Surgical Science, 2013, 4, 365-370
http://dx.doi.org/10.4236/ss.2013.48072 Published Online August 2013 (http://www.scirp.org/journal/ss)
The Effect of Percutaneous Screw Fixation of Lateral
Malleolus on Ankle Fracture Healing and Function
Girgis Latif1, Hayder Al-Saadi1*, Medhat Zekry2, Malallah Ali Hassan1, Jamal Al Mulla1
1Rashid Hospital and Trauma Center, Dubai, UAE
2Heart of England NHS Foundation Trust, Bimingham, UK
Received June 8, 2013; revised July 10, 2013; accepted July 19, 2013
Copyright © 2013 Girgis Latif et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Purpose: To measure the effectiveness of using percutaneous intramedullary screw fixation of the lateral malleolus
fracture on the healing and functional outcome of ankle fracture. Materials and Methods: Forty-six patients with We-
ber A and low Weber B displaced lateral malleolus fractures who underwent closed reduction and percutaneous internal
fixation with an intramedullary, fully threaded, screw were retrospectively reviewed. A 3.5-mm, fully threaded, self-
tapping bone screw (stainless steel from Pelvic Set Synthes). The length of the screw varies between 100 mm and 120
mm, depending on th e fracture lo cation and pa ttern. Results: All fractures united w ithin an averag e time to union of 8.2
weeks. In all patients the average time to full weight bearing was 6.8 weeks, whereas that in patients with isolated lat-
eral malleolus fractures was 4.5 weeks. There were no deep wound infections or complaints of painful hardware. At
latest follow-up, functional results were excellent in, 25 patients (54.3%) good in 20 (43.5%), fair in (2.2%). Conclu-
sion: If reduction of the lateral malleolus fracture can be obtained in a closed fashion (with the aid of an image x-ray
intensifier), we believe that fixatio n may be performed with an axial screw percutaneously. This technique is quick, safe
and easy to do with less complication.
Keywords: Ankle Fracture; Lateral Malleolus; Intramedullary Screw
1. Introduction
Restoring the normal anatomy of the lateral malleolus
has been recognized as the key to operative treatment of
ankle fractures [1]. Yablon pointed out that the talus
faithfully follows the lateral malleolus, and Harper
showed that relatively minor lateral malleolus fractures
allow for talar shaft and joint incongruity [1,2]. The
treatment options for lateral malleolar fractures are either
non operative or operative including; cerclage wiring, lag
screws, a plate and screws, a hook plate, tension band
wiring, axial pins, and axial screws [1-3]. Recently,
Acumed nail introduced to fix the fibular fracture [4]. In
1963, the AO group introduced their well-known meth-
ods of fixation principles like buttress plate and screws
and/or a lag screw, depending on the fracture pattern.
These methods provide stable anatomic fixation and re-
sults of numerous clinical studies are ex cellent [3,5,6].
It has been criticized by several authors because of the
small amount of overlying soft tissues laterally and pa-
tients’ complaints of pain over prominent hardware [7-9].
Among the different methods of fixing lateral malleo-
lus as an intramedullaryfixations using Steinmann pins
[10] and Rush rods [11], however, apprehension about
the hardware backi ng out has limited their usefulnes s.
Cancellous screws alone have also been used for fixa-
tion of Weber A fibula fractures [11,12], but, as with
smooth pins, these fixation devices may allow rotation of
the distal fragment. Several authors have described fixa-
tion of fibular fractures with an axial screw [14,15].
At our institution which is Level-One Trauma Centre
and Tertiary centre for Trauma in Dubai, UAE, we adop t
internal fixation policy of simple Weber A and low We-
ber B fibular fractures with a long intramedullary screw.
It has been utilized b ecause it is felt that this technique is
simpler than buttress plating and with less hardware
complications. The long intramedullary screw also al-
lows better purchase within the fibular canal than a
smooth pin (while accommodating the distal fibular lat-
eral bow), therefore eliminating hardware migration [5].
Furthermore, Bankston et al. demonstrated biomechani-
cally that this particular fixation device was superior in
strength, although not statistically followed up compared
*Corresponding a uthor.
