331ms
Updated: 5/27/2021

Gustilo Classification

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Questions
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Evidence
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Cases
2
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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)
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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%

(327/4657)

2

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

2%

(90/4657)

3

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

1%

(47/4657)

4

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

89%

(4144/4657)

5

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

0%

(15/4657)

L 1 A

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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?

QID: 4516
1

Type I

0%

(12/5449)

2

Type II

9%

(490/5449)

3

Type IIIA

37%

(2002/5449)

4

Type IIIB

53%

(2864/5449)

5

Type IIIC

1%

(50/5449)

L 5 B

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Evidence (14)
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EXPERT COMMENTS (44)
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