The aim of this study was to evaluate 1) long-term results of ankle fractures with a posterior malleolar fragment, and 2) the need for fixation of fragments smaller than 25%. Forty-five patients with ankle fractures and a posterior malleolar fragment were evaluated. Mean follow-up was 13 years (range, 2-24). The size and fixation of the fragment were registered. Outcome was assessed using an Ankle Fracture Scoring System (maximum: 150 points), a 10-point Numeric Scale for Pain (1 = no pain, 10 = unbearable pain) and an OsteoArthritis Score (0 = no osteoarthritis, 3 = severe osteoarthritis). The mean Ankle Fracture Scoring System, Numeric Scale for Pain and Osteoarthritis-score were 124, 2.5, and 1.2, respectively. The mean size of fixated fragments was significantly larger than that of nonfixated fragments (30% versus 16%). Those patients in which the posterior malleolar fragment was fixated did not have a statistically significant better outcome than those patients in which the fragments were not fixated (Ankle Fracture Scoring System: 119 versus 126, Numeric Scale for Pain: 2.6 versus 2.4, Osteoarthritis-score: 1.0 versus 1.2). There was no significant correlation between outcome and size of unfixated fragments. Fracture-dislocation was seen more often in combination with larger fragments (24% versus 15%) and resulted in statistically significant worse long-term outcome than nondislocated fractures, except for pain (Ankle Fracture Scoring System: 115 versus 134, Osteoarthritis-score: 1.7 versus 0.8). In conclusion, patients showed good results after 13 years follow-up and there was no evidence for the need for fixation of fragments smaller than 25%.