C
opyright © 2013 SciRes. SS

G. LATIF ET AL. 366
to other fixations with plate and screws [16]. They re-
ported their clinical results using open reduction and in-
ternal fixation of lateral malleolus fractures with an in-
tramedullary screw, which demonstrated stable fracture
fixation (allowing early weight bearing) and a 100% rate
of union in their series.
Tamara D. Ray, at all, used intramedullary screw fixa-
tion for lateral malleolus fracture in 24 patients and they
have good results [17].
2. Patients
Between 2006 an d 2012 we retr ospectively rev iewed 280
patients who underwent open reduction and internal fixa-
tion for fractures about the ankle.
Fifty-nine of these patients underwent intramedullary
fixation of a lateral malleolus fracture with an axially
directed screw. Forty-six of these patients were followed-
up for an average of 63.4 weeks. Fracture types included
in this study were 21 lateral malleolus fractures with tear
of the deltoid ligament, 15 bimalleolar fractures, and 10
trimalleolar fractures. Hospital and clinic records were
reviewed for evidence of early or late complications re-
lating to the wound, hardware, reduction, and union. Any
medial ankle surgery for open reduction and internal
fixation of a medial malleolus fracture or repair of a del-
toid ligament was also differentiated. Surgeon’s opera-
tion notes records were also evaluated for length of im-
mobilization, time to full weight bearing, and to tal length
of follow-up. Patients’ subjective findings at the time of
last clinic visit were also documented. New patients were
evaluated for anatomic healing and not for long term
results related to degenerative arthritis. Of the 46 patients
available for follow-up, 16 were female and 30 were
male. Their average age was 39.5 years (range 18 - 67).
Twenty one fractures were isolated lateral malleolus
fractures, of which six had an open deltoid ligament re-
pair in addition to open reduction and internal fixation of
the lateral malleolus. Twenty-five patients had a medial
malleolus fracture, with 15 of these being bimalleolar
and 10 being trimalleolar. Thirty-six fractures were clas-
sified as Weber B and 10 as Weber A. Allmedial mal-
leolus fractures were fixed with one or two cancellous
screws. No poste rior malleolar fractures required fixa-
tion in this group. (Figures 1-3 showing examples of
lateral malleolus fracture fixed by intramedullary screw
done in Rashid Hospital and Trauma Center).
3. Surgical Technique
To be amenable to fixation with an intramedullary screw,
a lateral malleolus fracture must be simple or minimally
comminuted because intramedullary fixation will not
reliably maintain length in comminu ted fractures. Ideally,
the lateral malleolus fracture should be of a transverse or
short oblique configuration. The technique involves us
(a) (b)
(c) (d)
Figure 1. (a) and (b): Pre-operative X-Rays; (c) and (d):
Post-operative X-Rays.
ing image intensification to aid anatomic reduction by
inverting the foot and then achieving and maintaining
fracture reduction with a towel clippe r cutaneously (This
technique may be more difficult in a markedly obese or
swollen ankle). While the fracture is stabilized, a stab
incision is made just distal to the tip of the lateral mal-
leolus, and a hole is made in the tip of the lateral malleo-
lus with a 2.5-mm drill bit trying to be somewhat poste-
rior on the lateral malleolus tip (avoid an terior insertion).
A 3.5-mm, fully threaded, self-tapping bone screw
(stainless steel from Pelvic Set Synthes) is then passed
across the fracture site and into the proximal fibular
fragment .The screw is tightened until its head reaches
the bone. It is not possible to make more compression at
the fracture site by further tightening of the screw be
cause it is a fully threaded screw and serrations are on
both sides of fracture site. Electric power drill can be

G. LATIF ET AL. 367
(a) (b)
(c) (d)
(e) (f)
Figure 2. (a) and (b): Pre-operative X-rays; (c) and (d):
Post-operative X-rays; (e) and (f): Follow up X-ray after
four months showing good healing.
used to insert the screw to give the screw the enough
power to be bent with the long axis of distal fibula. The
length of the screw varies between 100 mm an d 120 mm,
depending on the fracture location and pattern. When a
medial malleolus fracture is present, a separate incision is
made for open reduction of this fracture before lateral
malleolar fixation and the lateral malleolus is then fixed.
