Gustilo Classification

Abridged version
  • Type I
    • wound < 1 cm
  • Type II
    • 1-10cm
  • Type III A
    • > 10 cm, high energy
    • adequate tissue for coverage
    • includes segmental / comminuted fractures even if wound <10cm
    • farm injuries are automatically Gustillo III
  • Type IIIB
    • extensive periosteal stripping and requires free soft tissue transfer 
  • Type IIIC
    • vascular injury requiring vascular repair
Complete version
Energy Low energy Moderate High High High
Wound Size < 1 cm > 1cm 


>10cm >10cm
Soft Tissue Minimal Moderate  Extensive  Extensive  Extensive 
Contamination Clean
Moderate contamination  Extensive  Extensive  Extensive 
Fracture Pattern Simple fx pattern with minimal comminution Moderate comminution  Severe comminution or segmental fractures Severe comminution or segmental fractures  Severe comminution or segmental fractures 
Periosteal Stripping No No Yes Yes Yes
Skin Coverage Local coverage Local coverage Local coverage including Requires free tissue flap or rotational flap coverage Typically requires flap coverage
Neurovascular Injury Normal  Normal Normal  Normal Exposed fracture with arterial damage that requires repair
  • 1st generation cephalosporin for 24 hours after closure 
  • 1st generation cephalosporin for gram positive coverage.
  • Aminoglycoside (such as gentamicin) for gram negative coverage in type III injuries
    • the cephalosporin/aminoglycoside should be continued for 24-72 hours after the last debridement procedure
  • Penicillin should be added if concern for anaerobic organism (farm injury)
aminoglycoside (such as gentamicin) for gram negative coverage 
1st cephalosporin (ancef) for gram positive coverage. 
the cephalosporin/aminoglycoside should be continued for 72 hours after the last debridment procedure
penicillin should be added if concern for anaerobic organism (farm injury
Antibiotics (other considerations)
  • Flouroquinolones
    • should be used for fresh water wounds or salt water wounds
    • can be used if allergic to cephalosporins or clindamycin
  • Doxycycline and ceftazidime
    • can be used for salt water wounds

Antibiotic Indications for Open Fractures
  • Gustillo Grade I and II
    • 1st generation cephalosporin
  • Gustillo Grade III
    • 1st generation cephalosporin + aminoglycoside 
      • traditionally recommended, but there is no evidence in the literature to support its use
  • With farm injury / bowel contamination 
    • 1st generation cephalosporin + aminoglycoside + PCN
    • add PCN for clostridia 
  • Duration
    • initiate as soon as possible
      • increased infection rate when antibiotics are delayed > 3 hours from time of injury
    • continue for 72 hours after I&D
    • 48 hours after each procedure
  • Tetanus booster if not up to date

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Questions (1)

(OBQ12.156) A 36-year-old male sustains an open segmental tibia fracture associated with an overlying 8 cm soft tissue avulsion that requires skin grafting for soft tissue coverage. No vascular injury is identified. What is the most appropriate Gustilo-Anderson classification of this injury? Review Topic


Type I




Type II















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An 8cm open segmental tibia fracture requiring skin grafting (but not a skin flap) qualifies as a Gustilo Type IIIA.

An open segmental tibia fracture meets criteria to be a type III injury, and subclassification as a IIIA is due to the lack of a need for free or regional tissue transfer for coverage. Classification as a type IIIB would require a free or regional soft tissue transfer (flap) for coverage. Also, remember that definitive classification is done intraoperatively, after full assessment of the fracture and wound are complete.

Gustilo et al. performed a retrospective review of 673 patients and a prospective review of 352 patients with open fractures. Infection rate of the type I and II in the retrospective series was 12%, and this decreased with use of a standardized modern treatment protocol to 2.5% in the prospective cohort. Type III deep infection rate was 44% in the retrospective study and 9% in the prospective study.

Incorrect Answers:
Answer 1: Involves a wound <1 cm with minimal soft tissue stripping; simple fracture pattern
Answer 2: Involves a wound 1-10cm with mild soft tissue stripping; simple fracture pattern or mild comminution
Answer 4: Involves extensive soft tissue damage with high-energy fracture pattern; soft tissue requires free tissue transfer for coverage
Answer 5: Involves a vascular injury requiring repair

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