A posterior pilon fracture is a pilon variant that is a challenging injury to treat and can result in poor functional outcomes for patients. Owing primarily to the difficulty in approaching the fracture, there has been no widely accepted method of treatment. Treatments range from indirect reduction techniques to direct reduction via an open ankle dislocation. We present a method of open reduction and internal fixation of the posterior pilon using a posteromedial and/or posterolateral approach depending on the location of the fracture fragment. We describe the potential complications, postoperative rehabilitation, and the results we have seen using this method. We offer this method as a useful option to treating this difficult fracture pattern.