Grading of Open fractures has seen periodical changes over time.  Variable outcomes among different patterns of open fractures with differing severities prompted the development of grading systems that classify them based on increasing severity of the associated soft tissue injuries. 

Early attempts by Veliskakis [1] at grading open fractures were refined by Gustilo and Anderson in 1976 [2]. After reviewing their  initial classification of the most severe open injuries, Gustilo et al. subsequently modified their classification system into its current form in 1984 [3]. Ultimately, through their studies of prevention of infection in open long bone fractures [2,3], Gustilo et al. outlined the general principles of management of open fractures, and helped define the contemporary approach to the treatment of open fractures.

Original Classification [2]

 Gustilo and Anderson  prospectively followed more than 350 patients. They categorized open injuries into the familiar three categories, based on wound size, level of contamination, and osseous injury, as follows:

Type I = an open fracture with a wound less than 1 cm long and clean;

 Type II = an open fracture with a laceration greater than 1 cm long without extensive soft tissue damage, flaps, or avulsions; and

Type III = either an open segmental fracture, an open fracture with extensive soft tissue damage, or a traumatic amputation.

Special categories in Type III were gunshot injuries, any open fracture caused by a farm injury, and any open fracture with accompanying vascular injury requiring repair [2].

 Revision :  

Type III open fractures proved the most difficult to classify and treat owing to the varied injury patterns, increased morbidity from associated injuries, massive soft tissue damage or loss over the fracture sites, compromised vascularity, wound contamination, and fracture instability. Infection in Type III open fractures was observed 10% to 50% of the time [4]. With ranges like that, it became evident that the variation in severity, etiology, and prognosis of Type III injuries made a single classification insufficiently specific for the task at hand; the frequency of these injuries (greater than 60% of open fractures are Type III, according to one epidemiologic study [4]), made that issue even more pressing. In response to that problem, these high-energy open fractures were further subclassified by Gustilo et al. into A, B, and C according to the severity of the soft tissue injury, need for vascular reconstruction, and worsening prognosis, as follows [3]:

Type IIIA = open fractures with adequate soft tissue coverage of a fractured bone despite extensive soft tissue laceration or flaps, or high-energy trauma regardless of the size of the wound;

Type IIIB = open fractures with extensive soft tissue injury loss with periosteal stripping and bone exposure. This usually is associated with massive contamination [3]; and

Type IIIC = open fractures associated with arterial injury requiring repair [3].

 

Limitation of Gustilo Anderson Classification: 

1. Inter observer agreement was only about 50 to 60% and under estimation of grade is the most common error [5,6]

2. The surface injury does not always reflect the amount of deeper tissue damage the classification  does not account for tissue viability and tissue necrosis, which tend to evolve with time after more severe injuries. Many investigators suggested classification after debridement of the wound in OT [7,8]

 

AO Group's view on open fracture

Gustilo and Anderson classification of open fractures [2,3].
Type Description
I Skin wound less than 1 cm
Clean
Simple fracture pattern
II Skin wound more than 1 cm
Soft-tissue damage not extensive
No flaps or avulsions
Simple fracture pattern
III High-energy injury involving extensive soft-tissue damage
Or multifragmentary fracture, segmental fractures, or bone loss irrespective of the size of skin wound
Or severe crush injuries
Or vascular injury requiring repair
Or severe contamination including farmyard injuries

Further Subclassification of Type III as below

Gustilo classification of type III open fractures [3].
Type Description
IIIA Adequate soft-tissue cover of bone despite extensive soft-tissue damage
IIIB Extensive soft-tissue injury with periosteal stripping and bone exposure
Major wound contamination
IIIC High-energy injury involving extensive soft-tissue damage

 

 Final Version

In conclusion the Final Classification can be viewd as below and includes all revisions and refinements

Classification

Type I:

  • Wound less than 1 cm with minimal soft tissue injury
  • Wound bed is clean
  • Fracture is usually a simple transverse, short oblique fracture, with minimal comminution

 

Type II:

  • Wound is greater than 1 cm with moderate soft tissue injury
  • Fracture is usually a simple transverse, short oblique fracture, with minimal comminution

 

Type III:

  • Fractures that involve extensive damage to the soft tissues, including muscle, skin and neurovascular structures
  • Often accompanied by a high-velocity injury or a severe crushing component
  • Special patterns classified as Type III:
    1. Open segmental fracture, irrespective of the size of the wound
    2. Gunshot wounds -high velocity and short-range shotgun injuries
    3. Open fracture with neurovascular injury
    4. Farm injuries, with soil contamination, irrespective of the size of the wound
    5. Traumatic amputations
    6. Open fractures over 8 hours old
    7. Mass casualties; eg, war and tornado victims

 

  • Subtype IIIA
    1. Adequate soft tissue coverage despite soft tissue laceration or flaps or high energy trauma irrespective of the size of the wound
    2. Includes segmental or severely conminuted fractures

 

  • Subtype IIIBSubtype IIIC
    1. Extensive soft tissue lost with periosteal stripping and bony exposure
    2. Usually associated with massive contamination
    3. Fracture in which there is a major arterial injury requiring repair for limb salvage

 

Bottom Line: The inter observer agreement still remains around 60% and an underestimation of injury is a common occurrence. New classifications are proposed [By OTA and is under review]

 

References: 

1.  Veliskakis KP. Primary internal fixation in open fractures of the tibial shaft: the problem of wound healing. J Bone Joint Surg Br.

1959:41:342–354.

2. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am. 1976;58:453–458. 

3. Gustilo RB, Mendoza RM, Williams DN. Problems in management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma. 1984;24:742–746.

4. Court Brown CM, Rimmer S, Prakash U, McQueen MM. The epidemiology of open long-bone fractures. Injury. 1998;29:529– 534.

5.  Brumback RJ, Jones AL. Interobserver agreement in the classification of open fractures of the tibia: the results of a survey of two hundred and forty-five orthopaedic surgeons. J Bone Joint Surg Am. 1994;76:1162–1166.

6.  Horn BD, Rettig ME. Interobserver reliability in the Gustilo and Anderson classification of open fractures. J Trauma. 1993;7:357–360.

7.  Melvin JS, Dombroski DG, Torbert JT, Kovach SJ, Esterhai JL, Mehta S. Open tibial shaft fractures: I. Evaluation and initial wound management. J Am Acad Orthop Surg. 2010;18:10–19. 

8. Okike K, Bhattacharyya T. Trends in the management of open fractures: a critical analysis. J Bone Joint Surg Am. 2006;88:2739–2748.

Main Source Articles:

 1. Kim PH, Leopold SS. In brief: Gustilo-Anderson classification. [corrected]. Clin Orthop Relat Res. 2012 Nov;470(11):3270-4

2. http://www.orthopaedicsone.com/display/Main/Gustilo+open+fracture+classification [source of the final classification]


 Disclaimer : This is not a original article or a review and sections from various articles [as referenced] are been compiled to prepare  an overview. All credit belongs to the original authors.


 Compiled by Dr Ashok Shyam

 

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