High-energy tibial pilon fractures have varying degrees of metaphyseal comminution and shortening. Initial management usually includes bridging external fixation. With increasing understanding of the significance of the displaced posterior articular fragment, many surgeons choose to repair the posterior tibia through a posterolateral approach at the time the fibula is plated. The three-stage procedure consists of initial external fixation, a posterolateral approach, and finally, an anterior approach to the tibia. Anterior or anteromedial approaches have traditionally been used to access the anterior and medial columns of the distal tibia and are still used for certain anterior crush or medial split-depression patterns. These approaches, however, provide only limited exposure to the anterolateral articular surface, and tension from the inherent tone of the tibialis anterior muscle can contribute to wound complications or tendon adhesions, which can negatively affect functional outcome. The anterolateral approach provides ample exposure to the anterior and anterolateral distal tibia and can be combined with a limited medial approach to effectively access these fractures while minimizing soft-tissue complications.