In many patients who undergo open reduction-internal fixation of ankle fractures, there is a failure to achieve good clinical outcomes despite radiographic evidence of anatomic reduction. One possible reason for this is the high incidence of concomitant intra-articular pathology associated with ankle fractures that may go unrecognized using traditional open approaches. Arthroscopy in the setting of acute operative management of ankle fractures provides a means to completely assess intra-articular pathology, as well as provide direct therapeutic intervention in many instances. Arthroscopic management techniques include debridement of loose intra-articular fragments, assisted fracture reduction, microfracture of chondral injuries, and assessment of syndesmotic stability. The indications for arthroscopy in the setting of ankle fractures have not been fully defined; however, it is our practice to perform an arthroscopic assessment of all ankle fractures requiring surgical intervention. We present a sample of our experience using this technique that shows the severity of intra-articular pathology that is often found and occurs even in association with fracture patterns with seemingly innocuous radiographic appearances.