The use of external fixation methods has become increasingly popular throughout the past decade in the treatment of tibial pilon fractures to prevent the dreaded soft tissue complications after high velocity injuries. A variety of methods has been proposed, including ankle-spanning half-pin frames; circular (Ilizarov) frames with tensioned wires; or hybrid frames, either as the sole treatment or, more frequently, in conjunction with limited internal screw fixation. External fixation also has a role in staged protocols as a primary tool for reduction and preliminary fixation until soft tissue consolidation makes internal fixation feasible. Although good to excellent results are reported in a high percentage of cases in most studies and infection rates have dropped to less than 10%, even for high velocity injuries with considerable soft tissue compromise, no single form of treatment seems to be suitable for all types of pilon fractures. Major concerns after external fixation are the development of pin track infections, malunions or nonunions, and the danger of imperfect reduction of the articular surface. Staged protocols that are based on the severity of the fracture and soft tissue injury are likely to play a major role in the future treatment of pilon fractures. In the treatment of acute malleolar fractures, ankle-spanning external fixation is reserved for fractures with considerable soft tissue compromise, open fractures, or compartment syndrome as a temporary transfixation until internal fixation becomes feasible.