Eighty-one patients with supination external rotation type IV ankle injuries were randomized to receive either intramedullary nail fixation (n=42) or plate fixation (n=39). Outcomes of interest included the rate of postoperative complications, operation times, bone healing times, American Orthopaedic Foot & Ankle Society (AOFAS) scores, visual analog scale (VAS) scores for pain, and ankle range of motion. Outcomes were assessed up to 12 months. Overall, the results of the study revealed that the intramedullary nail group had a significantly lower rate of postoperative complications compared to the plate fixation group. Both treatments had similar results in terms of operation time, bone healing time, AOFAS scores, VAS scores, and functional evaluations. The findings suggest that intramedullary nail fixation may be preferable due to its lower complication rate.