Gustilo Classification for Open Fracture Calculator

How does this Gustilo Classification for open fracture calculator work?

This health tool offers a fracture classification based on wound dimension, type and energy of traumatic injury and the amount of soft tissue damaged.

Open fractures are defined as broken bones situated in communication with the environment through the skin. The degree of communication varies from small punctures to severely large areas of soft tissue exposed.

This Gustilo Classification for open fracture calculator is based on the commonly used Gustilo System that divides open fractures and discriminates between mild and severe injuries. It initiated as a first model that in time expanded and was updated to the nowadays widely used version.

The model uses certain factors in classifying the injury severity such as:

■ Amount of energy in the injury mechanism – ranging from low (simple fractures, stabbings or gun wounds) to high (high speed trauma). This is also factored in the Mangled Extremities Score.

■ The extent of soft tissue injury – ranging from minor to different severity degrees.

■ The extent of contamination – important factor in determining the injury severity in respect to the degree of contact with the environment.

Progression from the least severe stage i.e. grade I to the most severe i.e. grade III implies an increase in all the factors taken in consideration plus bone damage and/ or vascular injury and in general a higher chance of complications in the general prognosis.

In general the diagnosis is quite direct, only the degree of severity can take a little while, especially when the clinician also has to take in consideration the frx findings. Therefore the system proposed by Gustilo aims to reduce this step in open fracture management and treatment and to provide a universal guideline. It is often used in conjunction with other emergency room scoring systems such as the Revised Trauma Score.

Gustilo Classification of open fractures

Grade I

■ Low energy mechanism;

■ Clean wound less than 1 cm in length;

■ Minimal contamination, “inside-out injuries”;

■ Average time to union of around 21 - 28 weeks;

■ Antibiotic treatment indication: 1st generation cephalosporin.

Grade II

■ Moderate energy mechanism and soft tissue damage, flaps and/or avulsions present;

■ Wound greater than 1 cm but less than 10 cm in dimension;

■ Moderate contamination risk;

■ Average time to union of around 26 - 28 weeks;

■ Antibiotic treatment indication: 1st generation cephalosporin.

Grade III

■ High energy mechanism, extensive soft tissue damage, wound dimension over 10 cm in length;

■ Often associated with injuries that need vascular repair and/or have been open for 8 hours prior to treatment. Also applies to traumatic amputations;

■ Very high degree of contamination;

■ Average time to union of around 30 - 35 weeks;

■ Antibiotic treatment indication: 1st generation cephalosporin, aminoglycoside treatment (usually gentamicine) and preventive PCN in high risk of contamination injuries such as farm ones.

■ Frx findings characteristic:

- segmental frx w/ displacement

- frx w/ diaphyseal segmental loss

- frx w/ associated vascular injury requiring repair

- farmyard injuries or highly contaminated wounds

Grade III injury subdivisions

■ IIIA adequate periosteal coverage of the fractured bone although extensive soft tissue damage is present;

■ IIIB inadequate periosteal cover with bone damage and soft tissue damage. Also associated with massive contamination. Requires soft tissue flap repairing of the injury;

■ IIIC associates with arterial injury and extensive soft tissue laceration and often requires repairing vascular and skeletal fixation procedures.

References

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

2) Gustilo RB, Anderson JT. (1976) 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; 58(4):453-8.

3) The Management of Severe Open Lower Limb Fractures (2009). British Orthopaedic Association.

4) Johansen K, Daines M, Howey T, Helfet D, Hansen ST Jr. (1990) Objective criteria accurately predict amputation following lower extremity trauma. J Trauma; 30(5):568-72.