INSTRUCTIONAL REVIEW

 
Medial malleolar fractures
CURRENT TREATMENT CONCEPTS

The medial malleolus, once believed to be the primary stabilizer of the ankle, has been the
topic of conflicting clinical and biomechanical data for many decades. Despite the relevant
T. H. Carter, surgical anatomy being understood for almost 40 years, the optimal treatment of medial
A. D. Duckworth, malleolar fractures remains unclear, whether the injury occurs in isolation or as part of an
T. O. White unstable bi- or trimalleolar fracture configuration. Traditional teaching recommends open
reduction and fixation of medial malleolar fractures that are part of an unstable injury.
From Edinburgh However, there is recent evidence to suggest that nonoperative management of well-
Orthopaedic Trauma, reduced fractures may result in equivalent outcomes, but without the morbidity associated
Edinburgh, United with surgery. This review gives an update on the relevant anatomy and classification
Kingdom systems for medial malleolar fractures and an overview of the current literature regarding
their management, including surgical approaches and the choice of implants.
Cite this article: Bone Joint J 2019;101-B:512–521.

The last decade has witnessed an exponential surgeons will have, understandably, not thought
increase in the number of publications dealing with to question their approach to the management of
foot and ankle trauma, in particular, trauma involv- medial malleolar fractures. With improvements in
ing the posterior malleolus and syndesmosis.1 The technology and a desire to reduce the complica-
medial malleolus was universally accepted as the tions of surgery, the medial malleolus is regaining
primary ankle stabilizer until 1977, when Yablon attention.7,8 This review provides an update on the
et al2 published a landmark study concluding that it relevant surgical anatomy and classification of the
is, in fact, the fibula that reliably guides and main- fractures, with an overview of the current literature
tains talar reduction. The significance of the medial on the management of medial malleolar fractures.
malleolus and supporting ligamentous structures
has since been the subject of much clinical and Clinical anatomy
biomechanical debate, with conflicting results. The The surgically important anatomy of the medial
findings of Yablon et al2 were swiftly supported by malleolus and associated ligamentous complex was
Svend-Hansen et al,3 who reported that isolated well described by Pankovich and Shivaram in 19799
medial malleolar fixation in a bimalleolar injury following cadaveric studies. Before this, attempts to
resulted in poor long-term outcomes and post- define the anatomy and associated ligaments had
traumatic osteoarthritis in most patients (55%). been inconsistent and non-reproducible. The medial
Pettrone et al4 recorded improved outcomes with malleolus arises from the distal tibia as it termi-
fixation of both malleoli compared with isolated nates in a pyramidal process with a convex smooth
 T. H. Carter, BSc(Hons),
MBChB, MRCS(Ed), Speciality
medial fixation in bimalleolar injuries, in a series medial surface felt subcutaneously, and a hyaline
Registrar in Orthopaedics, of 146 ankle fractures. Conversely, Earll et al5 cartilage-lined concave articular surface. The ante-
Trauma Research Fellow examined tibiotalar loading in 15 normal cadaveric rior process, commonly referred to as the anterior
  A. D. Duckworth,MSc, PhD,
FRCSEd(Tr&Orth), Consultant ankles and concluded that sectioning the tibiocal- colliculus (Latin for ‘mound’), extends distally
Orthopaedic Trauma Surgeon caneal division of the superficial deltoid ligament and is roughened for the attachment of the anterior
  T. O. White, MD,
FRCSEd(Tr&Orth), Consultant (SDL) in isolation increased tibiotalar contact pres- fibres of the SDL. The intercollicular groove sepa-
Orthopaedic Trauma Surgeon sures by 30%, although this structure is seldom rates the anterior colliculus from the broader pos-
Edinburgh Orthopaedic
Trauma, Royal Infirmary of
repaired in clinical practice. A recent cadaveric terior colliculus, serving as an attachment for the
Edinburgh, Edinburgh, UK. biomechanical study by Lareau et al6 noted a posterior talotibial component of the deep deltoid
Correspondence should be
comparable decrease in medial tibiotalar contact ligament (DDL). The remaining components of the
sent to T. H. Carter; email: pressures of 27.8% following screw fixation of DDL originate from the posterior colliculus itself.
[email protected] an isolated medial malleolar osteotomy compared Together with the medial malleolus, the divi-
©2019 The British Editorial with non-fixation. An association between these sions of the deltoid ligament are collectively
Society of Bone & Joint Surgery
doi:10.1302/0301-620X.101B5.
biomechanical findings and the outcome in patients referred to as the medial malleolus osteoligamen-
BJJ-2019-0070 $2.00 has not been confirmed. tous complex (MMOLC).10 The SDL has three
Bone Joint J
Having familiarized themselves with one or components: the naviculotibial, calcaneotibial,
2019;101-B:512–521. two conventional techniques of fixation, many and superficial talotibial ligaments. The stronger
512 THE BONE & JOINT JOURNAL
 Medial malleolar fractures513

Fig. 1a Fig. 1b Fig. 1c

C
B

Fig. 1d Fig. 1e

a) to d) Radiological examples for each Herscovici14 type of medial malleolar fracture. e) An illustration of the classification.

