Pilon fractures of the distal tibia are complex, high-energy injuries with significant metaphyseal comminution and articular impaction. Management of these fractures requires both technical expertise and appreciation for the traumatized soft tissues. The tremendous compressive and shearing forces involved often lead to open fractures, compartment syndrome, neurovascular injuries, and posttraumatic arthrosis despite anatomic reconstruction. Complications should be expected and treated promptly, as failing to do so could deteriorate into an unsalvageable situation. Additionally, surgeons must consider their own handling of the soft tissues and weigh early definitive treatment against that of a delayed or staged protocol. Although minimally invasive techniques and the use of anatomically precontoured plates are now predominant, the principle of absolute stability and anatomic reduction of the articular surface remains the core objective.