Gustilo Anderson classification

The Gustilo Anderson classification, also known as the Gustilo classification, is the most widely accepted classification system of open (or compound) fractures.

The grading system is used to guide management of compound fractures, with higher grade injuries associated with higher risk of complications. Soft tissue injury is graded on a combination of:

  • amount of energy dissipated
  • extent of soft-tissue injury
  • degree of contamination

NB: fracture comminution is not considered in the grading system.

Gustilo-Anderson classification

  • grade 1: clean wound <1 cm in length
  • grade 2: wound 1-10 cm in length without extensive soft-tissue damage, flaps or avulsions
  • grade 3: extensive soft-tissue laceration (>10 cm) or tissue loss/damage or an open segmental fracture
    • open fractures caused by farm injuries
    • injuries requiring vascular intervention
    • fractures that have been open for 8 hours prior to treatment

Grade 3 injuries can be further subdivided by the degree of periosteal and vascular injury and soft tissue loss:

  • grade 3a: adequate periosteal coverage of the fracture bone despite the extensive soft-tissue laceration or damage
  • grade 3b
    • extensive soft-tissue loss, periosteal stripping and bone damage
    • usually associated with massive contamination
    • will often need further soft-tissue coverage procedure (e.g. free or rotational flap)
  • grade 3c: associated with an arterial injury requiring repair, irrespective of degree of soft-tissue injury

Treatment and prognosis

Surgical management:

  • injuries up to and including grade 3a can be treated with local soft tissue coverage
  • grade 3b injuries require free or rotational flap repair
  • grade 3c injuries require vascular repair and usually soft tissue free or rotational flap repair

Antimicrobial treatment:

  • all injuries require antibiotic coverage (usually a first-generation cephalosporin)
  • grade 3 injuries are usually also covered with gentamycin (for Gram-negative coverage)
  • farm injuries are usually also covered with penicillin (for anaerobe coverage)