DDL comprises the deep anterior talotibial ligament and the a supracollicular fracture (vertical, oblique, or transverse) with
deep posterior talotibial ligament, which is the strongest and an intact deltoid ligament; and 6) an avulsion ‘chip’ fracture
thickest ligament of the MMOLC. The tibialis posterior ten- considered as a sprain fracture of the SDL.
don lies within a deep fibrocartilage-lined groove and passes
intimately around the posterior colliculus, providing additional Classification of the fractures
stability to this zone of the malleolus. Combining the bony and Isolated fractures of the medial malleolus occur in only about
ligamentous anatomy, Pankovich and Shivaram11 proposed six 7% of fractures involving the ankle, although they are three
clinical patterns of injury, with varying degrees of instability times more common in combination with a lateral malleolar
determined by the location of the fracture and the ligamen- fracture (20%).12,13 Herscovici et al14 described a modification
tous disruption: 1) rupture of both the SDL and DDL with no of the Müller classification system,15 simplifying it into four
associated fracture; 2) an isolated fracture of the anterior col- distinct fractures based on the anteroposterior (AP) radiograph:
liculus with no medial instability; 3) a fracture of the anterior type-A, avulsion fractures, occur at the tip of the malleolus;
colliculus with rupture of the deep posterior talotibial ligament, type-B fractures occur between the tip and the plafond; type-C
resulting in medial instability; 4) a fracture of the posterior col- fractures occur at the level of the plafond; and type-D frac-
liculus with or without a fracture of the anterior colliculus; 5) tures extend in an oblique-vertical direction from the plafond

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514 T. H. Carter, A. D. Duckworth, T. O. White 

Hanhisuanto et al21 compared the outcome of 46 patients with

an isolated medial malleolar fracture treated conservatively
with 60 patients who were treated operatively using either fix-
ation with lag screws (57), Kirschner (K-)wire with a single
screw (SS) (n = 1), K-wires alone (n = 1), or a tension band
wire (TBW) (n = 1).21 Those whose fracture was displaced by
≤ 2 mm were treated conservatively and those with more dis-
placement or evidence of instability of the mortise underwent
surgery. The mean Olerud–Molander Ankle Score (OMAS),24
Foot and Ankle Outcome Score (FAOS),25 and visual analogue
scale (VAS) pain score were comparable in the two groups.
However, this study was limited by a greater initial displace-
ment in the operative cohort, as this may have signified a more
severe underlying chondral injury. This study also lacks long-
term radiological follow-up, and the rate of union in the two
groups was not determined. However, reassuringly, satisfactory
Fig. 2a Fig. 2b patient-reported outcomes would suggest that any asympto-
matic nonunions, if present, would probably not require further
a) Anteroposterior radiograph of a 27-year-old male patient with an intervention. Despite these limitations, this study provided sup-
isolated medial malleolar fracture without proximal fibular involvement.
port for the nonoperative management of a well-reduced medial
b) Clinical and radiological union after six weeks of weight-bearing in a
removable orthosis. malleolar fracture with ≤ 2 mm displacement. An example of
successful nonoperative management from the authors’ institu-
(Fig. 1). This simplistic system has been adopted in much of tion (Royal Infirmary of Edinburgh, Edinburgh, United King-
the recent literature,16-23 but as it is based only on AP imaging dom) is shown in Figure 2.
without considering the morphology of the fracture seen on a Stress fractures. Isolated stress fractures of the medial malleo-
lateral radiograph or CT, some have questioned its intra- and lus are rare, with a reported incidence of between 0.6% and 4%
interobserver reliability. of all stress fractures of the lower limb. Most affect young, male,
Aitken et al12 studied the AP radiographs of 130 patients high-demand athletes.26 They may not initially be evident on plain
with medial malleolar fractures. Four blinded trauma surgeons radiographs and further imaging, including CT, MRI, or bone
examined these on two occasions separated by a six-week inter- scan, may be required to make the diagnosis. There is typically
val, classifying fractures according to the Herscovici system. a vertically orientated fracture, possibly resulting from repetitive
Despite 18% of fractures being deemed ‘unclassifiable’, they loading of the foot in an adducted position.27 Two recent reviews
reported the system to be substantially reproducible (k = 0.64) by Caesar et al26 and Irion et al28 included a small number of
and moderately reliable (k = 0.54). Type-C fractures had the low-quality studies. Although good outcomes and a high rate of
lowest intra- and interobserver agreement due to the variation union (97%) can be expected with nonoperative management for
in obliquity of the fracture line, which, if originating below minor undisplaced fractures, the authors suggested some relative
the plafond, could easily be interpreted as a type-B fracture. indications for surgery including: 1) high level of competition; 2)
Given the difficulties with interpreting or indeed identifying a close proximity to competition; 3) evidence of fracture on plain
medial malleolar fracture on a lateral radiograph, coupled with radiographs; and 4) displacement of the fracture. Given the low
the associated radiation, costs, and preoperative delays of CT incidence and significant variation in the performance level of
scanning, this system appears to be the current standard that athletes, the management of stress fractures of the medial malle-
will probably undergo modifications with the passage of time. olus should be considered on an individual basis.
‘Unstable’ displaced fractures. The recent literature involv-
Nonoperative management ing the medial malleolus reveals conflicting opinions about
Isolated fractures. Herscovici et al14 assessed outcome follow- the ideal management of an unstable injury. The nonopera-
ing the nonoperative management of isolated medial malleolar tive management of medial malleolar fractures following sat-
fractures in 57 patients, with a mean age of 40 years (17 to 69), isfactory fibular stabilization was the focus of a randomized
all of whom were managed in a short-leg non-weight-bearing controlled trial conducted in Norway by Hoelsbrekken et al.7
cast for six weeks. At a mean follow-up of 35.6 months (26 to They prospectively reviewed 82 patients with unstable bi- and
86), they reported a rate of nonunion of 4%, two patients, both trimalleolar fractures, who were randomized to be treated either
of whom had type-C fractures that required fixation with bone with fixation (37) or non-fixation (45) of an associated well-re-
grafting. The outcome according to the American Orthopaedic duced medial malleolar fracture following fixation of the lat-
Foot and Ankle Society Score (AOFAS) was excellent, with eral malleolus. Four patients (9%) in the non-fixation group
a mean of 89.8 (69 to 100). There were no reports of medial developed a nonunion, but none required further surgery. The
instability, malalignment of the mortise, or post-traumatic mean OMAS, AOFAS, and VAS pain scores were comparable
degenerative changes. The authors concluded that conservative between the groups. The rate of malunion (11% vs 7%) and
management of isolated medial fractures was safe, regardless of radiological evidence of osteoarthritis (8% vs 2%) was higher
the initial displacement. in the fixation group, with the short follow-up available (mean,

