Fractures of the upper ankle joint are frequent injuries and part of routine clinical trauma surgery. In recent years, treatment strategies have changed in different ways due to advances in imaging diagnostics and a better understanding of the biomechanics. In addition, new implant systems are available. The goals of the reconstruction are anatomical reduction with restoration of the joint anatomy, reconstruction of the length, rotation and axial relationships as well as the restoration of stable joint guidance. In addition to the bony reconstruction, the focus is on restoring ligamentous instabilities. Keywords that are increasingly more in focus and controversial are: the posterior malleolar fragment, syndesmosis instability, the fourth malleolus and the importance of the deltoid ligament. For a good long-term result, anatomical reconstruction remains the basic requirement, regardless of the methods used.