Medial malleolus screws: out in one view and out

  • Jeffrey C. WeraEmail author
  • David Seligson
  • John T. Riehl
Original Article • ANKLE - TRAUMA


Cartilage damage or mechanical blocking from screw penetration into intra-articular cartilage can reduce the chances of successful outcomes during medial malleolus fixation. There have been diverging opinions among surgeons concerning the reliability of radiographic assessment of fracture fixation and malleolus screw positioning. Therefore, this radiographic study examines the location of medial malleolus lag screws relative to the ankle mortise articular surface. In three Sawbones models, Kirschner wires were overdrilled with a 4.0-mm cannulated cortical screw simulating screws that would be intra- and extra-articular when performing open reduction and internal fixation of a medial malleolar fracture. Under fluoroscopy, images were evaluated to determine whether known intra-articular screws appeared extra-articular in any radiographic view. No image from models with known intra-articular penetration appeared extra-articular in any view or under “live” fluoroscopy. At 20° internal rotation, a screw with a known extra-articular position appeared to be within the cartilage. Intra-operative fluoroscopy is necessary to ensure proper extra-articular placement of screws. If a screw is pictured extra-articular in any radiograph, then it can be assumed that the screw is indeed out of the joint.


Medial malleolus Ankle radiography Fracture Internal fixation 


Compliance with ethical standards

Conflict of interest

Dr. Wera has nothing to disclose. Dr. Seligson reports Grants from Fischer-Owen Orthopaedic Trust fund, during the conduct of the study; personal fees from University of Louisville Department of Orthopaedic Surgery, personal fees from Stryker, personal fees from Books, outside the submitted work. Dr. Riehl has nothing to disclose.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.


  1. 1.
    Giordano V, Gomes AFS, Amaral NP, Albuquerque RP, Pires RES (2011) Preventing surgical complications: a survey on surgeons’ perception of intra-articular malleolar screw misplacement in a cadaveric study. Patient Saf Surg 5:24PubMedCentralCrossRefPubMedGoogle Scholar
  2. 2.
    Goergen TG, Danzig LA, Resnick D, Owen CA (1977) Roentgenographic evaluation of the tibiotalar joint. J Bone Joint Surg Am 59:874–877PubMedGoogle Scholar
  3. 3.
    Pankovich AM (1991) Trauma to the ankle. In: Jahss MH (ed) Disorders of the foot and ankle: medical and surgical management, 2nd edn. W.B Saunders, Philadelphia, pp 2361–2414Google Scholar
  4. 4.
    Shelton ML (1994) Complications of fractures and dislocations of the ankle. In: Epps CH Jr (ed) Complications in orthopaedic surgery, vol 2, 3rd edn. J.B Lippincott, Philadelphia, pp 595–648Google Scholar
  5. 5.
    Gourineni KV, Knuth AE, Nuber GF (1999) Radiographic evaluation of the position of implants in the medial malleolus in relation to the ankle joint space: anteroposterior compared with mortise radiographs. J Bone Joint Surg Am 81:364–369PubMedGoogle Scholar
  6. 6.
    Geissler WB, Tsao AK, Hughes JL (1996) Fractures and injuries of the ankle. Rockwood and green’s fractures in adults, 4th edn. Lippincott-Raven, Philadelphia, pp 2201–2261Google Scholar
  7. 7.
    Michelson JD, Hamel AJ, Buczek FL, Sharkey NA (2002) Kinematic behavior of the ankle following malleolar fracture repair in a high-fidelity cadaver model. J Bone Joint Surg Am 84:2029–2038PubMedGoogle Scholar
  8. 8.
    Romiti SL, Leitschuh PC (2001) Hardware in the medial malleolus: is it intra-articular? Foot Ankle Int 22:905–907PubMedGoogle Scholar
  9. 9.
    Cole P, Levy B, Schatzker J, Watson JT (2009) Tibial plateau fractures. In: Browner B, Levine A, Jupiter J, Trafton P, Krettek C (eds) Skeletal trauma: basic science management and reconstruction, 4th edn. Elsevier, Philadelphia, pp 2201–2287CrossRefGoogle Scholar
  10. 10.
    Tweet ML, Calfee RP, Stern PJ (2010) Rotational fluoroscopy assists in detection of intra-articular screw penetration during volar plating of the distal radius. J Hand Surg Am 35:619–627PubMedCentralCrossRefPubMedGoogle Scholar
  11. 11.
    Soong M, Got C, Katarincic Akelman E (2008) Fluoroscopic evaluation of intra-articular screw placement during locked volar plating of the distal radius: a cadaveric study. J Hand Surg Am 33:1720–1723CrossRefPubMedGoogle Scholar
  12. 12.
    Beris AE, Kabbani KT, Xenakis TA, Mitsionis G, Soucacos PK, Soucacos PN (1997) Surgical treatment of malleolar fractures. A review of 144 patients. Clin Orthop Relat Res 341:90–98CrossRefPubMedGoogle Scholar
  13. 13.
    Roberts RS (1983) Surgical treatment of displaced ankle fractures. Clin Orthop Relat Res 172:164–170PubMedGoogle Scholar
  14. 14.
    Ricci WM, Tornetta P, Borrelli J Jr (2012) Lag screw fixation of medial malleolar fractures: a biomechanical, radiographic, and clinical comparison of unicortical partially threaded lag screws and bicortical fully threaded lag screws. J Orthop Trauma 26:602–606CrossRefPubMedGoogle Scholar
  15. 15.
    Brown OL, Dirschl DR, Obremskey WT (2001) Incidence of hardware-related pain and its effect on functional outcomes after open reduction and internal fixation of ankle fractures. J Orthop Trauma 15:271–274CrossRefPubMedGoogle Scholar
  16. 16.
    Femino JE, Gruber BF, Karunakar MA (2007) Safe zone for the placement of medial malleolar screws. J Bone Joint Surg Am 89:133–138CrossRefPubMedGoogle Scholar
  17. 17.
    Berkes MB, Little MTM, Lazaro LE et al (2013) Articular congruity is associated with short-term clinical outcomes of operatively treated SER IV ankle fractures. J Bone Joint Surg Am 95:1769–1775CrossRefPubMedGoogle Scholar
  18. 18.
    van Bergen CJA, Tuijhof GJM, Sierevelt IN, van Dijk CN (2011) Direction of the oblique medial malleolar osteotomy for exposure of the talus. Arch Orthop Trauma Surg 131:893–901PubMedCentralCrossRefPubMedGoogle Scholar
  19. 19.
    Kang K, Chen Y, Qiang M, Hao Y, Li H, Dai H (2014) The morphology of medial malleolus and its clinical relevance. Pak J Med Sci 30:348–351Google Scholar

Copyright information

© Springer-Verlag France 2015

Authors and Affiliations

  • Jeffrey C. Wera
    • 1
    Email author
  • David Seligson
    • 1
  • John T. Riehl
    • 2
  1. 1.Division of Orthopaedic Trauma, Department of Orthopaedic SurgeryUniversity of LouisvilleLouisvilleUSA
  2. 2.Orthopaedic SurgeryBaptist Health Care and Andrews InstitutePensacolaUSA

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