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 Medial malleolar fractures515

Fig. 3a Fig. 3b Fig. 3c

Anteroposterior radiographs of a 59-year-old female patient with a) a closed bimalleolar fracture. b) Following fibular fixation, the medial malleolus
reduced anatomically. c) Maintenance of a satisfactory radiological outcome one year following surgery.

42.5 months (24 to 72)). These results may support a decision patients. Eight weeks postoperatively, the rate of union in the
to leave a well-reduced medial malleolar fracture without fixa- open reduction group was 92.4% compared with 71.9% in the
tion (Fig. 3) and may be particularly relevant in patients with a percutaneous group (p < 0.001). The authors attributed this
medial soft tissue injury, fracture blisters, or open wounds. This difference to the interposed periosteal flap, which becomes
concept is supported by encouraging results from a recent ret- trapped during the rotational aspect of the injury and is clearly
rospective study, which demonstrated positive patient reported not retrieved during percutaneous fixation. They failed to
outcome in 54 patients with a nonoperatively managed medial report rates of infection or patient-reported outcome in either
malleolar fracture following intramedullary fibular stabilisa- group. There is also likely to have been selection bias given
tion.29 Further prospective data in this area are awaited.30 the retrospective design and disparity in the size of the groups.
Radiological follow-up was not performed beyond eight
Operative management weeks, preventing comparison of nonunion rates. A purely
Surgical approach and reduction of the fracture. Tradition- percutaneous approach has theoretical advantages but relies on
ally, medial malleolar fractures have been fixed through an anter- an acceptable closed reduction and would not be suitable for
omedial approach beginning just proximal to the fracture and younger patients with grossly displaced fractures or impaction
extending distally to cross the anterior one-third of the malleo- of the medial dome.
lus, terminating 2 cm distal to its tip. This approach places the Many argue that it is the quality of the articular reduction
great saphenous vein and nerve vulnerable to iatrogenic injury. that affects outcome. The arthroscopic assessment of reduc-
Others prefer the more posteriorly sited direct medial approach, tion was the subject of a small case series involving 12 con-
which reduces the risk of injury to these structures. Given the secutive patients.33 Despite encouraging results, the specialist
length and extensile nature of both incisions, they allow inspec- nature of this intervention makes it unlikely to be adopted by
tion and irrigation of the articular surface, retrieval of the peri- most surgeons, who through standard open incisions can guide
osteal flap that is often drawn into the fracture, and confirmation reduction by inspecting the external cortex and the anterior
of fracture reduction through inspection of the tibial cortex and, plafond. Reassuringly, and arguably more relevantly, most
if required, plafond margin. fractures (83%) with a satisfactory cortical reduction were also
More recently, minimally invasive approaches that reduce well reduced when assessed arthroscopically. The two patients
soft-tissue stripping have become popular, including a mini-­ (17%) with a poor intra-articular reduction had not complied
arthrotomy technique involving a 3 cm incision at the super- with preoperative restrictions of weight-bearing, and under-
omedial aspect of the mortise, medial to the tendon of tibialis went surgery more than two weeks after the injury with conse-
anterior.17 This approach continues to allow articular inspection, quent impaction of the medial dome. Arthroscopically assisted
irrigation, and reduction of the fracture, while fixation is per- reduction was possible in only one of these patients. Given
formed through a separate stab incision. A purely percutaneous that a modest improvement in reduction was only achieved
approach used in high-risk multi-comorbid patients through a in one patient, routine arthroscopic evaluation is unlikely to
1 cm wound distal to the tip of the malleolus has shown prom- be advantageous in the compliant patient without significant
ising results.31 Weinraub et al32 compared the rate of union of delay to surgery.
32 patients undergoing purely percutaneous medial fixation Screw or TBW fixation.  Most medial malleolar fractures
with open reduction and internal fixation performed in 458 requiring fixation are treated with screws. For fractures that

VOL. 101-B, No. 5, MAY 2019

516 T. H. Carter, A. D. Duckworth, T. O. White 

3 2 1

Fig. 4a Fig. 4b

a) Lateral radiograph and b) saw-bone model showing the three medial malleolar zones. Zone 1 (safe zone) is contained within the anterior colliculus
(green). The intercollicular groove (yellow) separates the safe zone from zone 3 (red). The tibialis posterior tendon runs in its groove (red stripes).

