Gustilo-Anderson Classification of Open Fractures

Gustilo-Anderson Classification:

Classification	Energy	Wound Size	Soft Tissue Damage	Contamination	Fracture Comminution	Periosteal Stripping	Skin Coverage	Neurovascular Injury
Type I	Low	≤ 1 cm	Minimal	Clean	Minimal	No	Local coverage	Normal
Type II	Moderate	1-10 cm	Moderate	Moderate	Moderate	No	Local coverage	Normal
Type IIIA	High	>10 cm	Extensive	Extensive	Severe	Yes	Local coverage	Normal
Type IIIB	High	>10 cm	Extensive	Extensive	Severe	Yes	Requires flap	Normal
Type IIIC	High	>10 cm	Extensive	Extensive	Severe	Yes	Requires flap	Vascular injury requiring repair

Open fractures, where the bone is exposed through the skin, are severe injuries that require careful assessment and management to minimize complications. The Gustilo-Anderson Classification is a widely used system that categorizes open fractures based on the size of the wound, the extent of soft tissue damage, and the presence of contamination or vascular injury. This classification helps guide treatment decisions and predict outcomes.

1. Overview of the Gustilo-Anderson Classification

The Gustilo-Anderson Classification divides open fractures into three main types (I, II, and III), with Type III further subdivided into A, B, and C categories based on the severity of the injury.

Type I

• Wound Characteristics: The wound is small, typically ≤ 1 cm, with minimal contamination.

• Soft Tissue Damage: There is minimal muscle injury.

• Energy: The injury results from low-energy trauma.

• Management Implications: These fractures generally have a lower risk of infection and complications.

Type II

• Wound Characteristics: The wound size ranges from 1 to 10 cm with moderate contamination.

• Soft Tissue Damage: There is moderate injury to the soft tissues, but no extensive crushing.

• Energy: The injury is moderate in energy.

• Management Implications: While the risk of infection is higher than in Type I, it remains manageable with appropriate care.

Type III

Type III fractures are severe injuries often caused by high-energy trauma. They are further subdivided based on the extent of soft tissue damage and the need for vascular repair.

• Type IIIA

  • Wound Characteristics: Typically >10 cm in size, associated with high-energy trauma.

  • Soft Tissue Damage: Extensive damage, but enough soft tissue remains for flap coverage.

  • Contamination: The wound is often heavily contaminated.

  • Special Considerations: Farm injuries are automatically classified as at least Type IIIA due to the high risk of infection.

  • Management Implications: These injuries require more intensive surgical and medical management.

• Type IIIB

  • Wound Characteristics: Similar to Type IIIA but with more extensive periosteal stripping.

  • Soft Tissue Damage: Significant tissue loss that necessitates flap coverage.

  • Management Implications: The need for advanced reconstructive surgery is common, and the risk of infection is very high.

• Type IIIC

  • Wound Characteristics: Involves vascular injury that requires repair.

  • Soft Tissue Damage: Varies, but the vascular injury is the critical factor.

  • Management Implications: These are the most severe cases, often requiring immediate vascular surgery in addition to orthopedic management.
    

2. Clinical Application of the Gustilo-Anderson Classification

This classification is not only useful in describing the injury but also plays a crucial role in guiding treatment and predicting patient outcomes. The classification is particularly valuable during intra-operative assessment, where the full extent of the injury can be accurately determined.

3. Antibiotic Management Based on Gustilo Classification

Appropriate antibiotic therapy is critical to prevent infection in open fractures. The Gustilo-Anderson Classification informs the choice of antibiotics:

• Type I and II:

  • Recommended Antibiotics: 1st generation cephalosporin (e.g., cefazolin).

• Type IIIA, IIIB, and IIIC:

  • Recommended Antibiotics: 1st generation cephalosporin plus aminoglycoside (e.g., gentamicin).

  • Special Considerations: For farm injuries, which carry a high risk of Clostridium infection, penicillin should be added to cover anaerobic bacteria. In cases involving water exposure, fluoroquinolones (e.g., ciprofloxacin) or doxycycline might be necessary.
    

  • Rationale for Using Both Gentamicin and Ceftriaxone:

    • Gentamicin is an aminoglycoside that provides excellent coverage against gram-negative organisms, including Pseudomonas species, which are common in contaminated wounds.

    • Ceftriaxone is a third-generation cephalosporin that provides broad coverage against gram-positive organisms, including Staphylococcus and Streptococcus species, as well as some gram-negative organisms.
      

    • Typical Dosing Regimen for Open Fractures:

      • Gentamicin:

        • Adult Dose: 5-7 mg/kg IV or IM once daily.

        • Duration: Typically administered for 3 days post-surgery, but this may be extended based on clinical judgment and infection risk.

      • Ceftriaxone:

        • Adult Dose: 1-2 g IV or IM once daily.

        • Duration: Usually given for 3-7 days, depending on the extent of the injury and surgical interventions.
          

    • Special Considerations:

    • Farm injuries or wounds with high contamination may require additional coverage with penicillin to cover anaerobic bacteria such as Clostridium species, which are associated with tetanus and gas gangrene.

    • Monitoring: While using gentamicin, it's essential to monitor renal function and, if used for more than a few days, serum drug levels to prevent nephrotoxicity and ototoxicity.
      

    • Clinical Application:

    • This antibiotic combination is initiated as soon as possible, ideally within 3 hours of the injury, to reduce the risk of infection.

    • The use of these antibiotics is part of a comprehensive management plan that includes surgical debridement and possibly staged wound closure depending on the extent of the injury.
      

4. Timing and Duration of Antibiotics

• Initiation: Antibiotics should be administered as soon as possible, ideally within 3 hours of injury. Delayed antibiotic therapy significantly increases the risk of infection.

• Duration: Continue antibiotics for 24-72 hours after the initial surgical debridement to minimize infection risks.
  

5. Role of Tetanus Prophylaxis

Given the potential for contamination, tetanus prophylaxis is essential in managing open fractures. Ensure the patient’s tetanus vaccination is up to date, particularly if the last booster was administered more than 5 years ago.

6. Conclusion

The Gustilo-Anderson Classification is an essential tool in the management of open fractures, offering a structured approach to evaluate and treat these complex injuries. By categorizing the severity of the fracture, healthcare providers can optimize treatment strategies, improve patient outcomes, and minimize complications such as infection and nonunion.