Perhaps the most important advancement in the surgical treatment of high-energy pilon fractures has been the recognition of the need to delay primary surgery. However, at open reduction internal fixation an adequate incision must be made to clearly visualize the articular surface in an attempt to restore intraarticular anatomy. This article illustrates our extensile approach and its effect on soft-tissue healing. The approach allows complete access to the ankle joint to achieve reduction and fixation of the articular surface, as far medially or laterally as is necessary. In addition, it allows for easy placement of plates medially, laterally, or anteriorly. For fractures extending more proximally, plates can be placed subcutaneously from distal to proximal through the open incision.