Mohammed et al.

SpringerPlus (2016) 5:530

DOI 10.1186/s40064-016-2155-z

Open Access

RESEARCH

A comparative study infixation methods

ofmedial malleolus fractures betweentension
bands wiring andscrew fixation
AyyoubA.Mohammed1,2,3*, KhalidAhmedAbbas4 andAmmarSalahMawlood4

Abstract
Objectives: The aim of this study is to compare two methods of internal fixations of fractured medial malleolus
which are simple screw fixation and tension band wiring.
Patients and methods: Over 5years we grouped 20 patients with fractured medial malleolus into two groups of
operative treatments, group1 treated by malleolar screw fixation and group2 by tension band wiring. The patients
were with same age group, gender, fracture type, and etiology. We use statistical analysis for make a comparative
study between the two ways of surgical treatment.
Results: The mean time for radiologic bone union was 11.8weeks in group1 patients and 9.4weeks in group2
patients (P=0.03). No patients had any sign of fixation failure or Kirschner wires migration. According to the modified
ankle scoring system of Olerud and Molander, excellent and good results were achieved in 80% in group1 patients
and 90% in group2 patients (P=0.049).
Conclusions: Tension-band wiring may be better treatment option for internal fixation of medial malleolar fractures
than screw fixation.
Recommendations: From these findings we recommend a further randomized clinical trial of larger number of
cases and longer follow-up duration in order to regard tension-band wiring a better operative option for fixation of
medial malleolar fractures.
Keywords: Ankle, Screw, Tension band, Fracture
Background
The ankle is a close-fitting hinge of which the two parts
interlock like a mortise (the box formed by the distal ends
of the tibia and fibula) and tenon (the upwards projecting
talus). The articulations of this joint complex are primarily between the dome of the talus and the tibial plafond,
which forms highly congruent saddle-shaped weightbearing surfaces. The talus has a medial facet, which
articulates with the medial malleolus of the distal aspect
of the tibia, and a lateral facet, which articulates with the
lateral malleolus. Ankle fractures are among the most
common musculoskeletal injuries. These injuries span a
*Correspondence: [email protected]
3
Al-Anbar Orthopedic Training Center, AlAnbar, Iraq
Full list of author information is available at the end of the article

spectrum from simple closed fractures to complex open

injuries. As a result, the orthopedic management is varied and can range from nonoperative casting to staged
surgery with a primary focus on damage control procedures followed by definitive fixation. These fractures typically result from a low-energy indirect rotational force
in which the ankle is twisted & the talus tilts &/or rotate
forcefully in the mortise, causing a low-energy fracture of
one or both malleoli, with or without associated ligament
injuries, but can also present as a more complex, high
energy injury (Solomon etal. 2010).
Nondisplaced fractures of the medial malleolus usually can be treated with cast immobilization; however, in
individuals with high functional demands, internal fixation may be appropriate to hasten healing and rehabilitation. Displaced fractures of the medial malleolus should

2016 Mohammed etal. This article is distributed under the terms of the Creative Commons Attribution 4.0 International
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Mohammed et al. SpringerPlus (2016) 5:530

Page 2 of 6

be treated surgically because persistent displacement

allows the talus to tilt into varus (Michelson 2006).

Patients andmethods
From January 2010 to January 2015 at our Teaching Hospitals, we randomized 20 consecutive patients with displaced closed fractures of medial malleolus, which were
isolated medial malleolus fractures or part of bi-malleolar fractures. All were treated by open reduction and
internal fixation with either malleolar screw or with tension-band wiring and the choice of mode of fixation were
on alternate basis. They were then allocated to one of two
treatment groups:
Group1 (10 patients) had malleolar screw fixation.
Group2 (10 patients) had tension-band wiring.
The populations were similar in age group (median
37 years), gender, fracture type (Weber type B and C),
and aetiology (twisting injury, fall, or motor vehicle accident) (Table1).
The fractures were classified according to the Danis
Weber classification. We exclude those with vertical fractures of medial malleolus because these fractures usually
require horizontally directed screws and difficult to be
fixed internally by tension-band wiring (Pankovich 2002).
Inclusion criteria:
1. Patient age 1560years.
2. Patient of Weber type B&C.
3. Surgical treatment.
4. Follow up for 6months.
Exclusion criteria:
1. Age <15years.
2. Age >60years.
3. Patient of Weber type A.
Table1 Details of 20 patients with medial malleolar fractures
Group1 (malleolar
screw)

