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

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(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

QID: 4516
1

Type I

0%

(10/4473)

2

Type II

8%

(361/4473)

3

Type IIIA

37%

(1654/4473)

4

Type IIIB

53%

(2387/4473)

5

Type IIIC

1%

(38/4473)

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