PURPOSE: Ankle injuries involving the tibiofibular syndesmosis often necessitate operative fixation to restore stability to the ankle. Recent literature in the adult population has suggested that suture button fixation may be superior to screw fixation. There is little evidence as to which construct is preferable in the pediatric and adolescent population. This study investigates outcomes of suture button and screw fixation in adolescent ankle syndesmotic injuries. METHODS: A retrospective matched cohort study over 10 years of pediatric patients who underwent ankle syndesmotic fixation at a large Level 1 Trauma Center was conducted. Both isolated syndesmotic injuries and ankle fractures with syndesmotic disruption were included. Preoperative variables collected include basic patient demographics, body mass index, and fracture type. Suture button and screw cohorts were matched based on age, race, sex, and open fracture utilizing propensity scores. Outcomes assessed include reoperation and implant failure. RESULTS: A total of 44 cases of operative fixation of the ankle syndesmosis were identified with a mean age of 16 years. After matching cohorts based on age, sex, race, and open fracture status, there were 17 patients in the suture button and screw cohorts, respectively. Patients undergoing screw fixation had a six times greater risk of reoperation (p = 0.043) and 13 times greater risk of implant failure (p < 0.001). Out of six cases of reoperation in the screw cohort, five were unplanned. CONCLUSION: Our findings favor suture button fixation in operative management of adolescent tibiofibular syndesmotic injuries. Compared with screws, suture buttons are associated with lower risk of both reoperation and implant failure. LEVEL OF EVIDENCE: level III therapeutic.