Gusillo–Anderson classification system of open fractures

A 19-year-old male is brought in after an ATV accident when he was off-roading on his grandparent’s farm. He has an obvious deformity to the right tibia with exposed bone visualized through a 12-cm open wound and gross organic contamination.

According to the Gustillo–Anderson classification of open fractures, which of the following is INCORRECT?

1. The difference between Types I, II, and III is related to wound size.

2. The difference between Types IIIA, IIIB, and IIIC is related to contamination.

3. Both Type II and IIIA injuries can be covered with local muscle and skin.

4. Type II injuries include comminution of the bone.

 

Discussion

The correct answer is (B). The different categories within Type III are delineated by soft tissue coverage needs as well as vascular status of the extremity as shown in Table 6–1.

 

Table 6–1 GUSTILO FRACTURES

 

Type	Subtype	Definition
I		Low energy with <1 cm wound
II III	A B	Low to moderate energy with >1 cm wound size High energy with severe bony comminution or segmental fracture Wound with exposed bone that requires soft tissue coverage
	C	Any open fracture with arterial damage that requires repair

 

What is the most appropriate antibiotic prophylaxis for the patient upon presentation?

1. First-generation cephalosporin

2. Cephalosporin and an aminoglycoside

3. Cefezolin, gentamicin, and penicillin

4. Clindamycin, gentamicin

 

Discussion

The correct answer is (C). Because this patient has a large wound which is most likely to be a Type III and was injured on a farm, antibiotic prophylaxis should include coverage of gram-positive, gram-negative, and anaerobic bacteria. In

addition, the patient should be given tetanus prophylaxis. However, there is a growing body of evidence that a second-generation cephalosporin only is adequate antibiotic prophylaxis for the majority of open fractures.

For the initial irrigation and debridement, which of the following options is most appropriate for this patient?

1. At least 12 L of fluid on high-pressure

2. 3 L of fluid and placement of an antibiotic pouch

3. 6 L of fluid that includes a soapy material

4. Low-pressure saline, 9 L

 

Discussion

The correct answer is (D). At least 3 L should be used for irrigation for each Gustillo–Anderson type, meaning that a Type III should be irrigated with a minimum of 9 L of fluid, and a Type I and Type II open fracture, 3 L and 6 L, respectively. The most effective lavage to reduce bacterial count is low-pressure, and it does not matter if there is soap or antibiotics in the fluid as long as there is enough volume, and the irrigation is accompanied by a thorough debridement of foreign material and dead tissue.

 

Objectives: Did you learn...?

 

The Gusillo–Anderson classification system of open fractures?

 

Optimal method of irrigation when performing a debridement and irrigation of open fractures?