Abstract: Objective To explore the application of tranexamic acid(TXA) in the ankle fracture fixation surgery with grade Ⅳ supination external rotation type. Methods Total 80 cases with grade Ⅳ supination external rotation ankle fractures from February 2015 to December 2019 were retrospective analyzed. According to whether the use of intraoperative tourniquet or preoperative tranexamic acid, patients were divided into three groups, group A(26 cases):the tranexamic acid was employed in preoperative and intraoperative tourniquet was not used, group B(29 cases):the tranexamic acid was not employed and intraoperative tourniquet was used, group C(25 cases):the tranexamic acid and tourniquet were not used. The total blood loss, overt blood loss, hidden blood loss and postoperative VAS score were gathered. The blood loss and related complications was comparative analysis between the three groups. Results The general information preoperative of three groups were not statistically significant(all P>0.05). The total blood loss, hidden blood loss, and overt blood loss in the group A were(170.6±12.2) mL,(89.8±7.0) mL,(80.8±11.1) mL respectively, in the group B were(215.4±39.5) mL,(187.8±39.9) mL,(27.6±7.4) mL respectively, and in the group C were(298.8 31.2) mL,(143.3 22.4) mL,(155.5 19.1) mL respectively. The total amount of blood loss in group A and group B were significantly lower than group C, the amount of the hidden blood loss of group A was significantly lower than group B and group C, and the amount of overt blood loss of group B was significantly lower than group A and group C(all P<0.05). The VAS scores 1, 2, 3 days after surgery of group A were significantly lower than group B and group C(all P<0.05). Followed up for 3 months, there were 1 poor healing of incision case in group B and 3 poor healing of incision cases in group C, and the wound healed well after strengthening dressing change. Conclusion The tranexamic acid used in the ankle fracture fixation surgery with the grade Ⅳ rotation of external rotation type can reduce the total amount of blood loss and postoperative blood loss, does not increase the incidence of postoperative related complications, and can reduce the postoperative pain score. It is in line with the concept of rapid rehabilitation actively advocated by the state, and has a good application prospect in the traumatic orthopedics.