Intraoperative roentgenograms (AP, lateral, mortise, and
stress views) are always obtained to confirm the reduc-
tion of the fracture, the position of the screw, and the
stability of the syndesmosis. The wound is then closed
(a) (b)
(c) (d)
(e) (f)
Figure 3. (a) and (b): Pre-operative X-rays; (c) and (d):
Post-operative X-rays; (e) and (f): Follow up X-ray after
one year showing good healing.
with one interrupted suture and gauze dressing with no
cast used in these patients, and the time of non-weight
bearing mobilization varies according to the fracture pat-
tern and associated injuries. Using this percutaneous tech-
nique, the use of a tourniquet is optional. Figure 4
showing the difference in surgical approach between

G. LATIF ET AL. 368
plate fixation and intramedullary screw fixation.
4. Results
The mechanisms of injury (Table 1) in the 46 patients
included in this study were falls (43.5%), motor vehicle
accidents (34.8%), motorcycle crashes (13%), and direct
blows (8.7%). Evaluation of immediate postoperative
roentgenograms for adequacy of reduction (Table 2)
revealed a good reduction in 43 of 46 (93.5%) patien ts, a
fair reduction in 3 of 46 (6.5%) patients, (Table 3). Re-
duction obtained in the operating room was maintained
(a)
(b)
Figure 4. (a) Clinical picture showing the surgical wound
needed for plate and screw fixation of lateral malleolus; (b)
Clinical picture showing the surgical wound needed for
Intramedullary screw fixation of lateral malleolus.
Table 1. Mechanism of injury.
Mechanism Number of Patients Percentage
Fall 20 43.5
Motor vehicle 16 34.8
Motorcycle 6 13
Direct blow 4 8.7
Total 46
Table 2. Radiographic criteria.
Good Fibula out to length
<2 mm of posterior displacement
<1 mm increase in medial clear space
Fair Fibula shortened < 2 mm
2 - 4 mm of posterior displacement
1 - 3 mm increase in medial clear space
Poor Fibula shortened > 2 mm
>4 mm of posterior displacement
> 3 mm increase in medial clear space
Table 3. Reduction on roentgenography.
Rating Number of Patients Percentage
Good 43 93.5
Fair 3 6.5
Poor 0 0
Total 46
in all of the patients who could be followed for 6 weeks
or longer (46 patients). In the 26 patients who were fol-
lowed to the time of fracture union, the average time to
union wa s 8.2 weeks.
Duration of non-weight bearing mobilization varied
from 6 to 10 weeks, with an average of 8.8 weeks. Time
to full weight bearing ranged from 3 to 12 weeks, with an
average time to full weight bearing of 7.2 weeks. There
was a 100% rate of union for all lateral malleolus frac-
tures in this group.
No deep wound infections occurred. No patient has
complained of tenderness or prominence of the hardware,
and no patient has complained of impingement symp-
toms.
A functional rating scale (Table 4) was used to sub-
jectively evaluate ankles in the patients who continued
with clinic appointments or could be contacted by phone.
Of these patients (Table 5), 25 patients (54.3%) had an
excellent result and 20 (43.5%) were considered to have
a good result. One patient (2.2%) who had a fair func-
tional rating had a shortened lateral malleo lus (2 mm).
Patients were evaluated for anatomic healing and not
for long-term results related to degenerative arthritis.
5. Discussions
The importance of stable, anatomic fixation of the lateral
malleolus fragment is highly appreciated to achieve sat-
isfactory results in ankle fractures. Various methods of
lateral malleolar fixation have been utilized, all with ac

G. LATIF ET AL. 369
Table 4. Functional rating (compar e d with normal ankle).
Excellent Normal ran g e o f m ot i o n w i thout pain or stiffness
and return to previous activity level
Good Normal range of motion without stiffness, return to previous
activity level with only occasional pain following activity
Fair Decreased range of motion, frequent pain following activity
Poor Decreased range of motion, pain and stiffness at rest
Table 5. Functional results.
