The purpose of this study was to determine the ability of intramedullary fibular fixation to maintain reduction until healing and to determine the overall complication rate in high-energy pilon fractures associated with fibular fractures.Retrospective study.Level I university trauma center.From 2000 to 2007, 972 pilon fractures were treated at our institution, 38 of which were treated with an intramedullary device for the associated fibular fracture. Two patients had acute amputations and two died; 1-year follow-up was obtained in 27 of the remaining patients. Average length of follow-up was 21 months.A retrospective chart and radiograph review was conducted of all patients for data extraction.Fibular fixation type and length, fibular healing, and complications.Average patient age was 36 years (range, 18-59 years). Four of the fibular fractures were segmental. All fractures had at least 50% of the cortex intact to prevent shortening. The average height of the fibular fractures from the distal tip was 6.9 cm (range, 1.3-22.2 cm). In 20 patients, a 3.5-mm fully threaded cortical screw was used for stabilization, and in the remaining seven, a 2.5-mm wire was used. The intramedullary implant extended 8.5 cm above the most proximal fracture line on average (range, 1.6-29.8 cm). Fibular alignment was within 3 degrees of anatomic in all cases after initial fixation. At final follow-up, fibular alignment had not changed more than 1 degrees in any case. No complications related to the fibular incision occurred, and all fibula fractures healed within 3 months.In axially and rotationally stable fibular fracture patterns associated with pilon fractures, intramedullary fibular stabilization was effective in maintaining fibular alignment. This technique led to reliable fracture healing in appropriately selected fractures and may be particularly advantageous in patients with compromised lateral and posterolateral soft tissues.