Fig. 5a Fig. 5b

a) Anteroposterior intraoperative fluoroscopy showing lag screw fixation of the medial malleolus in a 75-year-old male patient. b) Screw ‘back-out’
and loss of reduction, two weeks postoperatively.

preclude the use of a screw, such as distal avulsions or those Ebraheim et al37 evaluated the outcome in relation to the
with severe comminution, traditional AO teaching recommends technique of fixation that was used for transverse, oblique,
TBW fixation.34 This method has been supported by biome- and vertical medial malleolar fractures. They concluded that
chanical and clinical data showing superior pull-out strength transverse fractures should be treated with TBW rather than
of TBW constructs compared with cancellous screws, although lag screws given the lower rate of revision (5% vs 24%) and
the technique has been modified by replacing the transosseous complications (16% vs 41%), but with radiological union being
tunnels with proximal ‘anchor screws’.35,36 comparable for both techniques (79% vs 78%). Radiological

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 Medial malleolar fractures517

Fig. 6a Fig. 6b

a) Anteroposterior intraoperative fluoroscopy of a 78-year-old female patient with poor bone quality showing a bimalleolar fracture treated with
percutaneous bicortical lag screw fixation of the medial malleolus. b) Six weeks postoperatively.

Fig. 7a Fig. 7b Fig. 7c

a) Anteroposterior radiograph of a 44-year-old male patient with a typical supination-adduction type of fracture. b) Intraoperative fluoroscopy follow-
ing anti-glide plating with two partially threaded cancellous lag screws. c) Six months postoperatively.

and patient-reported outcomes were better following cancellous requiring removal.36,38 In an attempt to overcome this, some
lag screw fixation of oblique fractures and buttress plating of have replaced stainless steel wire with knotless systems, using a
vertically orientated fractures. Despite the potential biomechan- combination of low-profile wires and tapes, but with conflicting
ical and clinical advantages, the authors did not comment on the results in saw-bone biomechanical testing.39,40
unfortunately common drawback of TBW fixation involving Downey et al41 compared a group of 18 patients treated with
symptomatic metalwork, with approximately 15% of patients knotless tension band (KTB) fixation with 89 patients treated

VOL. 101-B, No. 5, MAY 2019

518 T. H. Carter, A. D. Duckworth, T. O. White 

Excessively long screws can bypass the best-quality cancel-

lous bone in which to gain good purchase, which may result in
lower compression at the fracture site. Ricci et al43 suggested
screws of 40 mm to 45 mm in length should be used. Similarly,
excessively short screws may not fully engage proximally, lead-
ing to the potential for distraction rather than the desired com-
pression. Labronici et al44 examined 116 cadaveric tibiae and
reported that the mean distance from the medial malleolar tip to
the distal tibial medullary canal was 55 mm, and concluded that
screw length should be no more than 45 mm to achieve opti-
mum purchase. They did not report the mean age of the speci-
mens and no measurement of bone density was performed, but
the large sample size strengthens the generalizability of these
results and supports the findings of Parker et al,42 who recom-
mended 45 mm fully threaded screws.
The decision to use one or two screws has been recently
investigated by Buckley et al,23 who randomized 140 patients to
either double screw (DS) or SS fixation, of whom 127 patients
(91%) were followed-up. There was no significant difference
at any time during the two-year follow-up period in the pri-
mary outcome measure (36-Item Short-Form Health Survey
questionnaire) or secondary outcomes including operating
time, length of stay in hospital, or complications between the
groups. A syndesmosis screw failed in one patient in the SS
Fig. 8 group, and medial malleolar screw fixation failed in one patient
in the DS group. Displacement of the medial malleolar frac-
Lateral radiograph of a 38-year-old male patient who had pain radiating ture, which was subsequently treated conservatively, occurred
to the sole of his foot due to irritation of the posterior tibial nerve
following unsatisfactory fixation. The symptoms improved markedly
in one patient in each group. A total of 14 patients randomized
after removal of the screws, which had been inserted with an incorrect to the DS group crossed over to the SS group intraoperatively
trajectory. as the surgeon felt the fragment was too small for safe DS fix-
ation. This is frequently encountered with the smaller fracture
with traditional TBW fixation. No patients required removal of of the anterior colliculus, which commonly represents an SDL
metalwork in the KTB group compared with 8% in the TBW avulsion injury. These level 1 data conclude that SS fixation is
group, with comparable clinical outcomes and time to union. efficacious in the treatment of most medial malleolar fractures
A rudimentary cost analysis suggested that despite the KTB and support the findings from a previous retrospective review.45
implant costing three times that of the TBW, it was 13% cheaper Screw fixation: zone of insertion.  Fixation of medial malle-
due to the avoidance of secondary costs. Given the small num- olar fractures is not without risk. Damage to local structures
ber of patients in the study and higher initial costs of implants, including the tibialis posterior tendon, either from the tip of a
further prospective data are required. screw posteriorly or the head of a screw distally, has been well
Screw fixation: length, type, and number. Parker et al42 recently described in small retrospective studies.46 Femino et al47 divided
challenged the traditional AO approach to medial malleolar fix- the medial malleolus into three zones from anterior to posterior
ation, which recommends two parallel partially threaded cancel- and described the ‘safe zone’ for screw placement (Fig. 4). An
lous lag screws. Using 21 randomized unpaired cadaveric tibiae, oblique supracollicular fracture was created in ten unmatched
they measured compression at a simulated medial malleolar frac- cadaveric tibiae. Three screws were inserted parallel to the
ture site during fixation in four experimental groups using: A) a anterior tibial cortex, one in each of three zones: zone 1 (safe
4.0 mm × 45 mm × 15 mm partially threaded cancellous screw, zone), anterior colliculus; zone 2, intercollicular groove; and
B) a 4.0 mm × 45 mm fully threaded cancellous screw, C) a 4.0 zone 3, posterior colliculus. Screws placed in zone 3 resulted
mm × 45 mm fully threaded cancellous screw with a 4.0 mm in 100% abutment of the tibialis posterior tendon and the ten-
glide hole; and D) a 4.0 mm × 30 mm × 16 mm partially threaded don was injured in 50%. Screws in zone 2 were only a mean
cancellous screw. The greatest compression at the fracture site of 2 mm away from the groove containing the tendon. In large
was achieved by group B and the authors concluded that fully patients, the anterior colliculus may be capacious enough to
threaded cancellous screws achieve more purchase in the radio- accept two screws. In smaller patients, zone 2 screws should
dense physeal scar compared with partially threaded screws of be inserted as close as possible to the posterior border of the
equivalent length (45 mm). The study was limited by the homog- anterior colliculus, identified as the tip of the malleolus. This
enous sample of elderly, osteoporotic cadaveric tibiae and the can be confirmed on lateral fluoroscopy (Fig. 4). Inspection of
conclusions can only really pertain to this group. It may be that in the tibialis posterior tendon following insertion of such screws
younger patients with greater bone density, fully threaded screws is recommended. Screws in the posterior colliculus should be
might, in fact, function as distracting positional screws. removed electively following union of the fracture, to reduce

