Objective To evaluate the clinical use of delayed open reduction and internal fixation technique in the treatment of Rud?i Ⅲ Pilon fractures. Methods From May 1997 to June 2003, 38 patients with Rud?i Ⅲ Pilon fractures underwent immediate calcaneal traction as well as treatment with methylprednisolone and mannitol. After 5-8 days, all patients underwent regular open reduction and internal fixation with cloverleaf buttress plates. One week after the operation, ankle joint began to exercise with no weight bearing. Results All patients were followed up for average 18 months and evaluated subjectively and objectively by using systems of Teeny and Wiss, which showed good results for 74 %, mild for 21% and poor for 5%. All fractures healed within an average of 5.7 months except for two cases of infections and one soft tissue complication. Conclusion Delayed open reduction and internal fixation offers acceptable way for treatment of severe Pilon fractures.