Forty-two patients with pilon fractures were followed 24 to 96 (mean, 53) months post-fracture. Fractures were classified as Type I (26%), Type II (29%), or Type III (45%) as defined by Ruedi and Allgower. Type I fractures were usually torsional in nature whereas Type II and III injuries were usually the result of a fall from a height or motor vehicle accident. Type I and II pilon fractures were amenable to anatomic open reduction and stable internal fixation and 80% or more had satisfactory results. Only 44% of Type III fractures treated by open reduction and internal fixation produced a satisfactory outcome. Nonanatomic reduction, unstable fixation, infection, nonunion, and/or angulation were the usual causes of failure of this form of treatment.