BACKGROUND Treatment of open fractures continues to be a challenge for orthopedic and trauma surgeons, and early treatment recommendations, which persist in the literature for decades, often do not have supporting data. METHODS This is a critical review of the literature surrounding controversies in the initial management of open fractures. It also focuses on the utility of negative pressure dressings in the care of associated complex wounds. Studies were selected based on their relevance to the treatment of open fractures. RESULTS A total of 40 studies were included. The following topics were critically discussed: timing of initial debridement, antibiotic coverage, utility of obtaining cultures, and timing of wound closure. CONCLUSION The majority of open fractures require urgent, not emergent, irrigation and debridement. Antibiotics are essential in preventing infection in open fractures. Timely wound closure after all necrotic tissue has been debrided decreases complications in open fractures. Finally, negative pressure wound therapy has dramatically changed the care of associated complex wounds.