Tension Band Wiring (TBW) Procedure for Medial Malleolus Fracture
The optimal surgical approach for medial malleolus fractures is open reduction and internal fixation using tension band wiring technique, which provides excellent stability and promotes early mobilization while preventing post-traumatic arthritis. 1
Preoperative Assessment and Planning
Obtain appropriate imaging:
- Standing (weight-bearing) anteroposterior (AP), medial oblique, and lateral radiographs as recommended by the American Academy of Orthopaedic Surgeons 1
- Consider CT for complex injuries or posterior malleolar involvement 1
- MRI may be useful if radiographs are negative but clinical suspicion remains high 1
Evaluate fracture pattern to determine suitability for TBW:
- Particularly effective for transverse fractures
- Consider fragment size and comminution (small fragments may require alternative fixation) 2
Surgical Procedure for Tension Band Wiring
Step 1: Patient Positioning and Preparation
- Position patient supine with a bump under the ipsilateral hip
- Apply tourniquet to the proximal thigh
- Prep and drape the ankle in standard sterile fashion
- Exsanguinate the limb and inflate tourniquet
Step 2: Surgical Approach
- Make a curved anteromedial incision centered over the medial malleolus
- Carefully dissect through subcutaneous tissue, protecting the saphenous vein and nerve
- Identify the fracture site and clear any hematoma or debris
Step 3: Fracture Reduction
- Reduce the fracture anatomically using pointed reduction clamps
- Verify reduction under direct visualization and fluoroscopy
- Temporarily hold reduction with K-wires if necessary
Step 4: K-Wire Placement
- Insert two parallel 1.6mm or 2.0mm K-wires from the tip of the medial malleolus, across the fracture site
- Ensure K-wires are parallel and perpendicular to the fracture line
- Advance K-wires to engage the opposite cortex for stability
- Verify position with fluoroscopy
Step 5: Tension Band Application
- Drill a transverse tunnel at the tibial metaphysis, approximately 3-4cm proximal to the fracture site
- Pass a 1.0mm or 1.25mm stainless steel wire through this tunnel
- Loop the wire in a figure-of-eight configuration around the protruding ends of the K-wires
- Tighten the wire using wire tighteners to create compression across the fracture site
Step 6: Securing the Construct
- Bend the proximal ends of the K-wires 180 degrees and tap them into the bone to prevent soft tissue irritation
- Cut and twist the ends of the stainless steel wire, burying the twisted portion to prevent soft tissue irritation
- Verify final construct stability and fracture reduction with fluoroscopy
Step 7: Wound Closure
- Irrigate the wound thoroughly
- Close the deep fascia with absorbable sutures
- Close the skin with non-absorbable sutures or staples
- Apply sterile dressing and a well-padded short leg splint
Postoperative Management
- Initial immobilization for 2 weeks in a splint or cast 1
- Clinical and radiographic follow-up at 2 weeks and 4-6 weeks to ensure maintained alignment and assess healing 1
- Begin early mobilization after initial immobilization period to prevent stiffness 1
- Progressive weight-bearing based on radiographic evidence of healing
- Consider accelerated protocol with early mobilization for appropriate patients, potentially allowing return to activities by 13-14 weeks (versus 18-19 weeks with traditional protocol) 1
Special Considerations
- For very small or comminuted fragments, mini-screws may be a better alternative to TBW 2
- For stress fractures of the medial malleolus, consider early ORIF in athletes desiring quick return to activity 3, 4
- Hook plates may provide advantages in cases with small or fragmented fragments 5
- Not all medial malleolar fractures require fixation - anterior collicular fractures may be managed non-operatively in some cases 6
Potential Complications
- Hardware irritation requiring removal
- Delayed union or non-union
- Post-traumatic arthritis
- Infection
- Persistent pain or instability 1