Gustilo IIIC fractures represent the most severe spectrum of lower extremity trauma, characterized by high-energy skeletal injury, vascular disruption, and soft-tissue loss. Contemporary management demands early orthoplastic collaboration, rapid revascularization, and thoughtful soft-tissue reconstruction to optimize limb salvage. This review synthesizes current evidence and evolving strategies, including timing of coverage, flap selection, and adjunctive microsurgical techniques including flow through flaps, to guide decision-making in these complex injuries. Emphasis is placed on functional restoration, prevention of complications, and integration of modern limb-salvage paradigms to achieve high-quality outcomes in this challenging patient population.