Historically, the treatment and outcomes related to pilon fractures have been variable despite anatomic reduction and fixation. Early results with treatment via early primary open reduction and internal fixation yielded mixed clinical outcomes, especially suboptimal complication rates, including infection, malunion, and nonunion. Treatment with external fixation also exhibited similar outcomes with mixed support reported in the literature. Despite continued controversy, the advent of newer implant technologies, improved surgical techniques, and management with a staged protocol have resulted in encouraging clinical outcomes with minimization of postoperative complications. Crucial decisions made during treatment can help to maximize outcomes while minimizing complication rates. Particular attention to the fracture pattern with radiographic guidance can help direct surgical decision making with appropriate care given to optimize soft-tissue status. A variety of available incisions can facilitate proper bony and articular reduction. During the late and failed stages of fracture management, additional treatment options include external ring fixation, arthrodesis, and arthroplasty. As complications arise, meticulous, prompt care can help to achieve the best possible outcomes.