Group2 (tensionband)

Median age in years

37 (2450)

37 (2153)

Male:female

4:6

4:6

Right:left

5:5

6:4

Weber B:Weber C

7:3

7:3

Twisting

Fall

Motor cycle accident

Causes of the fracture

4. Patient diagnosed and treated by Doctors other than

the authors.
5. Follow up <6months.
6. Open fractures
7. Pathological fractures
8. Fracture with incomplete treatment by the department.
9. Incomplete follow up.
10. Insufficient clinical data of the case.
Preoperative planning

Preoperative evaluation includes assessment of general health and a thorough assessment of neurovascular
status of the lower extremity. Radiographic evaluation
includes anteroposterior, mortise, and lateral views of the
ankle. The surgery was performed before the ankle swells
up or when the swelling subsided, which was usually after
510days of elevation.
Surgical technique

All the patients in this study were operated upon under

general anesthesia. The patient was positioned supine and
an Esmarch or a pneumatic tourniquet was applied to the
mid thigh. After routine skin preparation and draping, we
made an anteromedial incision that began approximately
2cm proximal to the fracture line, extended distally and
slightly posteriorly, and ended approximately 2cm distal
to the tip of the medial malleolus. We prefer this incision
for two reasons: first, the tibialis posterior tendon and
its sheath are less likely to be damaged, and second, the
surgeon able to see the articular surfaces, especially the
anteromedial aspect of the joint, which permits accurate
alignment of the fracture. Handling the skin with care
and reflecting the flap intact with its underlying subcutaneous tissue. The blood supply to the skin of this area
is poor, and careful handling is necessary to prevent skin
sloughing. We protect the great saphenous vein and its
accompanying nerve. A small fold of periosteum commonly is interposed between the fracture surfaces. We
removed this fold from the fracture site with a curet or
periosteal elevator, exposing the small serrations of the
fracture. We debrided small, loose osseous or chondral
fragments; large osteochondral fragments were preserved. With a small bone-holding clamp, the displaced
malleolus was brought into normal position and, while
holding it there, internally fixed with either malleolar
screw or tension-band wiring.
In group1 patients a 3.2-mm hole was drilled in a
superior posterior direction while distal fragment was
held reduced with a pointed clamp or with two Kirschner wires bent to stay out of way as temporary fixation
devices. Length of hole was measured, and a malleolar
screw was inserted without tapping till it reached the

Mohammed et al. SpringerPlus (2016) 5:530

other cortex. Kirschner wires were removed after screw

was tightened. In two cases the fragments were large and
tend to rotate, so we used additional point of fixation (a
second screw or Kirschner wire).
In group2 patients the fracture was internally fixed with
two 2-mm smooth Kirschner wires drilled perpendicular to the fracture line. The Kirschner wires should be
parallel, and their ends were bent at 90 angles. This will
eventually prevent the figure-of-eight wire from slipping
over the exposed ends of the Kirschner wires. A stainless
steel 1.2-mm AO wire was passed through the previously
drilled hole and around the bent ends of the Kirschner
wires in a figure-of-eight configuration. The wire was
then tightened.
We were carefully inspected the interior of the joint,
particularly at the superomedial corner, to make sure that
Kirschner wires or the screw had not crossed the articular surfaces. In conditions were image intensifier was
available, we made roentgenograms to verify the position
of the screw or the Kirschner wires and any faulty insertion could be avoided. Screen control was used in 3 cases
only in our study. At the end of operation we deflated the
tourniquet, obtained haemostasis, and closed the wound
with interrupted suture. We avoided tight stitches to prevent necrosis of the skin edges. We applied thick padding
and a posterior plaster splint with the ankle in neutral
position.
After treatment

The ankle is immobilized in a posterior plaster splint

with the ankle in neutral position and elevated.
Postoperative X-ray was taken with anterior, lateral,
and mortise views.

