Seven randomized controlled trials, including 586 patients with ankle fractures, were analyzed to compare fibular intramedullary nail fixation (FINF) versus plate fixation (PF). Pooled outcomes of interest included functional outcomes at 3, 6, and 12 months, overall complication rates, infection, pain, hardware failure, nerve injury, and bony union. Results indicated no significant differences in functional outcomes at any postoperative time point. FINF demonstrated a significantly lower infection rate, but PF had a significantly lower hardware failure rate. No differences were observed in bony union rates. The study suggests that FINF is a viable alternative to PF, with comparable effectiveness but differing safety profiles, requiring further research to refine indications and minimize complications.