Open tibial fractures are challenging injuries to deal with. To receive the best outcome they require the services of both an experienced orthopaedic trauma surgeon and plastic surgeon with an interest in lower limb trauma. The A&E management should follow ATLS protocols followed by administration of prophylactic antibiotics. The surgical management includes adequate débridement, lavage, skeletal stabilisation and ultimately soft tissue coverage. The best method of skeletal stabilisation is yet to be proven, although from the studies available it appears that reamed and unreamed nailing as well as external fixation are all acceptable surgical options, each with their own advantages and disadvantages, which the surgeon should be aware of. The results of immediate soft tissue coverage following open tibia fractures are encouraging, however this method is not yet adequately proven to be safe by randomised controlled trials, and hence cannot be encouraged routinely. Definitive soft tissue cover should certainly be achieved within 5–10 days of the injury. Bone morphogenic proteins may have a role in promoting union of grade III open tibial fractures. When patients have a mangled extremity score of greater than or equal to 7, or grade IIIC injuries, surgeons should consider early amputation, rather than limb salvage.