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 Medial malleolar fractures519

Fig. 9a Fig. 9b Fig. 9c

a) Anteroposterior radiograph demonstrating a comminuted medial malleolar fracture in a 48-year-old male patient. b) Poor intraoperative reduction
with over-compression of the medial malleolus, c) resulting in malunion. The patient complained of medial-sided pain and the screws were removed
six months postoperatively.

the risk of chronic attrition and tendon rupture. An additional Despite the encouraging clinical, radiological, and biome-
key clinical point from this study relates to the trajectory of the chanical evidence, bicortical fixation does not appear to have
screw, which should be parallel to the anterior tibial cortex. A been widely adopted. Selecting a long fully threaded screw up
screw that starts in the safe zone but has a posterior trajectory to 120 mm in length may be somewhat unfamiliar to both sur-
may produce similar morbidity. geon and scrub nurse, but can be of significant benefit, particu-
These findings have been supported by Zhang et al,48 who larly if there is concern about the compression achieved with
analyzed 3D CT scans in 215 patients without a previous frac- standard, shorter, partially threaded screws.
ture or congenital abnormality and found that, with a mean AP Plate fixation.  Vertical shear fractures of the medial malleo-
distance of 11.7 mm, the anterior colliculus could only accom- lus are classically sustained in a supination-adduction injury.
modate two 4.0 mm screws safely in the largest patients. This These are inherently unstable and usually require fixation. Par-
work, in conjunction with the conclusions from the study by tially threaded cancellous screws have long been used in these
Buckley et al,23 suggests that two screws may not be required. patients, with divergent screws providing better biomechanical
Unicortical or bicortical fixation.  The incidence of symp- qualities than parallel screws.53 Wegner et al54 compared four
tomatic metalwork following fixation of a medial malleolar fixation groups for the treatment of a simulated vertical shear
fracture may be increased in patients with osteoporotic bone, fracture in a synthetic bone model. Anti-glide plating (Fig. 7)
especially when the maximum insertional torque of the screw was significantly stiffer and could withstand higher loads to fail-
has been exceeded through over-tightening and ‘stripping’.42 ure than fixation with bicortical, parallel unicortical, or diver-
This leads to reduced compression and may predispose to screw gent unicortical screws. One drawback of anti-glide plating is
‘back-out’ (Fig. 5). Removal of screws does not always guaran- the larger exposure and soft-tissue stripping, which is required.
tee the resolution of symptoms.49 The technique of bicortical lag In patients with vulnerable soft tissues, bicortical screw fixation
screw fixation (Fig. 6) has been well described50,51 and reported may provide enough stability without additional insult.
by Ricci et al43 in a primarily clinical study supplemented with The traditional description of the anti-glide technique involves
biomechanical testing. They included 92 patients (46 treated proximal-only screws within a standard one-third tubular plate.
with partially threaded screws and 46 with a bicortical lag Jones et al55 compared this technique with a modified construct
screw) and found a significantly lower rate of prominent medial including a further unicortical lag screw compressing the frac-
metalwork and radiological loosening in the bicortical group. ture. In a synthetic model, this configuration showed superior
Biomechanical testing confirmed greater torque applied to the stiffness and maximum load to failure compared with the tra-
bicortical screws, which was indirectly extrapolated to greater ditional technique and a more contemporary pre-contoured
compression at the fracture site. Supporting studies have shown ‘hooked’ plate with no lag screw fixation. Given the low cost and
superior biomechanical pull-out strength of bicortical fixation16 accessibility, a configuration including one or more lag screw(s)
and positive outcomes in high-risk patients, including those should be the benchmark when using anti-glide plating (Fig. 7).
with osteoporosis, diabetes, peripheral vascular disease, and Alternative implants. In an attempt to reduce the rate of
chronic renal impairment.52 symptomatic metalwork, headless screws have been recently

