This document summarizes evidence from extensive research on the treatment of open tibial fractures comparing external fixation to nailing. It finds that for type 3B open fractures with bone loss, contamination, and delayed presentation, external fixation may have lower deep infection rates than nailing. However, existing studies have had a low number of type 3B cases. A high-quality randomized controlled trial is still needed directly comparing nailing to external fixation for severe 3B open tibial fractures. External fixation can allow for repeat debridement but risks loss of alignment, while infection after nailing requires multiple surgeries. The best treatment choice depends on the specific fracture characteristics and surgeon experience.