Gustilo-Anderson classification

The Gustilo-Anderson classification grades an open fracture by the soft-tissue injury, not by the bone. It guides antibiotics, the speed of surgery and whether you need a plastic surgeon.

Type I: wound under 1 cm, clean.

Type II: wound of 1 to 10 cm without extensive soft-tissue damage.

Type IIIA: extensive soft-tissue damage, but the bone is still covered, or the injury was high-energy whatever the wound size.

Type IIIB: extensive soft-tissue loss with periosteal stripping and exposed bone, usually with massive contamination. It needs flap cover.

Type IIIC: an arterial injury that needs repair.

Segmental fractures and traumatic amputations count as Type III.

BOAST 4, the British Orthopaedic Association standard for severe open lower-limb fractures, asks for intravenous antibiotics as soon as possible, ideally within 1 hour of injury. It asks for debridement within 12 hours for other solitary high-energy open fractures and within 24 hours for low-energy ones, or immediately if the wound is highly contaminated or there is vascular compromise. It asks for definitive soft-tissue cover within 72 hours of injury if that cannot be done at debridement, and for transfer to a centre that offers orthoplastic care. It names no drug, so follow your local protocol. These are consensus standards, not trial-proven thresholds.

Grade at debridement, not in the ED, because the true extent of the wound shows once it is opened and cleaned. The grade describes the soft tissue, so a 2 cm wound over a segmental fracture is still Type III. Agreement is modest: when 245 surgeons graded 12 videotaped open tibial fractures, average agreement was 60%.

Viva question: A 2 cm clean wound lies over a segmental tibial fracture. What grade is it, and why?

Read more: Gustilo and Anderson, J Bone Joint Surg Am, 1976 · Gustilo et al., J Trauma, 1984 · Brumback and Jones, J Bone Joint Surg Am, 1994 · BOAST 4

Education only, not medical advice. Management depends on the patient and your local protocol.