VOL. 101-B, No. 5, MAY 2019

520 T. H. Carter, A. D. Duckworth, T. O. White 

investigated by Barnes et al.56 A total of 44 patients were have been developed with this in mind. Perhaps the introduction
reviewed clinically and radiologically at a median of 35 weeks of these more expensive, complex devices is complicating the
(12 to 208) postoperatively. No patient had a nonunion and situation further. If we carefully consider the standard implants
none required removal of metalwork, although the screws were we routinely use and modify the technique, with bicortical screw
removed in one as part of treatment for infection. Despite the fixation being a perfect example, the outcomes could potentially
adaptations in design, including the screw head lying flush be improved more simply. In patients with severe fracture com-
with bone, nearly a quarter of patients (23%) complained of minution, poor bone quality, or vulnerable soft tissues, we should
mild medial discomfort. This ongoing discomfort is likely to question the need to intervene at all in a well-reduced medial
be related to scar tissue and may explain why symptoms do not fracture, especially in elderly patients. If fixation is required,
always improve following removal of metalwork.49 respect should be paid to the ‘safe zone’ of the malleolus and
In a small study by Tekin et al,18 12 patients were reviewed one screw used where possible. Undoubtedly, more high-quality
after antegrade, as opposed to retrograde, headless compression research is required to provide further direction.
screw fixation of type-B fractures. No patients had a nonunion,
prominent metalwork, instability, or infection and all had a good Take home message
or excellent outcome with a mean AOFAS score of 95.0 (87 to - Although the surgical anatomy is well understood, the op-
timal treatment of fractures of the medial malleolus remains
99). Bulut and Gursoy20 compared headless compression screws unclear.
with partially threaded lag screws and TBW fixation in the treat- - Nonoperative management of well-reduced medial malleolar fractures
ment of isolated medial malleolar fractures. There was signifi- may yield equivalent outcome to internal fixation, without the associated
cantly less medial-sided pain and removal of metalwork in the surgical morbidity.
- In the presence of poor bone quality, bicortical fixation should be con-
headless screw group, but no significant difference in the primary sidered for displaced fractures.
outcome measure (AOFAS; p = 0.239). Despite good clinical - The ‘safe zone’ of the medial malleolus must be respected in order to
outcomes, there is a lack of supportive biomechanical evidence reduce the risk of iatrogenic injury to the tibialis posterior tendon.
in the literature. A significant reduction in secondary intervention
would be required to offset the greater initial cost of the screws. Twitter
Other devices, including low-profile malleolar sleds consist- Follow T. H. Carter @OrthoDocTCr
ing of two prongs inserted in a retrograde manner from the tip Follow A. D. Duckworth @DuckworthOrthEd
of the malleolus and secured with proximal cancellous screws,
have been introduced to reduce the incidence of symptomatic References
1. White TO, Carter TH. Ankle fractures: facts and fiction. Bone & Joint 360
metalwork following TBW fixation of comminuted fractures.57 2018;7(4):3–8.
These implants may have superior biomechanical properties, 2. Yablon IG, Heller FG, Shouse L. The key role of the lateral malleolus in displaced
including higher pull-out strength, when compared with uni- fractures of the ankle. J Bone Joint Surg [Am] 1977;59-A:169–173.
cortical screw fixation in transverse fractures.58 Absorbable 3. Svend-Hansen H, Bremerskov V, Baekgaard N. Ankle fractures treated by fix-
implants might have a future role, specifically in reducing rates ation of the medial malleolus alone. Late results in 29 patients. Acta Orthop Scand
1978;49:211–214.
of re-operation, but have been associated with foreign body 4. Pettrone FA, Gail M, Pee D, Fitzpatrick T, Van Herpe LB. Quantitative criteria
reaction, skin necrosis, and re-fracture.59,60 Given the additional for prediction of the results after displaced fracture of the ankle. J Bone Joint Surg
expense associated with these alternative implants, high-quality [Am] 1983;65-A:667–677.
prospective studies are required to justify their routine clinical 5. Earll M, Wayne J, Brodrick C, Vokshoor A, Adelaar R. Contribution of the del-
toid ligament to ankle joint contact characteristics: a cadaver study. Foot Ankle Int
use, with high-risk patients most likely to benefit.
1996;17:317–324.
Complications.  The fixation of medial malleolar fractures is 6. Lareau CR, Bariteau JT, Paller DJ, Koruprolu SC, DiGiovanni CW. Contribution
not without risk. In addition to the routine risks of infection of the medial malleolus to tibiotalar joint contact characteristics. Foot Ankle Spec
and implant-related pain, intra-articular screw penetration and 2015;8:23–28.
inadvertent injury to the tibialis posterior tendon with its adja- 7. Hoelsbrekken SE, Kaul-Jensen K, Mørch T, et al. Nonoperative treatment of
the medial malleolus in bimalleolar and trimalleolar ankle fractures: a randomized
cent neurovascular bundle have been described (Fig. 8).46,47,61
controlled trial. J Orthop Trauma 2013;27:633–637.
The challenge of achieving adequate fixation in comminuted 8. Kusnezov NA, Eisenstein ED, Diab N, Thabet AM, Abdelgawad A. Medial
or osteoporotic bone has been discussed. Due to the high rate malleolar fractures and associated deltoid ligament disruptions: current manage-
of prominent metalwork following TBW fixation, most sur- ment controversies. Orthopedics 2017;40:e216-e222.
geons would use screw(s) whenever possible. Unfortunately, 9. Pankovich AM, Shivaram MS. Anatomical basis of variability in injuries of the
medial malleolus and the deltoid ligament. I. Anatomical studies. Acta Orthop Scand
over-compression frequently results in over-reduction of 1979;50:217–223.
the fracture, closing down the medial clear space or causing 10. Davidovitch RI, Egol KA. The medial malleolus osteoligamentous complex and its
malalignment, both of which may produce inferior outcomes role in ankle fractures. Bull NYU Hosp Jt Dis 2009;67:318–324.
and continue to present a management challenge (Fig. 9). 11. Pankovich AM, Shivaram MS. Anatomical basis of variability in injuries of the
In conclusion, the literature demonstrates that there is no sin- medial malleolus and the deltoid ligament. II. Clinical studies. Acta Orthop Scand
1979;50:225–236.
gle technique, operation, or implant that can be used universally 12. Aitken SA, Johnston I, Jennings AC, Chua ITH, Buckley RE. An evaluation of
in the treatment of medial malleolar fractures. With rising costs the Herscovici classification for fractures of the medial malleolus. Foot Ankle Surg
of health care and potential disruption to the busy lifestyles of our 2017;23:317–320.
patients, there is an added incentive to ‘get it right first time’ while 13. Court-Brown CM, McBirnie J, Wilson G. Adult ankle fractures--an increasing
problem? Acta Orthop Scand 1998;69:43–47.
facilitating safe early mobilization and return to activity. Promi-
14. Herscovici D Jr, Scaduto JM, Infante A. Conservative treatment of isolated frac-
nent metalwork is tolerated poorly, and new designs of implants tures of the medial malleolus. J Bone Joint Surg [Br] 2007;89-B:89–93.

