Geriatric ankle fracture management requires a comprehensive approach that balances appropriate patient optimization, fracture reduction, stability, and early mobilization. Surgical and nonsurgical options should be cautiously considered based on patient and fracture characteristics. Early weight-bearing treatment options should be pursued when possible. There are a myriad of treatment options including fibular intramedullary devices or minimally invasive joint prep tibiotalocalcaneal nailing that minimize soft tissue disruption and can provide robust stability sufficient to allow early weight-bearing postoperatively when appropriate. It is essential for geriatric patient treatment teams to optimize outcomes and minimize complications in this often-challenging patient population.