We describe the clinical picture and indications for three fix and flap strategies（fix and flap, fix followed by flap, and flap followed by fix）that we have selectively used to treat severe open extremity fractures. Gopal’s fix and flap, which is completed within 72 hours of injury, remains the best reconstruction strategy to avoid deep wound infection and post-traumatic vessel disease. The indications for fix followed by flap are as follows: In the upper extremities, the eventual length of the bone after osteosynthesis determines our approach to the nerve and musculotendinous reconstruction. In the lower extremities, we decide the area of soft tissue reconstruction after osteosynthesis depending on whether we are treating a joint and metaphysis fracture or multiple fractures of a long bone. The indications for flap followed by fix are cases with previous infection, in which the priority is soft tissue reconstruction rather than bone reconstruction. It is important for the operator to use different treatment strategies for bone and soft tissue reconstruction, and it is necessary to select the best method.
