Gustilo et al separated open fractures of the long bones into types based on the extent and nature of the injuries. This can be used to help guide management decisions. The authors are from Hennepin County Medical Center in Minneapolis, Minnesota.
|
Type |
Features |
|
I |
wound <= 1.0 cm in length and clean |
|
II |
wound > 1.0 cm without extensive soft tissue damage, flaps or avulsions |
|
III |
open segmental (caused by high energy trauma) fracture, OR presence of extensive soft tissue damage, flaps or avulsions OR traumatic amputation |
|
IIIA |
extensive soft tissue injury or flaps with soft tissue coverage of bone, OR segmental (caused by high energy trauma) irrespective of the size of the wound |
|
IIIB |
extensive soft tissue injury with periosteal stripping and bone exposure |
|
IIIC |
presence an arterial lesion requiring repair |
|
III-gunshot |
open fracture caused by gunshot injury |
|
III-farm |
open fracture associated with a farm injury |
where:
• Type III was subdivided since the original classification was found to be too inclusive relative to injury severity and prognosis. The subclassification correlates with risk of infection and need for amputation.
• The original classification did not specify a laceration of 1.0 cm in length. I have assigned it as a Type I lesion.
• Type IIIB lesions often show massive contamination.
• In the implementation I included moderate and heavy contamination of the wound as Type III.
Management decisions in 1984:
(1) Culture of all wounds.
(2) Administer prophylactic antibiotics before and for several days after surgery.
(3) Copious irrigation of the wound with removal of environmental debris and debridement of nonviable tissue.
(4) Secondary closure is used for all Type III injuries. Primary closure of a Type I or II fracture can be considered if (a) the surgeon is experienced; (b) there has been an adequate debridement of tissue; (c) wound is clean. If in doubt, then the wound should not be closed.
(5) Fracture stabilization. Primary internal fixation was not done except in the presence of an associated vascular injury.
(6) If an arterial lesion is present, vascular surgery is required. If a partial or complete amputation has occurred, reattachment should be considered if the expertise is available.
(7) If the wound was left open, the wound was inspected daily with additional debridement as needed.
(8) Early cancellous bone grafting if needed.
(9) Split-thickness skin grafts were required for wound coverage in most cases.
Specialty: Surgery, orthopedic, Emergency Medicine, Critical Care, Surgery, general
