Five studies (951 patients) were included in this systematic review and meta-analysis comparing surgical and conservative treatment of unstable ankle fractures. Outcomes of interest included the risk of non-union, mal-union, infection, radiological signs of osteoarthritis, and early treatment failure, as well as functional outcomes. Pooled results for the risk of non-union, mal-union and early treatment failure were significantly in favour of the surgical group compared to the conservative group. No significant differences in the risk of infection or radiological signs of osteoarthritis were observed between the surgical and conservative groups. Functional outcomes were not pooled due to heterogeneous methods of measurements; functional outcomes were variable among the 5 studies.