Gustillo's Classification of Open Fractures - Sean Symons 24/7/2003

Prevention of Infection in the Treatment of One Thousand and Twenty-five Open Fractures of Long Bones.

JBJS A 1976 June; 58(4):453-458

Gustilo RB and Anderson JT; Hennepin Medical Centre, Minneapolis

Open fractures recognised as surgical emergencies due to high rate of sepsis requiring adequate debridement andirrigation.

Opinion differed over;

  1. Primary v secondary closure of wound
  2. Indications for primary internal fixation and timing of delayed internal fixation
  3. Use of antibiotics and length of treatment

Retrospective Study 1955-68 of 673 long bone open fractures treated by adequate debridement and copiousirrigation, primary closure whenever possible, internal fixation at surgeonsdiscretion and routine intravenous antibiotics for 7-10 days.

Conclusions were internal fixation increases infection rate, primary closure after segmental open fracture, open fracture with extensive soft tissue injury or traumatic amputation causes high infection rates and prophylactic antibiotic therapy is essential.

Prospective Study 1969-73 of 352 long bone open fractures categorised as

  • Type 1 - wound < 1cm and clean
  • Type 2 - laceration >1cm long without extensive soft tissue injury
  • Type 3 - extensive soft tissue injury, traumatic amputation, segmental fracture, gunshot injury, farm injury, or accompanying vascular injury requiring repair.

Protocol for treatment;

  • All open fractures are emergencies
  • Cultures obtained on admission and wound closure
  • Intravenous antibiotics from admission for 3 days following surgery or delayed wound closure
  • Thorough debridement and copious irrigation
  • Primary internal fixation with vascular repair only
  • Primary wound closure for types 1 & 2, delayed wound closure for type 3

Conclusions;

  • All open fractures are emergencies treatment requiring thorough debridement and copious irrigation
  • Primary wound closure for types 1 & 2, delayed wound closure for type 3 fractures
  • No internal fixation used including open fractures with vascular injury requiring repair
  • Intravenous antibiotics from admission for 3 days following surgery or delayed wound closure

Problems in the Management of Type 3 (Severe) Open Fractures: A New Classification of Type 3 Open Fractures.

JBJS A 1984 August;24(8): 742-746

Gustilo RB, Mendoza RM and Williams DN, Hennepin Medical Centre, Minneapolis

The major problem oftreating Type 3 Open Fractures is the high incidence of wound infection.

Aim is to establish the factors that lead to wound infection in these fractures.

Prospective study of Type 3 Open Fractures in long bones between 1976-1979.

Over 90% were caused by high-energy trauma.



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