Stability is the key issue in the management of ankle fractures. Unstable ankle fractures require operative management to achieve anatomic fixation, restoration of ankle joint stability and normal mechanics. It is essential to diagnose all elements of the injury, including soft tissue and syndesmotic injuries. Therefore, CT scanning is recommended preoperatively. Whilst the vast majority of these fractures require direct fixation, posterior malleolus fracture morphology, rather than size, should guide the need for fixation. Surgeons should be familiar with posterior approaches (posterolateral, posteromedial). Syndesmotic stability should be intraoperatively tested (open or arthroscopically), after fracture fixation. Anterior syndesmotic avulsion fractures (also called “anterior malleolar fractures”), should also be diagnosed and stabilised. Combined approaches are often used to achieve anatomic reduction and fixation. Alternative stabilisation strategies, such as primary hindfoot nailing, or percutaneous fixation, may be required for elderly fragile patients or those with complicated diabetes mellitus. Arthroscopically assisted fixation is used in some fractures, also aiding syndesmosis assessment.