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15. Müller ME, Nazarian S, Koch P, Schatzker J. The Comprehensive Classification 43. Ricci WM, Tornetta P, Borrelli J Jr. Lag screw fixation of medial malleolar
of Fractures of Long Bones. Springer-Verlag, 1990. fractures: a biomechanical, radiographic, and clinical comparison of unicortical par-
16. Pollard JD, Deyhim A, Rigby RB, et al. Comparison of pullout strength between 3.5- tially threaded lag screws and bicortical fully threaded lag screws. J Orthop Trauma
mm fully threaded, bicortical screws and 4.0-mm partially threaded, cancellous screws 2012;26:602–606.
in the fixation of medial malleolar fractures. J Foot Ankle Surg 2010;49:248–252. 44. Labronici PJ, Pires RE, Franco MV, et al. Medial malleolar fractures: an ana-
17. Saini P, Aggrawal A, Meena S, Trikha V, Mittal S. Miniarthrotomy assisted tomic survey determining the ideal screw length. Ann Med Health Sci Res 2016;
percutaneous screw fixation for displaced medial malleolus fractures - a novel tech- 6:308–310.
nique. J Clin Orthop Trauma 2014;5:252–256. 45. Shah Y, Syed T, Myszweski T, Zafar, F. Comparison of outcome following either
18. Tekin AC, Ҫabuk H, Dedeoglu SS, et al. Anterograde headless cannulated screw one or two screws for medial malleolar fracture fixation. J Bone Joint Surg [Br]
fixation in the treatment of medial malleolar fractures: evaluation of a new technique 2010;92-B:255–256.
and its outcomes. Med Princ Pract 2016;25:429–434. 46. DeMill SL, Bussewitz BW, Philbin TM. Injury to the posterior tibial tendon
19. Kochai A, Türker M, Çiçekli Ö, et al. A comparative study of three commonly used after open reduction internal fixation of the medial malleolus. Foot Ankle Spec
fixation techniques for isolated medial malleolus fracture. Eklem Hastalik Cerrahisi 2015;8:360–363.
2018;29:104–109. 47. Femino JE, Gruber BF, Karunakar MA. Safe zone for the placement of medial
20. Bulut T, Gursoy M. Isolated medial malleolus fractures: conventional techniques malleolar screws. J Bone Joint Surg [Am] 2007;89-A:133–138.
versus headless compression screw fixation. J Foot Ankle Surg 2018;57:552–556. 48. Zhang K, Chen Y, Qiang M, et al. The morphology of medial malleolus and its
21. Hanhisuanto S, Kortekangas T, Pakarinen H, Flinkkilä T, Leskelä HV. The clinical relevance. Pak J Med Sci 2014;30:348–351.
functional outcome and quality of life after treatment of isolated medial malleolar 49. Brown OL, Dirschl DR, Obremskey WT. Incidence of hardware-related pain and
fractures. Foot Ankle Surg 2017;23:225–229. its effect on functional outcomes after open reduction and internal fixation of ankle
22. Sohal HS, Garg RS, Jindal S, et al. Minifragment T-plate fixation: an alterna- fractures. J Orthop Trauma 2001;15:271–274.
tive method for medial malleolus fracture fixation. J Foot Ankle Surg (Asia-Pacific) 50. Parada SA, Krieg JC, Benirschke SK, Nork SE. Bicortical fixation of medial
2016;3:10–14. malleolar fractures. Am J Orthop (Belle Mead NJ) 2013;42:90–92.
23. Buckley R, Kwek E, Duffy P, et al. Single-screw fixation compared with double 51. Kupcha P, Pappas S. Medial malleolar fixation with a bicortical screw: technique
screw fixation for treatment of medial malleolar fractures: a prospective randomized tip. Foot Ankle Int 2008;29:1151–1153.
trial. J Orthop Trauma 2018;32:548–553. 52. King CM, Cobb M, Collman DR, Lagaay PM, Pollard JD. Bicortical fixation of
24. Olerud C, Molander H. A scoring scale for symptom evaluation after ankle fracture. medial malleolar fractures: a review of 23 cases at risk for complicated bone healing.
Arch Orthop Trauma Surg 1984;103:190–194. J Foot Ankle Surg 2012;51:39–44.
25. Roos E, Brandsson S, Karlsson J. Validation of the foot and ankle outcome score 53. Amanatullah DF, Khan SN, Curtiss S, Wolinsky PR. Effect of divergent
for ankle ligament reconstruction. Foot Ankle Int 2001;22:788–794. screw fixation in vertical medial malleolus fractures. J Trauma Acute Care Surg
26. Caesar BC, McCollum GA, Elliot R, Williams A, Calder JD. Stress fractures of 2012;72:751–754.
the tibia and medial malleolus. Foot Ankle Clin 2013;18:339–355. 54. Wegner AM, Wolinsky PR, Robbins MA, et al. Antiglide plating of vertical
27. Sherbondy PS, Sebastianelli WJ. Stress fractures of the medial malleolus and medial malleolus fractures provides stiffer initial fixation than bicortical or unicortical
distal fibula. Clin Sports Med 2006;25:129–37. screw fixation. Clin Biomech (Bristol, Avon) 2016;31:29–32.
28. Irion V, Miller TL, Kaeding CC. The treatment and outcomes of medial malleolar 55. Jones DA, Cannada LK, Bledsoe JG. Are hook plates advantageous compared to
