Between 1982 and 1992, 79 pylon fractures were treated with internal fixation as the primary treatment at the trauma department of the Hannover Medical School. In a retrospective study 71 patients were evaluated, and 51 of them were re-examined clinically and radiographically an average of 68 months after injury. The purpose of this study was to compare these different forms of surgical management concerning their long-term results: 1. Minimal invasive internal fixation for reconstruction of the joint with external transfixation of the ankle joint and/or plaster cast until bony healing occurred. 2. Primary internal fixation with plating of tibia and fibula following the AO techniques. 3. Internal fixation with a plate applied in a second step after initial reconstruction of the joint with minimal internal fixation and short-term external transfixation. Evaluation was based on the infection rate, the development of posttraumatic arthritis and the range of motion in the ankle joint as objective criteria. Subjective criteria were pain, swelling, and restrictions of working or leisure activities. Although only closed fractures were treated primarily by internal fixation with plating no significant differences between the three groups were found in the classification of fractures and soft tissue damage. All but 4 fractures were type-C lesions according to the AO classification, and 19 patients sustained open injuries. The infection rate for minimal invasive internal fixation was significantly lower with a two-step procedure (group 3) than with the one-step procedure according to a suitable statistic test (P < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)