48 patients with a trimalleolar fracture featuring a posterior fragment with >25% articular involvement, >2mm displacement, and ankle instability were included in this study. Patients were randomized to the management of the posterior malleolus fragment using indirect reduction and anteroposterior fixation or direct reduction and posteroanterior fixation. The outcomes assessed over the 12-month follow-up included the quality of reduction, range of motion deficit, and complications. All fractures had healed completely by 3 months. The quality of reduction was significantly better with direct reduction and posteroanterior fixation. There was no significant difference in range of dorsiflexion deficit between the two groups.