What is the Gustilo classification for open fractures?

Gustilo Classification for Open Fractures

The Gustilo-Anderson classification is the most established system for classifying open fractures, categorizing them into types I, II, and III (with further subdivisions of IIIA, IIIB, and IIIC) based on wound size, contamination, soft tissue damage, and vascular injury. 1

Classification Details

Type I

• Small wound (<1 cm)
• Clean wound
• Minimal soft tissue damage
• Simple fracture pattern
• Minimal contamination

Type II

• Wound >1 cm but <10 cm
• Moderate soft tissue damage
• No extensive periosteal stripping
• Moderate contamination
• No flaps needed

Type III

• Extensive soft tissue damage
• High energy injury
• Segmental fractures, comminution, or bone loss
• Significant contamination
• Further subdivided into:

Type IIIA

• Adequate soft tissue coverage despite extensive laceration or flaps
• High-energy trauma regardless of wound size

Type IIIB

• Extensive soft tissue injury with periosteal stripping
• Requires soft tissue reconstruction (flap coverage)
• Massive contamination
• Bone exposure

Type IIIC

• Any open fracture with associated arterial injury requiring repair
• Vascular injury regardless of degree of soft tissue injury

Clinical Significance and Management Implications

Antibiotic Prophylaxis Based on Classification

• Type I & II: Cefazolin 2g IV or clindamycin 900mg IV (if beta-lactam allergic) 2, 3
• Type III: Cefazolin plus gram-negative coverage with an aminoglycoside; piperacillin-tazobactam is preferred 2
• Duration should be limited to 24 hours post-injury in the absence of infection 3

Wound Management

• All types: Initial irrigation with simple saline solution without additives 2
• Type II and III: More aggressive debridement required
• Type IIIB: Requires soft tissue reconstruction
• Type IIIC: Requires vascular repair as priority

Important Considerations

Interobserver Reliability

• The Gustilo classification has limited interobserver reliability with only 60% agreement among surgeons 4
• Classification may change from initial assessment to definitive grading in approximately 12.6% of cases 5

Alternative Classification

• The OTA open fracture classification system (OTA-OFC) provides another validated measure with reportedly greater interobserver agreement 2
• OTA-OFC assesses five independent domains: skin, muscle, arterial injury, contamination, and bone loss 6
• Despite this, the Gustilo-Anderson classification remains more widely used in clinical practice and literature 2

Factors Associated with Classification Changes

• Fracture sites other than tibia
• Presence of bone loss
• Width and length of wound
• Skin loss at presentation 5

Clinical Outcomes

• Healing times increase with higher Gustilo types: approximately 21.1 weeks for type II, 21.7 weeks for IIIA, and 24.9 weeks for IIIB 7
• Type III fractures, particularly IIIB and IIIC, have higher rates of infection, nonunion, and need for additional procedures

Common Pitfalls

• Initial misclassification (occurs in ~12% of cases) - particularly underestimating severity
• Overreliance on wound size alone rather than considering mechanism and soft tissue damage
• Failing to recognize vascular injury that would upgrade to type IIIC
• Not reassessing classification after complete debridement (the classification was originally designed to be applied after operative debridement)

The Gustilo classification remains the most widely used system for open fractures despite its limitations, guiding critical treatment decisions including antibiotic selection, timing of surgery, and need for specialized soft tissue coverage.