The Gustilo open fracture classification system is the most commonly used classification system for open fractures. It was created by Ramón Gustilo and Anderson, and then further expanded by Gustilo, Mendoza, and Williams.
This system uses the amount of energy, the extent of soft-tissue injury and the extent of contamination for determination of fracture severity. Progression from grade 1 to 3C implies a higher degree of energy involved in the injury, higher soft tissue and bone damage and higher potential for complications. Important to recognize that grade 3C fracture implies vascular injury as well.
Video Gustilo open fracture classification
Classification
Maps Gustilo open fracture classification
Reliability
There are many discussions regarding the inter-observer reliability of this classification system. Different studies show inter-observer reliability of approximately 60% (ranging from 42 to 92%), representing poor to moderate agreement, which is a limitation of this classification system. This is due to that much of the criteria are overlapping with possibility of observer errors. However, this classification is easy to use, able to predict prognostic outcomes and guide treatments. Generally, the higher the rate of Gustillo classification, the higher the rate of infection and complications. But treatment regimen should be interpreted with caution due to observer errors.
Although this classification system has a fairly good ability to predict outcome, but it is imperfect. The Gustillo classification does not take into account the viability and death of soft tissues over time which can affect the outcome of the injury. Besides, the number of the underlying medical illnesses of the patient also affects the outcome. Whether the timing of wound debridement, soft tissue coverage, and bone have any benefits on the outcome is also questionable. Besides, different types of bones have different rate of infection because they are covered by different amount of soft tissues. Gustilo initially does not recommend early wound closure and early fixation for Grade III fractures. However newer studies has shown that early wound closure and early fixation reduces infection rates, promotes fracture healing and early restoration of function. Therefore, assessment of all open fractures should include the mechanism of injury, the appearance of soft tissues, the likely levels of bacterial contamination and the specific characteristics of the fractures. Accurate assessment of the fracture can only performed inside an operating theatre.
For more comprehensive prognosis purposes, other classification systems, like Sickness Impact Profile (as a health status measure), Mangled Extremity Severity Score (MESS) and Limb Salvage Index (LSI) (decision to amputate or salvage a limb) have been devised.
History
In 1976, Gustilo and Anderson refined the early classification system proposed by Veliskasis in 1959. An early study conducted by Gustilo in 1976, has shown primary closures with prophylactic antibiotics of Type I and type II fractures reduced the risk of infection by 84.4%. Meanwhile, early internal fixation and primary closure of the wound in Type III fractures has greater risk of getting osteomyelitis. However, Type III fractures occurs in 60% if the all the open fracture cases. Infection of the Type III fractures are observed in 10% to 50% of the time. Therefore, in 1984, Gustilo subclassified Type III fractures into A, B, and C with the aim of guiding the treatment of open fractures, communication and research, and to predict outcome. Based of the results of the previous studies, Gustilo initially recommended therapeutic irrigation and surgical debridement for all fractures with primary closure for Type I and II fractures; secondary closure without internal fixation for Type III fractures. However, soon after that, he recommended internal fixation devices for Type III fractures.
References
See also
- Tscherne classification
- Hanover fracture scale
- AO soft tissue grading system
Source of article : Wikipedia
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