The Gustilo and Anderson classification, sometimes referred to just as the Gustilo classification, is the current (c. 2025) most commonly used system to describe open fractures ¹.

Usage

The system is routinely used to guide the antimicrobial management of open fractures.

Classification

Over the years, there have been many modifications to the original description by Gustilo and Anderson ³. Currently, the most accepted classification considers four characteristics of the injury: wound size, level of contamination, soft tissue injury, and bone injury ¹.

Type I

• wound: <1 cm

• contamination: clean

• soft tissue injury: minimal

• bone injury: simple, minimal comminution

Type II

• wound: 1-10 cm

• contamination: moderate

• soft tissue injury: moderate, some muscle damage

• bone injury: moderate comminution

Type III

• IIIa:

  • wound: >10 cm

  • contamination: high

  • soft tissue injury: severe with crushing, soft tissue coverage of bone possible

  • bone injury: usually communited

• IIIb:

  • wound: >10 cm

  • contamination: high

  • soft tissue injury: very severe loss of cover, usually requires soft tissue reconstructive surgery

  • bone injury: usually communited

• IIIc:

  • wound: >10 cm

  • contamination: high

  • soft tissue injury: vascular injury requiring repair

  • bone injury: usually communited

Treatment and prognosis

The infection has been described as 1.9% in type I injuries, and 8% in type II injuries, but it increases to 41% in type III injuries ¹.

Antimicrobial management is subject to change and most institutions have their own guidelines considering their most common communitary microbial agents and antibiotic resistances.

Common protocols are usually ²:

• type I and II: 1st-generation cephalosporin (e.g. cefazolin)

• type III: 3rd-generation cephalosporin (e.g. ceftriaxone) associated with Gram-negative coverage (e.g. gentamicin, ciprofloxacin, levofloxacin)

• association of anaerobe coverage is recommend for potential organic contamination (e.g. metronidazole)

• tetanus prophylaxis is recommend for all open fractures

Practical points

• definitive classification is intra-operative

See also

• open fractures