Fractures of the distal tibial plafond (ie, pilon) comprise a broad range of injury mechanisms, patient demographics, and soft-tissue and osseous lesions. Patients often present with considerably comminuted fracture patterns and notable soft-tissue compromise. Surgical intervention must be performed with respect for the exceedingly vulnerable soft-tissue envelope and with a properly executed technique. Even with proper timing, favorable host factors, and expert surgical technique, restoration of function and avoidance of complications are not always achievable. Recently validated techniques further diminish the risk of soft-tissue and osseous sepsis. These techniques include early (ie, "immediate") fixation, upgrading, primary arthrodesis, staged sequential posterior and anterior fixation, acute shortening, and transsyndesmotic fibular plating. Proper application of these recently adopted techniques may be instrumental in achieving aseptic union of pilon fractures.
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