A total of 140 patients diagnosed with Lauge-Hansen supination-external rotation (SER) IV ankle fractures were identified in this prospective randomized trial. 24 patients were identified as having an unstable syndesmosis (external rotation stress test) comparatively to the ipsilateral ankle, and were randomly allocated to either receive syndesmotic screw fixation or no syndesmotic fixation. The remaining 116 patients had a stable syndesmosis compared to the uninjured ankle. This study aimed to compare the intermediate functional and clinical outcomes of patients with external rotation ankle fractures who underwent syndesmotic transfixation versus those without fixation. No significant differences were observed in functional and radiographic outcome between the syndesmotic fixation and no fixation groups.