Gustilo Anderson Classification

What are open fractures?

Open fractures, also known as open limb fractures, is an injury where the fractured bone and/or fracture hematoma are exposed to the external environment via a traumatic violation of the soft tissue and skin. The skin wound may lie at a site distant from the fracture and not directly over it. Therefore, any fracture that has a concomitant wound should be considered open until proven otherwise.

Causes

Open fractures can result from various traumatic events, including:

• High-energy injuries such as car accidents or falls from significant heights
• Sports-related injuries, especially those involving high-impact collisions
• Direct trauma from objects, such as gunshot wounds or severe blunt force

Complications

The complications associated with open fractures are serious and can significantly impact the patient’s recovery. These complications include:

• Infection due to exposure of the bone and tissues to the external environment
• Delayed bone healing or nonunion, where the bone does not heal properly
• Soft tissue injury, which can lead to long-term functional impairment and other complications
• Chronic pain and inflammation
• Increased risk of osteomyelitis (bone infection)

What is the Gustilo Anderson Classification?

The Gustilo-Anderson Classification, first described in 1976 by Gustilo and Anderson and later modified in 1987, is a widely used system for categorizing open fractures. Its primary purpose is to provide a prognostic and communicative framework that guides the management of these injuries. This classification helps clinicians determine the severity of an open fracture based on specific criteria such as wound size, degree of contamination, and the extent of soft tissue damage (Gustilo & Anderson, 1976).

What are the classifications of open tibial fractures?

The Gustilo-Anderson Classification categorizes open fractures into three major types: Type I, Type II, and Type III, with Type III further subdivided into A, B, and C.

• Type I fractures are characterized by a wound less than 1 cm long, minimal contamination, and mild soft tissue injury.
• Type II fractures involve a wound size between 1 and 10 cm with moderate contamination and soft tissue damage.
• Type III fractures are the most severe, involving wounds larger than 10 cm, significant contamination, and extensive soft tissue damage.

Type III fractures are further classified into:

• Type IIIA: Adequate soft tissue coverage despite extensive lacerations or flaps.
• Type IIIB: Extensive soft tissue loss, periosteal stripping, and bone exposure. These injuries often require flap coverage. They are now sub-classified into 1, 2, and 3 based on the number of patent vessels, respectively (Gustilo et al., 1987).
• Type IIIC: Any open fracture associated with arterial injury requiring repair, regardless of wound size.

Regardless of the examination findings, all high-energy traumas are considered Type III (Gustilo et al., 1984). This comprehensive classification system aids in predicting the risk of infection and other complications, thereby guiding the management and treatment strategies for patients with open fractures.

Benefits of using this template

Utilizing the Gustilo Anderson Classification template in clinical practice offers numerous advantages, ensuring a standardized and effective approach to managing open tibial shaft fractures and other open fractures. Here are some key benefits:

Standardized communication

Using the Gustilo Anderson Classification allows healthcare professionals to communicate clearly and effectively about the severity of open fractures. This common language helps coordinate care among different specialists, ensuring that everyone involved in the patient's treatment is on the same page.

Improved prognostic accuracy

The classification provides a structured way to assess and predict patient outcomes. By categorizing fractures based on specific criteria, clinicians can better anticipate potential complications and tailor their treatment plans, leading to more effective and personalized patient care.

Guiding treatment protocols

The template helps select appropriate fracture treatment and protocols, including antibiotic administration, surgical intervention such as internal fixation, and rehabilitation strategies. This ensures that patients receive the most suitable care based on the severity and characteristics of their fractures.

What to consider when grading

Several important factors must be considered when using the Gustilo Anderson Classification to grade open fractures to ensure an accurate and effective assessment.

Thorough examination

A comprehensive physical examination is crucial in grading open fractures. Clinicians should carefully assess the size of the wound, the extent of soft tissue damage, the level of contamination, and any signs of vascular injury. This detailed evaluation helps accurately categorize the various open fracture wounds and plan the appropriate treatment. As Gustilo and Anderson (1976) highlighted, a meticulous examination forms the foundation of effective open fracture management.

Use of imaging and negative pressure wound therapy

Supplemental imaging, such as X-rays and MRIs, is vital in assessing the management of open fractures. X-rays can reveal skeletal abnormalities, while MRIs provide detailed views of soft tissue involvement in compound fracture. These imaging techniques are essential for identifying underlying issues that may not be apparent during the physical examination, ensuring a more comprehensive understanding of the injury and guiding further treatment decisions.

Consideration of patient factors

It is essential to consider patient-specific factors, such as age, overall health, and any pre-existing conditions that may affect healing and recovery. These factors can influence the grading and initial management of the fracture and the choice of treatment protocols. Personalized care that considers these variables can improve patient outcomes and reduce the risk of complications (Gustilo & Anderson, 1976).

References

Gustilo, R. B., & Anderson, J. T. (1976). Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: Retrospective and prospective analyses. The Journal of Bone and Joint Surgery. American Volume, 58(4), 453–458. https://pubmed.ncbi.nlm.nih.gov/773941/

Gustilo, R. B., Mendoza, R. M., & Williams, D. N. (1984). Problems in the management of type III (severe) open fractures: A new classification of type III open fractures. Journal of Trauma and Acute Care Surgery, 24(8), 742–746. https://journals.lww.com/jtrauma/Abstract/1984/08000/Problems_in_the_Management_of_Type_III__Severe_.9.aspx

Gustilo, R. B., Gruninger, R. P., & Davis, T. (1987). Classification of type III (severe) open fractures relative to treatment and results. Orthopedics, 10(12), 1781–1788. https://pubmed.ncbi.nlm.nih.gov/3324085/