Updated: 5/27/2021

Gustilo Classification

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Questions
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100%
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Evidence
11
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Cases
2
Topic
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  • Abridged version
    • Type I
      • wound ≤1 cm, minimal contamination or muscle damage
    • Type II
      • wound 1-10 cm, moderate soft tissue injury
    • Type IIIA
      • wound usually >10 cm, high energy, extensive soft-tissue damage, contaminated
      • adequate tissue for flap coverage
      • farm injuries are automatically at least Gustillo IIIA
    • Type IIIB
      • extensive periosteal stripping, wound requires soft tissue coverage (rotational or free flap)
    • Type IIIC
      • vascular injury requiring vascular repair, regardless of degree of soft tissue injury
    • Most accurate way to grade open fratures is by intra-operative examination
  • Complete version
    • Gustilo Classification
      I
      II
      IIIA
      IIIB
      IIIC
      Images
      Energy
      Low
      Moderate
      High
      High
      High
      Wound size
      ≤ 1 cm
      1-10 cm
       usually >10 cm
       usually >10 cm
      usually >10 cm
      Soft tissue damage
      Minimal
      Moderate
      Extensive
      Extensive
      Extensive
      Contamination
      Clean
      Moderate 
      Extensive
      Extensive
      Extensive
      Fracture Comminution
      Minimal 
      Moderate
      Severe
      Severe
      Severe
      Periosteal Stripping
      No
      No
      Yes
      Yes
      Yes
      Skin Coverage
      Local coverage
      Local coverage
       Local coverage
      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
    • Antibiotics based on Gustilo Classification
      Grade I and II
      Grade IIIA, IIIB and IIIC
      Special considerations
      Antibiotics













      • 1st generation cephalosporin (e.g. cefazolin)












      • 1st generation cephalosporin for gram positive coverage 
      • Aminoglycoside (such as gentamicin) for gram negative coverage








      • Penicillin should be added if concern for anaerobic organism (farm injury)
      Flouroquinolones (e.g. ciprofloxacin) should be used for fresh water wounds or salt water wounds (can be used if allergic to cephalosporins or clindamycin 
      •  Doxycycline and 3rd or 4th-generation cephalosporin  (e.g. 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 controversy about this regimen
    • 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 24-72 hours after I&D
    • Tetanus booster if not up to date (no booster in last 5 years)
Questions (3)
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(OBQ13.160) A 25-year-old male presents with a Gustilo-Anderson IIIB tibia fracture after a motor cycle crash. Which of the following descriptions matches this classification?

QID: 4795
1

Distal third tibial shaft fracture with extensive soft tissue injury and a pale foot following adequate closed reduction

7%

(317/4500)

2

Posterolateral ankle fracture-dislocation with 8cm laceration on medial ankle, amenable to primary closure

2%

(88/4500)

3

Midshaft tibia fracture with 1cm anterior laceration requiring compartment releases intraoperatively

1%

(46/4500)

4

Proximal third tibial shaft fracture with extensive soft tissue loss requiring gastrocnemius flap

89%

(4003/4500)

5

Closed pilon fracture that will require delayed surgical fixation after initial external fixation

0%

(14/4500)

L 1 A

Select Answer to see Preferred Response

(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?

QID: 4516
1

Type I

0%

(11/5260)

2

Type II

9%

(463/5260)

3

Type IIIA

37%

(1933/5260)

4

Type IIIB

53%

(2773/5260)

5

Type IIIC

1%

(49/5260)

L 5 B

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Evidence (11)
VIDEOS & PODCASTS (1)
CASES (2)
EXPERT COMMENTS (42)
Private Note