Aim: To assess and compare the functional outcomes, radiological results, and complication rates between extramedullary and intramedullary fixation methods for lateral malleolus fractures. Materials and Methods: This prospective comparative study included 40 patients aged 18 to 60, of both sexes, with ankle fractures that met the inclusion criteria of distal third fibula fractures (Danis-Weber types A, B, and low type C) and bimalleolar ankle fractures. Randomization was conducted using a random number table (Odd: ORIF by extramedullary plating; Even: intramedullary fixation). Post-operative care included antibiotics, early mobilization, and physiotherapy. Patients were followed up every four weeks for 24 weeks, assessed by post-operative X-rays and reduction quality criteria. Serial X-rays monitored radiological outcomes, evaluating anatomical reduction, stability of fixation, and average union time. Functional outcomes, such as time to weight bearing, were measured using Ankle Functional Scores, with complications recorded throughout the follow-up. Results: Significant differences in mean incision size and surgery duration were observed between the extramedullary and intramedullary groups (P = 0.0001). Radiological reduction and complication rates were comparable across groups. Functional outcomes showed notable improvement between 3 and 6 months of follow-up (P = 0.001). AOFAS scores at 3 and 6 months were similar across both groups. Conclusion: Intramedullary fixation can be considered an alternative to extramedullary fixation for lateral malleolus fractures. However, large-scale, multi-center, randomized studies are required to further validate surgical indications and functional outcomes.