From the Guidelines
The Gustilo-Anderson classification system is still widely used for grading open fractures, but the OTA open fracture classification system (OTA-OFC) is preferred in the current literature due to its greater interobserver agreement and validation as a measure of injury severity 1.
Open Fracture Grading Systems
The Gustilo-Anderson classification system categorizes open fractures into three main types based on wound size, contamination, soft tissue damage, and fracture complexity. However, the OTA-OFC is based on the extent of the injury to five independent domains, including skin, muscle, arterial, contamination, and bone loss.
Key Characteristics of Each System
- The Gustilo-Anderson system:
- Type I fractures have clean wounds less than 1 cm with minimal soft tissue damage and simple fracture patterns.
- Type II fractures have wounds larger than 1 cm without extensive soft tissue damage or flaps.
- Type III fractures are the most severe and are subdivided into IIIA, IIIB, and IIIC.
- The OTA-OFC system provides a more detailed assessment of the injury severity, which can guide treatment decisions and predict outcomes.
Treatment Implications
The choice of classification system can impact treatment decisions, including the need for urgent debridement, appropriate antibiotic therapy, and the choice of fixation method. The use of the OTA-OFC system is recommended due to its greater interobserver agreement and validation as a measure of injury severity 1.
Antibiotic Therapy
Appropriate antibiotic therapy is crucial in the management of open fractures, with the choice of antibiotics depending on the type and severity of the fracture. A strong recommendation is made for the use of perioperative and postoperative systemic antibiotics for open fractures, using cefazolin or clindamycin for all types and adding gram-negative coverage with an aminoglycoside for Gustilo/Anderson Type III (and possibly Type II) open fractures 1.
From the Research
Open Fracture Grading Systems
- The Gustilo-Anderson classification is a widely used system for grading open fractures, taking into account the severity of the fracture and the risk of infection 2, 3.
- The classification system includes three main types of open fractures: Type I (low-energy fractures with minimal soft-tissue damage), Type II (moderate-energy fractures with more extensive soft-tissue damage), and Type III (high-energy fractures with severe soft-tissue damage and contamination) 2, 4.
Comparison with Other Classification Systems
- The Orthopaedic Trauma Association Open Fracture Classification (OTA-OFC) is another system used to classify open fractures, which takes into account factors such as bone loss, skin damage, and arterial injury 4.
- Studies have shown that the OTA-OFC system has a stronger association with the severity of open fractures, particularly in terms of arterial and skin damage, compared to the Gustilo-Anderson classification 4.
Clinical Applications and Recommendations
- Prophylactic antibiotic therapy is an important aspect of open fracture management, with recommendations varying depending on the type and severity of the fracture 2, 3.
- The use of single-agent cefotetan has been studied as a potential prophylactic antibiotic regimen for Gustilo-Anderson Type III open fractures, with promising results in terms of reducing infection rates and antibiotic costs 5.
- However, it is essential to revisit and correct misperceptions and errors in the classic open fracture studies to ensure accurate understanding and application of the Gustilo-Anderson classification system 6.