stress fractures: a systematic review of the literature. Sports Health 2014;6:527–530. antiglide plates for vertical shear malleolar fractures? Am J Orthop (Belle Mead NJ)
29. Carter T, Mackenzie S, Bell K, et al. Selective fixation of the medial malleolus in 2016;45:E98-E102.
unstable ankle fractures. Injury 2019;11 [Epub ahead of print]. 56. Barnes H, Cannada LK, Watson JT. A clinical evaluation of alternative fixation
30. Carter TH. Medial Malleolus: Operative Or Non-operative (MOON). U. S. National techniques for medial malleolus fractures. Injury 2014;45:1365–1367.
Library of Medicine. https://clinicaltrials.gov/ct2/show/NCT03362229 (date last 57. Maniar H, Kempegowda H, Tawari AA, et al. Medial malleoli fractures: clini-
accessed 11 March 2019). cal comparison between newly designed sled device and conventional screws. Foot
31. Smith M, Medlock G, Johnstone AJ. Percutaneous screw fixation of unstable Ankle Spec 2017;10:296–301.
ankle fractures in patients with poor soft tissues and significant co-morbidities. Foot 58. Wegner AM, Wolinsky PR, Cheng RZ, et al. Sled fixation for horizontal medial
Ankle Surg 2017;23:16–20. malleolus fractures. Clin Biomech (Bristol, Avon) 2017;42:92–96.
32. Weinraub GM, Levine P, Shi E, Flowers A. Comparison of medial malleolar frac- 59. Li ZH, Yu AX, Guo XP, et al. Absorbable implants versus metal implants for the
ture healing at 8 weeks after open reduction internal fixation versus percutaneous treatment of ankle fractures: a meta-analysis. Exp Ther Med 2013;5:1531–1537.
fixation: a retrospective cohort study. J Foot Ankle Surg 2017;56:277–281. 60. Tang J, Hu JF, Guo WC, Yu L, Zhao SH. Research and application of absorbable
33. Swart EF, Vosseller JT. Arthroscopic assessment of medial malleolar reduction. screw in orthopedics: a clinical review comparing PDLLA screw with metal screw in
Arch Orthop Trauma Surg 2014;134:1287–1292. patients with simple medial malleolus fracture. Chin J Traumatol 2013;16:27–30.
34. Schatzker J. Screws and plates and their application. In: Müller ME, Allgöwer M, 61. Giordano V, Gomes AF, Amaral NP, Albuquerque RP, Pires RE. Preventing
Schneider R, Willenegger H (eds.). Manual of Internal Fixation: Techniques Recom- surgical complications: a survey on surgeons’ perception of intra-articular malleolar
mended by the AO-ASIF Group. Third ed. New York: Springer-Verlag, 1991:226–228. screw misplacement in a cadaveric study. Patient Saf Surg 2011;5:24.
35. Johnson BA, Fallat LM. Comparison of tension band wire and cancellous bone
screw fixation for medial malleolar fractures. J Foot Ankle Surg 1997;36:284–289. Author contributions:
36. Georgiadis GM, White DB. Modified tension band wiring of medial malleolar T. H. Carter: Conceptualized the review, Reviewed the literature, Wrote the
ankle fractures. Foot Ankle Int 1995;16:64–68. manuscript.
37. Ebraheim NA, Ludwig T, Weston JT, Carroll T, Liu J. Comparison of surgical A. D. Duckworth: Wrote the manuscript.
techniques of 111 medial malleolar fractures classified by fracture geometry. Foot T. O. White: Wrote the manuscript.
Ankle Int 2014;35:471–477.
Funding statement:
38. Ostrum RF, Litsky AS. Tension band fixation of medial malleolus fractures. J Orthop Although none of the authors has received or will receive benefits for
Trauma 1992;6:464–468. personal or professional use from a commercial party related directly or indi-
39. Fowler TT, Pugh KJ, Litsky AS, Taylor BC, French BG. Medial malleolar frac- rectly to the subject of this article, benefits have been or will be received but
tures: a biomechanical study of fixation techniques. Orthopedics 2011;34:e349-e355. will be directed solely to a research fund, foundation, educational institution,
40. Clyde J, Kosmopoulos V, Carpenter B. A biomechanical investigation of a knot- or other non- profit organization with which one or more of the authors are
less tension band in medial malleolar fracture models in composite Sawbones®. J associated.
Foot Ankle Surg 2013;52:192–194. ICMJE COI statement:
41. Downey MW, Duncan K, Kosmopoulos V, et al. Comparing the knotless tension The authors report institutional funding from Acumed to support trauma
band and the traditional stainless steel wire tension band fixation for medial malleo- research, including the salary of T. H. Carter. The authors also report edu-
lus fractures: a retrospective clinical study. Scientifica (Cairo) 2016;2016:3201678. cational support for the Edinburgh International Trauma Symposium paid by
42. Parker L, Garlick N, McCarthy I, et al. Screw fixation of medial malleolar frac- Smith & Nephew.
tures: a cadaveric biomechanical study challenging the current AO philosophy. Bone This article was primary edited by J. Scott.
Joint J 2013;95-B:1662–1666.

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