The treatment of tibial pilon fractures has evolved substantially over the past decades due to ever-increasing high-energy injuries. Open reduction and internal fixation of these intra-articular fractures requires an appreciation for a number of basic principles: respect the soft tissues, understand the fracture pattern, use safe surgical approaches, and provide stability that allows for early motion of the ankle. Surgical strategy should be customized based on the fracture pattern, access needed for fracture visualization and reduction, and status of the soft tissues. Given the ability to obtain an accurate stable reduction, smaller implants are typically adequate using multiple small incisions. We view this surgical tactic as continuing the evolution of complex fracture treatment whose origins lie in the influences of pioneers such as Dr Sigvard T. Hansen Jr.