External fixation in severe open tibial shaft fractures: indications, orthoplastic strategy, and infection-aware decision-making.

Intramedullary nailing remains the preferred definitive fixation for most open tibial shaft fractures once contamination is controlled and soft tissues permit internal implantation. External fixation should be chosen according to intent: damage control, preservation of orthoplastic access, staged bridge to internal fixation, or definitive frame-based reconstruction. Temporary frames are most useful in polytrauma, vascular injury, severe swelling, gross contamination, and wounds needing serial debridement, flap planning, or negative-pressure therapy. Conversion to intramedullary nailing is appropriate only when margins are declared, coverage is complete or reliably scheduled, contamination is controlled, and fracture-related infection (FRI) is not suspected. Definitive circular or hybrid fixation is favored when repeated excision, vascular repair, segmental bone loss, bone transport, uncertain margins, or suspected/established FRI makes buried metal less attractive. Successful frame treatment requires safe pin placement outside flap and implant corridors, restoration of length, axis, and rotation without distraction, timely soft-tissue coverage, and standardized infection and pin-site pathways.