Intramedullary nailing of open fractures requires careful surgical judgment, consideration of alternative techniques, and the ability to use a number of different methods, including various designs with or without obligatory reaming. With good technique and well-selected indications, intramedullary nailing of open fractures may offer advantages not available through other types of fracture stabilization. Open fractures of the femur are best treated with delayed closed reamed nailing. Acute open nailing of the femur is justified to salvage life and limb in multiply injured patients. Acute nonreamed nailing of open fractures of the tibia has been shown to give results comparable to external skeletal fixation. The role for intramedullary nailing of open fractures of the upper extremity is limited.