Ankle fractures with a posterior malleolus component are complex injuries. The most commonly used operative methods include indirect reduction via a percutaneous anterior approach and direct reduction via a posterolateral approach. For large posterior malleolus fractures with medial extension, direct reduction via a posteromedial approach is an alternative operative option. The authors hypothesized that fixation of large posterior malleolus fractures via a posteromedial approach results in anatomic reduction and stable plate fixation. From 2008 to 2015, 22 (9.0%) of 244 consecutive operative ankle fractures were identified as posterior malleolus fractures treated using a posteromedial approach. Patient charts were retrospectively reviewed for demographics, operative details, follow-up time, and any postoperative complications. Postoperative radiographs were reviewed to ensure that anatomic reduction and stable fixation was maintained. Sixteen (72.7%) of 22 patients were female, and the average age at the time of surgery was 54.1 years (range, 26-86 years). The average follow-up time was 13.0 months (range, 2.0-41.4 months). Twenty-one (95.5%) of 22 patients healed on a radiographic and clinical basis. There was an 18.2% (4 of 22) postoperative complication rate: 1 patient had a nonunion, 1 patient had cellulitis, 1 patient had osteomyelitis involving the fibula, and 1 patient had symptomatic heterotopic ossification. Open reduction and internal fixation of posterior malleolus fractures via a posteromedial approach achieved anatomic reduction, stable plate fixation, and complete healing in all but 1 patient. This study demonstrates that the posteromedial approach is a reasonable alternative to other more commonly used methods for treating these fractures. [Orthopedics. 2020;43(3):e166-e170.].