From the Guidelines
Open fractures are classified using the Gustilo-Anderson classification system, which grades them based on severity from I to IIIC, and the most recent evidence recommends management with immediate stabilization, tetanus prophylaxis, and intravenous antibiotics, with the specific approach depending on the grade of the fracture 1. The Gustilo-Anderson classification system is used to grade open fractures based on severity, with Grade I involving a clean wound less than 1cm with minimal soft tissue damage, Grade II having a wound greater than 1cm with moderate soft tissue injury but without extensive damage, and Grade III fractures having significant soft tissue damage and further divided into IIIA, IIIB, and IIIC 1. Some key points to consider in the management of open fractures include:
- Immediate stabilization and tetanus prophylaxis
- Intravenous antibiotics, with cefazolin 2g every 8 hours for Grade I/II fractures, and adding gentamicin 5mg/kg daily and considering penicillin 4 million units every 4 hours for Grade III injuries 1
- Wound irrigation and debridement in the operating room, ideally within 6-8 hours of injury
- Stabilization using external fixation for severe injuries or internal fixation for less complex cases
- Soft tissue coverage should be achieved within 7 days, potentially requiring plastic surgery involvement for complex reconstructions
- Serial debridements may be necessary for heavily contaminated wounds The most recent evidence, from 2023, recommends the use of perioperative and postoperative systemic antibiotics for open fractures, with 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. It's also important to note that the OTA open fracture classification system (OTA-OFC) provides another validated measure of the severity of these injuries and reportedly has greater interobserver agreement compared with the Gustilo-Anderson classification, but the recommendations continue to use the Gustilo-Anderson classification because this corresponds most closely to the primary sources on which these recommendations are based 1.
From the Research
Grades of Open Fractures
The grades of open fractures are typically classified using the Gustilo-Anderson classification system, which includes three main grades:
- Grade I: An open fracture with a wound less than 1 cm long and minimal soft tissue damage.
- Grade II: An open fracture with a wound more than 1 cm long and moderate soft tissue damage.
- Grade III: A severe open fracture with extensive soft tissue damage, including wounds more than 10 cm long, and possible contamination with dirt or other foreign materials.
Management of Open Fractures
The management of open fractures involves several key components, including:
- Antibiotic prophylaxis: The use of antibiotics to prevent infection, with the specific regimen depending on the grade of the fracture and other factors 2, 3.
- Surgical debridement: The removal of dead tissue and other contaminants from the wound to promote healing.
- Fracture stabilization: The use of various methods, such as casting or surgery, to stabilize the fracture and promote healing.
- Wound care: The management of the wound to promote healing and prevent infection.
Unified Classification of Open Fractures
A new "unified" classification system has been proposed, which combines elements of the Gustilo-Anderson and OTA classification systems 4. This system has been shown to have good validity, reliability, and acceptability, and may potentially replace other existing classification systems.
Antibiotic Prophylaxis for Gustilo-Anderson Type III Open Fractures
The use of single-agent cefotetan as a prophylactic antibiotic for Gustilo-Anderson Type III open fractures has been studied, with results suggesting that it may provide superior antibiotic stewardship with similar infectious sequelae compared to more traditional antibiotic prophylaxis regimens 5.