Open fractures are high-energy injuries that require a principle-based approach, starting with detailed evaluation of patient status and injury severity. Early, systemic, wide-spectrum antibiotic therapy should cover gram-positive and gram-negative organisms, and a common regimen is a 3-day administration of a first-generation cephalosporin and an aminoglycoside, supplemented with ampicillin or penicillin to cover anaerobes in farm or vascular injuries. Local antibiotic delivery with the bead pouch technique increases the local concentration of antibiotics, minimizes systemic toxicity, and prevents secondary wound contamination. Thorough irrigation and surgical debridement is critical for prevention of infection. Primary wound closure remains controversial because of concerns for gas gangrene. Partial wound closure is an alternative, with delayed wound closure within 3 to 7 days. In the presence of extensive soft tissue damage, local or free muscle flaps should be transferred to achieve coverage. Stable fracture fixation should be achieved with a method suitable for the bone and soft tissue characteristics. Early bone grafting is indicated for bone defects, unstable fractures treated with external fixation, and delayed union. A management plan guided by the above principles will achieve the goals of prevention of infection, fracture healing, and restoration of function in most of these challenging injuries.