Gustilo open fracture classification
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. It is important to recognize that a Gustilo score of grade 3C implies vascular injury as well as bone and connective-tissue damage.
Reliability
There are many discussions regarding the inter-observer reliability of this classification system. Different studies have shown inter-observer reliability of approximately 60%, representing poor-to-moderate agreement of scale grading between health-care professionals. This is due to much of the criteria being at risk of observer errors, and is a known liability of this scaling system. However, this classification is simple and hence easy to use, and is generally able to predict prognostic outcomes and guide treatment regimes. Generally, the higher the grading of Gustillo classification, the higher the rate of infection and complications; any Guistilo classification rating should still be interpreted with caution due to observer errors before any definite therapeutic plans are made.Although this classification system has a fairly good ability to predict fracture outcomes, it is not perfect. 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 rates of infection because they are covered by different amounts of soft tissues. Gustilo initially does not recommend early wound closure and early fixation for Grade III fractures. However, newer studies have 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 be performed inside an operating theatre.
For more comprehensive prognosis purposes other classification systems, such as the Sickness Impact Profile, Mangled Extremity Severity Score and Limb Salvage Index, have been devised by Dr Shanmuganathan Rajasekaran.