Seven randomized controlled trials, including 566 patients with lateral malleolar fractures, were included in this systematic review and meta-analysis comparing intramedullary nailing (IMN) versus open reduction and plate fixation. Pooled outcomes of interest included infection rate, Olerud and Molander Ankle Score (OMAS), union rate, radiological outcomes, nerve injury rate, reoperation rate, loss of reduction, and total complication rate. The meta-analysis demonstrated that the infection rate was significantly lower in the IMN group compared to the plate group. No significant differences were found in OMAS, union rate, radiological outcomes, nerve injury rate, reoperation rate, loss of reduction, and total complication rate. These findings suggest that IMN may be a preferable method due to its lower infection rates.