Background <p>Geriatric ankle fractures require treatment strategies aimed at early, safe mobilization with a risk of complications as low as possible. Surgical procedures are associated with an increased perioperative risk.</p> Objective <p>To determine which fractures can be safely managed conservatively in older patients and which criteria are decisive.</p> Material and methods <p>Narrative review of the literature on randomized trials and systematic reviews.</p> Results <p>Stable fractures, including Weber&#xa0;A and stable Weber B fractures, isolated medial malleolar fractures (Herscovici types A–C), and non-displaced posterior malleolar fractures, can be treated conservatively with full weight-bearing as tolerated when ankle stability is confirmed. The assessment of ankle stability using radiographs of weight bearing is decisive, optionally supplemented by stress views or computed tomography (CT) during weight bearing. Even fractures with radiological signs of instability can be managed conservatively in selected cases of geriatric patients when the individual frailty and mobility are taken into consideration. Randomized trials demonstrate no functional advantage of surgery over conservative treatment with full-contact casts in patients older than 60&#xa0;years.</p> Conclusion <p>With appropriate patient selection, conservative treatment represents an evidence-based and functionally comparable treatment option with lower complication rates than surgery.</p>