The present narrative review provides a summary of current concepts for the treatment of ankle fractures in elderly patients. Despite a high complication rate, open reduction and internal fixation is the gold standard for operative care. However, individual patient-based treatment decision considering the soft-tissue status, the fracture pattern, as well as the patient's mobility and comorbidities is mandatory to achieve sufficient patient outcomes. Due to high complication rates after surgery in the past, techniques such as fibular nails or minimal invasive techniques should be considered.