Gustilo-Anderson Classification

Abstract

History Open fractures usually are high-energy injuries. This, along with the exposure of bone and deep tissue to the environment, leads to increased risk of infection, wound complications, and nonunion [12, 28, 31]. Antibiotics, surgical débridement, and internal fixation have improved outcomes of open fracture management in important ways, but the underlying principles for treating open fractures have remained the same since World War I: primary asepsis, adequate debridement, immobilization, and protection of wounds against disturbance and reinfection [25, 26]. Despite the overall improvement in outcome after open fractures, the 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. These grading systems seek to help guide treatment, improve communication and research, and predict outcome. Such classifications have been in use for some time [29]; however, it is the Gustilo-Anderson classification that has become the most commonly used system for classifying open fractures. Early attempts by Veliskakis [29] at grading open fractures were refined by Gustilo and Anderson in 1976 [16]. 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 [17]. Ultimately, through their studies of prevention of infection in open long bone fractures [16, 17], Gustilo et al. outlined the general principles of management of open fractures, and helped define the contemporary approach to the treatment of open fractures. Purpose Like many classification systems, the purpose of the Gustilo-Anderson schema is to provide a prognostic framework that guides treatment and facilitates communication among surgeons and clinician-scientists. Decades of research correlating the Gustilo-Anderson type with infection risk have helped refine surgical protocols, change antibiotic recommendations, and determine appropriate timing for interventions including débridement, internal fixation, and soft tissue coverage [14, 23, 24, 27, 31]. As a widely known and relatively straightforward system, which has become the standard of classifying open fractures, the Gustilo-Anderson classification also is useful for education of residents and other trainees in the treatment of patients with orthopaedic trauma [19]. Description of the Gustilo-Anderson Classification At the time of the seminal paper [16], it already was common knowledge that open fractures required prompt débridement and irrigation, but there was considerable ambiguity regarding how different patterns of injury behaved in response to the treatments of that period. The original study [16] included an initial retrospective evaluation, followed by a prospective test of the system that Gustilo and Anderson developed. The retrospective part of the study evaluated 673 open fractures of long bones in 602 patients to determine the impact of primary versus secondary closure, use of primary internal fixation, and routine use of antibiotics in the treatment algorithm of open long-bone fractures. The key findings were that primary closure without primary internal fixation and prophylactic antibiotics for Type I and Type II open fractures reduced the risk of infection as much as 84.4% [16], whereas acute internal fixation and primary closure after segmental fractures, extensive lacerations, avulsion, or traumatic amputation resulted in a greater likelihood of subsequent osteomyelitis. Gustilo and Anderson then 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 [16]. 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 [17]. 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 t