Page 3 of 6

Table2 The modified ankle score ofOlerud andMolander

Parameter
Pain
None

25

Minor (weather-dependent)

20

During sports

15

During walking on smooth surfaces

Constant and severe

Stiffness
None

All the patients were reviewed at 1014 days, 6 weeks,

3, and 6months after operation. At each assessment we
perform a physical examination and X-ray was taken
soon after the operation, at 6 weeks, and during subsequent visits to assess radiological healing.
After 1014 days the stitches were removed and the
wound examined and any complication was reported
and treated accordingly. The posterior plaster splint was
changed and the patient was instructed to remove it
every day and to start range-of-motion exercises.
Weight bearing was restricted for 6weeks, after which
the splint discarded and partial weight bearing started.
Full weight bearing is allowed after 12weeks.
Evaluation

We evaluate all the patients clinically, radiologically, and

functionally using a modification of the scoring system
proposed by Olerud and Molander (1984) (Table2). The

10

In the morning

Constant

Swelling
None

10

Only in the evening

Constant

Stair-climbing
No problem

10

Impaired

Impossible

Sports
Normal

10

Impaired

Impossible

Supports
None

10

Tape or wrap

Stick or crutch

Daily activity & work

Unchanged level

25

Reduced

20

Change of job

10

Severely impaired

Follow up

Score

Total

0
100

scores for each component of this scale were assessed by

use of a questionnaire, in combination with clinical objective criteria. The scoring scale has a maximum of 100
points (>91 excellent results, 8190 good results, 7180
fair results, <70 poor results) (Laarhoven etal. 1996).
The continuous variables were analysed between
groups using Independent sample t test. P value of <0.05
was considered statistically significant.

Results
There were no significant differences between the two
groups in age (median 37 years), gender, fracture type
(Weber type B and C), and aetiology (twisting, fall, or
motor vehicle accident).
Review of postoperative radiographs confirmed
anatomic reduction with stable fixation in all twenty

Mohammed et al. SpringerPlus (2016) 5:530

patients. All the series of radiographs showed normal

fracture healing and no patient had malunion, nonunion,
or loss of reduction.
The mean time for radiologic bone union was
11.8 weeks (ranging from 8 to 18 weeks) in group1
patients and 9.4 weeks (ranging from 6 to 12 weeks) in
group2 patients (P=0.03) (Fig.1).
No patients had any sign of fixation failure or Kirschner
wires migration. According to the modified ankle scoring
system of Olerud and Molander (1984), 1 (10%) patient
in group1 and 2 (20 %) patients in group2 were excellent: good in 7 (70%) patients in group1 and 7 (70%) in
group2: fair in 1 (10%) patients in group1 and 1 (10%) in
group2: poor in 1 (10 %) patients in group1 and non in
group2 patients (Figs.2, 3).
Excellent and good results were achieved in 80 %
in group1 patients (Fig. 4) and 90 % in group2 patients
(Fig.5) (P=0.049).

Page 4 of 6

Fig.2 The scoring results for group1 patients

Discussion
Even though many reports of operative treatment
of medial malleolar fractures have been published,
Fig.3 The scoring results for group2 patients

Fig.1 Mean time of radiologic union

comparison of the reports is difficult largely because of

lack of uniformity in the subject material and in the criteria to assess the results.
According to the modified ankle scoring system of
Olerud and Molander (1984), the current study showed
that excellent and good results were achieved in 80% in
group1 patients (treated with malleolar screws) and 90%
in group2 patients (treated with tension-band wiring)
(the difference was significant P = 0.049). This agrees
with the results of Sang-Hanko and Young-Junpark who
was achieved excellent and good results in about 78 %
of cases treated with malleolar screws and 89% of cases
treated with tension-band wiring (Sang-Hanko and
Young-JunPark 2002).
In our study the mean time for radiologic bone union
was 11.8weeks (ranging from 8 to 18weeks) for group1
patients and 9.4weeks (ranging from 6 to 12weeks) for
group2 patients (significant difference P = 0.03). This
is similar to SK. Nurul Alam study that was reported a
meantime of 12weeks for malleolar screws and 9weeks
for tension-band wiring (Nurul Alam etal. 2007).
We have experienced only one case of delayed union
(5 %) out of 20 cases of the study and no non-union
developed. This case was a 50 years old female treated
with malleolar screw fixation and the fracture took
around 18weeks to unite. This result slightly differs from
the results of SK. Nuru Alam who was achieved 100 %

Mohammed et al. SpringerPlus (2016) 5:530

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Fig.4 X-ray of patient in group1 treated with malleolar screw (a preoperative AP view, b preoperative lateral view, c first postoperative day)

Fig.5 Pre- and post-operative X-rays of patient in group2 treated with tension-band wiring (a preoperative AP view, b preoperative lateral view, c
12weeks postoperative)

union rate in both groups without any case of delayed

union (Nurul Alam etal. 2007).
The low incidence of delayed union and non-union in
our study might be attributed to stable anatomic reduction and limited soft tissue stripping, or due to small
number of cases. Some authors reported loss of reduction
with the use of tension-band technique as a result of K.
wires become loose end and migrate proximally (Mack
and Szabo 2005). On the other hand many authors did
not agree with the frequency of this complication and
reported that with the proper surgical techniques, wire
migration was not a problem (Kinik and Mergen 1999).
In our study we did not see any wire migration or loss of
reduction. Tension-band fixation of the medial malleolar fractures has been described or referred to previously

by many authors (Muller et al. 2000; Finsen et al. 1989).