Rating Number of Patients Percentage
Excellent 25 54.3
Good 20 43.5
Fair 1 2.2
Poor 0 0
Total 46
ceptable results. The most common method of fixation of
lateral malleolar fractures is the buttress plating. It pro-
vides stable fixation and maintains length of the lateral
malleolus.It is preferred in cases where the malleolus is
comminuted, as length could not be reliably maintained
with an IM screw, in compound fractures and fractures
with syndesmotic injury where syndesmotic screw needed
(Weber type C). The complications of plate fixation of the
lateral malleolus are wound healing, especially in swol-
len ankles and painful, prominent hardware often de-
velop late.
Schaffer and Manoli [10] realized that lateral hardware
could lead to wound problems and they evaluated the
technique described by Weber in which a buttress plate is
placed posteriorly on the lateral malleolus. They de-
scribed this as the “anti-glide” technique [10]. They per-
formed biomechanical studies and demonstrated that this
method of fixation was more stable than a laterally
placed plate and lag screw. However, this technique is
more demanding in that the surgical dissection posteri-
orly is difficult. Also, the hardware is left in con tact with
the peroneal tendons, which could cause irritation and
pain.
Covino et al. [18] (in their retrospective clinical re-
view and a biomechanical evaluation of lateral malleolus
fixation) they noted no significant difference between
interfragmentary versus plate fixation. They believed
interfragmentary fixation avoided possible complications
of lateral hardware and eliminated the possibility of
screw penetration into the ankle joint. Intramedullary
fixation of lateral malleolus fractures provides stable
fixation without prominent subcutaneous hardware. The
Intramedullary position of the hardware reduces torque
and bending moment on the device. Intramedullary fixa-
tion of weight bearing long bone fractures has largely
replaced compression plating because of these biome-
chanical advantages. The advantages are also evident in
the treatment of non-comminuted lateral malleolus frac-
tures, and the technique should be utilized in indicated
cases. Intramedullary fixation provides stable fixation,
allowing early mobilization in this series.
Bankston, et al. [16] they found the Intramedullary
screw provided 66.5% of the strength of native bone
compared to the lateral buttress plate provided 61.5%.
This was not statistically significant, but it did prove that
an Intramedullary screw provides stable fixation, thereb y
assuring that rehabilitation can be institu ted early without
the risk of loss of reduction.
If reduction of the fracture can be achieved in a closed
fashion (with the aid of image intensification), we be-
lieve that fixation of a lateral malleolus fracture may be
performed with an axial Intramedullary screw percuta-
neously. Our closed technique utilizes minimal soft-tis-
sue dissection, thus decreasing the incidence of wound
complications and painful hardware sites that are occa-
sionally observed after open reduction and plating tech-
niques. Other advantages include improved healing and
shortened rehabilitation time because the fracture hema-
toma is not violated. We have initially selected only
transverse or short oblique fractures as the primary can-
didates for this percutaneous technique. However, as our
experience grows, perhaps other fracture configurations
can also be treated by this method. Nevertheless, if an
acceptable reduction cannot be achieved using this closed
technique, one can and should proceed with open reduce-
tion and internal fixation without hesitation and without
anything lost in th e process.
Our protocol may be improved upon in several areas.
First of all, a prospective, randomized study comparing
this percutaneous method of lateral malleolus fixation
with open reduction and internal fixation with the axial
screw, as well as with that of standard AO technique
should be performed. The unstable lateral malleolus
should be the only type of fracture included in subse-
quent investigations so that accurate conclusions may be
drawn. To properly conduct this research, the number of
patients should be increased and a longer follow-up pe-
riod would be mandatory. Finally, use of more rigid sub-
jective and objective criteria would allow more specific
conclusions to be drawn about the patients’ long-term
functional results.
6. Conclusion
Intramedullary screw fixation of lateral malleolus re-
quires minimal soft-tissue dissection, thereby decreasing
wound complications and painful hardware sites that are
occasionally observed after open techniques. This closed

G. LATIF ET AL. 370
technique also eliminates screw penetration of the ankle
joint and damage to the peroneal tendons, which can be
risks when a plate or lag screws are employed as internal
fixation. Surgical time is also reduced and tourniquet use
is optional. If an acceptable reduction cannot be obtained
using this technique, open reduction and internal fixation
should b e p erformed.
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