Preservation of the soft tissue is of particular importance in the care of pilon fractures. Improper soft tissue management has been attributed to high rates of nonunion, nerve injury, and failures (1–12). Traditional open reduction internal fixation (ORIF) of pilon fractures allows for direct visualization of the fracture(s) but is criticized for the large exposure and periosteal stripping. As a result, this approach has been blamed for high nonunion rates as well as failure of the soft tissue to accommodate implants (1, 5, 8, 13). External fixation has also been used but has not demonstrated much advantage to internal fixation and requires significant postoperative care. Also, external fixation has a higher incidence of malunion (6, 14) and has inherent risks for pin-tract infections (14, 15). In an attempt to limit the iatrogenic soft tissue injury (5, 6, 7), some surgeons have used a limited ORIF concentrating on restoration of the articular surface combined with ring or hybrid external fixation. The “2-stage” technique combines the benefits of both external and internal fixation, and is thought to limit soft tissue related complications by allowing soft tissue recovery time before the introduction of internal fixation. Initial temporary external fixation combined with limited exposures for internal fixation (2-stage technique) at a later date allows for less disruption of the soft tissue envelope, leading to a decrease in complications associated with traditional open approaches. This may be achieved through relatively “small incisions” extending from the pole of the malleolus to the metaphyseal fracture(s), although these incisions can still be quite long, especially when significant articular reconstruction and/or bone grafting is required. Other descriptions include “limited approach” or “minimally invasive”; and this differs from a true percutaneous approach. With the advent of locking plate technology, surgeons have successfully managed a variety of fractures though smaller incisions to introduce the plate(s)—the percutaneous approach. Unlike traditional plating methods, locking plates do not rely on frictional forces between the plate/bone interface to achieve compression and stability. This allows for less damage to the periosteal blood supply, which may theoretically decrease the incidence of delayed or nonunion, soft tissue complications, and possibly secondary loss of fixation (16, 17). A recent study by Salton et al (18) demonstrated no major complications and only 4 minor soft tissue complications in a series of 19 patients treated with a limited incision and percutaneous medial plate fixation. More recently available contoured locking plates with multiple options for metaphyseal screw placement through the “percutaneous” incision allow for the surgeon to achieve stability through this access point. With percutaneous locking plates, the incision may be even smaller than used with the traditional 2-stage technique.