Ostrum and Litski recently demonstrated the biomechanics advantages of the tension-band over other fixation
techniques for medial malleolus. When resisting pronation forces and applying compression force tension-band
were four times stronger than malleolar screw (Ostrum
and Listsky 2008). This might explain the faster union rate
we were achieved in group2 patients (mean of 9.4weeks)
as compared with group1 patients (mean of 11.8weeks).
Rovinsky in his study showed that the tension-band is
more technically advantageous over other types of fixation for fixation of small fragment fracture of medial
malleolus and is not recommended for the fixation of vertical fracture (Rovinsky etal. 2000). We agree with these
results as in our study we fixed few vertical fractures with

Mohammed et al. SpringerPlus (2016) 5:530

horizontally directed malleolar screws but we excluded

them from the comparison groups. Screw fixation alone
may provide poor stability against torsion forces (Savage
et al. 2009; Kim et al. 2005). This may requires an additional point of fixation, which may be a second screw or a
Kirschner wire. Dr. Jones in his study disagrees with these
results and showed that single screw fixation had similar
results to double screw fixation (Jones 1997). In the current study we use additional point of fixation (second
screw and K wire) in two cases in which the fragment was
large and tend to rotate as screw fixation alone may provide poor stability against torsion forces.
Limitation of movements and swelling of the ankle are
usually the result of neglect in treatment of soft tissue.
Although better range of motion was noticed in group1
patients (80 %) as compared with group2 (70 %), it did
not reach significance (P = 0.628). This could be attributed to wide soft tissue dissection that was needed with
the use of tension-band. These results may show similarity with the results of SK. Nurul Alam who reported
in his study that the group treated with malleolar screw
showed better range of motion (Nurul Alam etal. 2007).
During surgical fixation of medial malleolar fractures
excessive pressure with bone clamps to hold the fracture reduction must be avoided to prevent crushing of
the fragment particularly if the bone is osteoporotic. The
fracture reduction instead can hold temporarily with
K wire. Careful and meticulous soft tissue handling is
important for prevention of postoperative wound complications, delayed union, and, joint stiffness. We did
not face any case of osteoarthritis during the follow-up
period. The reason could be explained by the fact that the
anatomic reduction was stable and no non-union or it
may be due to short follow-up period.

Conclusions
1. The tension-band wiring is more technically advantageous for small fragment fixation of medial malleolar
fractures.
2. The tension-band wiring may be more available and
its usage could translate into over all cost saving
when applied to the large number of ankle fractures
treated surgically in our country.
3. The faster radiological union which was achieved
with the use of tension-band wiring as compared
with malleolar screw could be added to the over all
advantages of using this technique.
Recommendations
These findings will have to be supported by a randomized
clinical trial of larger number of cases and longer followup duration before recommending the tension-band

Page 6 of 6

wiring over malleolar screw for fixation of medial malleolar fractures.

Authors contributions
AAM wrote and designed the manuscript, and checked the accuracy or
integrity of all parts of the work and propriety. KAA wrote the manuscript,
acquired the data, analyzed and interpreted the data. ASM acquired, analyzed,
interpreted the data and performed the statistical analysis. All authors read
and approved the final manuscript.
Author details
1
Department ofSurgery, College ofMedicine, University ofAnbar, AlAnbar,
Iraq. 2Al-Ramadi Teaching Hospital, AlRamadi, Iraq. 3Al-Anbar Orthopedic
Training Center, AlAnbar, Iraq. 4Al-Yarmook Teaching Hospital, Baghdad, Iraq.
Competing interests
The authors declare that they have no competing interests.
Ethical approval
Our research, has received approval by Anbar Medical College ethics
committee.
Informed consent
Informed consent was obtained from all individual participants included in
the study.
Received: 22 October 2015 Accepted: 12 April 2016

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