Ankle fractures are one of the most common injuries treated by orthopaedic surgeons. No globally accepted algorithm exists for post-injury imaging. It is unclear whether routine x-rays change management or simply present an extra expense. The authors randomized 247 patients to routine care (X-rays at 1, 2, 6, and 12 weeks) versus a reduced-imaging protocol (radiographs at 6 and 12 weeks only performed if clinically indicated. Outcomes included the Olerud-Molander Ankle Score (OMAS), the American Academy of Orthopaedic Surgeons (AAOS) ankle score questionnaire, the EuroQol 5-Dimensions 3-Level (EQ-5D-3L), and Short Form 36 (SF-36). In addition, pain, number of radiographs and healthcare costs were measured. 154 (63%) patients underwent surgery. Patients in the reduced-imaging group had significantly fewer median radiographs (4 vs. 5, p < 0.005). OMAS, AAOS, EQ-5D-3L, pain levels, health perception, self-perceived recovery, and complications did not differ between the two groups. Radiography costs were significantly lower in the reduced imaging group (-48 euros per patient). Overall costs were comparable between groups. Overall, a reduced imaging protocol resulted in fewer x-rays and lower radiography costs with no impact on function. Overall costs, however, were not impacted.