elevated approximately 1 mm on either side of fracture. Through the fracture site, the joint is irrigated to remove debris and fracture hematoma, occasionally the tendon of tibialis posterior obstructs reduction, and the tendon needs to be retracted to help reduction. The reduction is held with a pointed reduction clamp and fixed temporarily with a small diameter K-wire and fixed with either

  1. Two 4.0 mm partially threaded cancellous screws if the fragment is small; only one 4.0 mm partially threaded cancellous screw is used. The screws are started near the tip of malleoli and directed perpendicular to fracture site without engaging opposite cortex but the thread needs to cross the fracture site or
  2. Tension band wire around two parallel K-wires; the proximal end of stainless steel wires is placed through a drill hole around a horizontally placed screw with or without washer [Figure 1] and [Figure 2].
Figure 1: Fixation of fracture fragment with 2 K-wires

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Figure 2: Intraoperative tension band wiring of medial malleolus

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  Results Top

Among the 97 patients, 27 patients underwent fixation with two cancellous screws, primary tension band wiring done in 54 cases, and 16 patients underwent fixation with one 4 mm cancellous screw. There were 3 cases of failure of fixation and all three cases of failed fixation occurred with fixation of single screw [Figure 3], especially when an attempt to keep smaller incision was made or in the presence of comminution. All three cases are revised with a tension band wiring without any requirement of additional bone graft. There is a failure of 18.75% in cases of fixation with single screw fixation of medial malleoli. Of the three cases, one was a failed attempt for percutaneous screw fixation in the hope for soft-tissue preservation and the second one was a comminuted medial malleolar fragment while the third failure was because of trimalleolar fracture. In all the three cases, the fracture united after changing the single screw implant to tension band wiring.
Figure 3: Failed medial malleolar fixation in trimalleolar fracture in an attempt to have minimal skin incision

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  Discussion Top

Tension band wiring of medial malleolus around two K-wires and a horizontally placed screw has shown greater strength than the conventional two partially threaded cancellous screws and resists bending forces responsible for fracture.[8],[9] Tension band wiring has the disadvantage of slightly longer duration of fixation as it requires proximal dissection and horizontal screw fixation and possible soft-tissue irritation of tibialis posterior and implant prominence, while most authors like Kanakis et al.[10] suggest tension band wiring regularly for all cases. Most authors reserve it for small and/or osteoporotic fragment.[1],[3],[9],[11],[12] Our results also suggest that the fixation of tension band to be reserved for small and/or osteoporotic fragments as suggested by multiple authors like Hughes J, Georgiadis GM, White DB, and Trafton PG.

  Conclusion Top

The authors opine not to attempt percutaneous screw fixation in the hope of respect for soft tissue as the chances of slipping of reduction and interposition of periosteum are high approximately in 18.75% of cases and to fix the small and osteoporotic fragment of medial malleolus with tension band wiring [Figure 4] and [Figure 5]. Tension band wiring has a problem of prominent hardware and irritation of soft tissues, so we advise to use two cannulated partially threaded cancellous screws with threads crossing fracture site whenever the fragment is large enough to support the screw heads and to revise failed fixation with tension band wiring. In our series, 55.7% had small fragments with difficulty to support two screw heads, so we had to do tension band wiring in them as a primary procedure.
Figure 4: Preoperative comminuted medial malleolus fracture

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Figure 5: Postoperative X-ray showing good reduction with tension band wiring

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Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Hughes J. The medial malleolus in ankle fractures. Orthop Clin North Am 1980;11:649-60.  Back to cited text no. 1
Weber BG, Colton C. Malleolar fractures. In: Mueller ME, Allgower M, Schneider R, Willenegger H, editors. Manual of Internal Fixation: Techniques Recommended by the AO-ASIF Group. 3rd ed. New York, NY: Springer-Verlag; 1991. p. 595-612.  Back to cited text no. 2
Georgiadis GM, White DB. Modified tension band wiring of medial malleolar ankle fractures. Foot Ankle Int 1995;16:64-8.  Back to cited text no. 3
Castro MD. Insufficiency fractures after total ankle replacement. Tech Foot Ankle Surg 2007;6:15.  Back to cited text no. 4
Vander Griend RA, Savoie FH, Hughes JL. Fractures of the ankle. In: Rockwood CA Jr., Green DP, Bucholz RW, editors. Rockwood and Green's Fractures in Adults. Philadelphia: J.B. Lippincott Company; 1991. p. 1983-2001.  Back to cited text no. 5
Rovinsky D, Haskell A, Liu Q, Paiement GD, Robinovitch S. Evaluation of a new method of small fragment fixation in a medial malleolus fracture model. J Orthop Trauma 2000;14:420-5.  Back to cited text no. 6
Bucholz RW, Henry S, Henley MB. Fixation with bioabsorbable screws for the treatment of fractures of the ankle. J Bone Joint Surg Am 1994;76:319-24.  Back to cited text no. 7
Johnson BA, Fallat LM. Comparison of tension band wire and cancellous bone screw fixation for medial malleolar fractures. J Foot Ankle Surg 1997;36:284-9.  Back to cited text no. 8
Ostrum RF, Litsky AS. Tension band fixation of medial malleolus fractures. J Orthop Trauma 1992;6:464-8.  Back to cited text no. 9
Kanakis TE, Papadakis E, Orfanos A, Andreadakis A, Xylouris E. Figure eight tension band in the treatment of fractures and pseudarthroses of the medial malleolus. Injury 1990;21:393-7.  Back to cited text no. 10
Trafton PG. Fractures and soft tissue injuries of the ankle. In: Staff WS, editor. Skeletal Trauma. Philadelphia: W.B. Saunders; 1992. p. 1871-956.  Back to cited text no. 11
Skie MC, Ebraheim NA, Woldenberg L, Randall K. Fracture of the anterior colliculus. J Trauma 1995;38:642-7.  Back to cited text no. 12


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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