The aim of this review is to determine whether suture button fixation is more effective than traditional screw fixation for the management of acute distal tibiofibular syndesmotic injuries. Syndesmotic injuries are common and require surgical management to avoid chronic pain and instability, and to improve long-term functional outcomes. Screw fixation and suture button fixation are the 2 techniques of choice for treatment; however, there remains ongoing debate surrounding which treatment modality delivers the best outcomes, leading to significant variability in practice. The suture button is a relatively new technique; therefore, there is a need for an updated, high-quality systematic review to help guide best practice in syndesmosis injury management. This review will consider studies comparing suture button versus screw fixation of acute (<6 weeks) distal tibiofibular syndesmotic injuries. Patients aged 18 or over, with syndesmotic injuries requiring surgical stabilization, with or without an associated fracture, will be included. The primary outcome of interest will be composite functional ankle scores. Secondary outcomes will include range of motion, pain, joint malreduction, complications rates, re-operation rates, and return to work/sport. This review will be conducted in accordance with the JBI guidelines for systematic reviews of effectiveness. The following electronic databases will be searched: PubMed, Embase, Scopus, The Cochrane Register of Controlled Trials, and Web of Science, in addition to gray literature databases. No publication date or language limits will be applied. Two independent reviewers will screen titles, abstracts, and full-text studies, assessing methodological quality using the JBI critical appraisal tools. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach will be used to assess certainty in the findings. PROSPERO CRD42022331211.