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Ankle fractures have a significantly worse functional outcome when they include a posterior tibial fragment. In 57 trimalleolar fractures, the effect of size, internal fixation, and anatomic reduction of the posterior fragment on the prognosis was evaluated.A modified Weber protocol was used, providing a rating system for subjective, objective, and radiographic results. A visual analogue scale for subjective actual pain was also scored.The involvement of the articular surface ranged from 8% to 55%. Size or fixation of the fragment did not influence prognosis. Joint congruity in fragments ≥ 10% of the articular surface was a significant factor influencing prognosis. Overall, the modified Weber protocol result was excellent in 10%, good in 15%, fair in 25%, and poor in 50% of patients. However, the low average visual analogue scale of 3.0 in the whole group does not appear representative of 50% poor results, indicating that the modified Weber protocol is fairly strict and overestimates the number of poor results.Joint congruity with or without fixation was a significant factor influencing prognosis. Congruity should be achieved for fragments ≥ 10% of the tibial articular surface.