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. Open Fracture: Gustilo classification. Open fractures have been classified by Gustilo as follows, with higher numbers indicating more severe injuries. Open fractures, also called compound fractures, are severe injuries to bones. These injuries almost always require surgery. Learn more.

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Open fractures usually are high-energy injuries. This, along with the exposure of bone and deep tissue to the environment, leads to increased risk of infection, wound complications, and nonunion [ 122831 ].

Despite the overall improvement in outcome after open fractures, the variable outcomes among different patterns of open fractures with classigication severities prompted the development of grading systems that classify them based on increasing severity of clasxification associated soft tissue injuries.

These grading systems seek to help guide treatment, improve communication and research, and predict outcome. Such classifications have been in use for some time [ 29 ]; however, it is the Gustilo-Anderson classification that has become the most commonly used system for classifying open fractures. Early attempts by Veliskakis [ 29 ] at grading open fractures were refined anxerson Gustilo and Anderson in [ 16 ].

After reviewing their initial classification of the most severe open injuries, Gustilo et al. Ultimately, through their studies of prevention of infection in open long bone fractures [ 1617 ], Gustilo et al. Like many classification systems, the purpose of the Gustilo-Anderson schema is to provide a prognostic framework that guides classjfication and facilitates communication among surgeons and clinician-scientists.

Open Fracture: Gustilo classification

As a widely known and relatively straightforward system, which has become the standard of classifying open fractures, the Gustilo-Anderson classification also is useful for education of residents and other trainees in the treatment of patients with orthopaedic trauma [ 19 ]. The original study [ 16 ] included an initial retrospective evaluation, followed by a prospective gustllo of the system that Gustilo and Anderson developed. The retrospective part of the study evaluated open fractures of long bones in patients to determine the impact of primary versus secondary closure, use of primary internal fixation, and routine use of antibiotics in the treatment algorithm of open long-bone fractures.

The key findings were that primary closure without primary internal fixation and prophylactic antibiotics for Type I and Type II open fractures reduced the risk of infection as much as Gustilo and Anderson then prospectively followed more than patients. They categorized open injuries into the familiar three categories, based on wound size, level of contamination, and osseous injury, as follows: Special categories in Type III were gunshot injuries, any open fracture caused by a farm injury, and any open fracture with accompanying vascular injury requiring repair [ 16 ].

Type III open fractures proved the most difficult to classify and treat owing to the varied injury patterns, increased morbidity from associated injuries, massive soft tissue damage or loss over the classificatiob sites, compromised vascularity, wound contamination, and fracture instability.

Gustilo-Anderson Classification

In response to that problem, these high-energy open fractures were further subclassified by Gustilo et al. Because much of the literature on the subject of open fractures uses the Gustilo-Anderson classification or a variant of it, it is important to know whether the classification is reliable.

Brumback and Jones [ 5 ] and Horn and Rettig [ 19 ] have examined the reliability of the Gustilo-Anderson classification system [ 1617 ]. In another study [ 19 ], 10 patients with open fractures had photographic slides of their wounds and radiographs taken before and after debridement and stabilization.

These slides subsequently were evaluated by 22 orthopaedic surgeons eight attending orthopaedic surgeons and 14 orthopaedic residents. The kappa value [ 920 ] in this study was 0. The fact that these two studies [ 519 ] on the subject found only moderate reliability of the Gustilo-Anderson classification system among different observers is an important clinical limitation of this schema.


The variability among individuals and their interpretation of the Gustilo-Anderson classification [ 16 ] results in a spectrum of injuries having too much overlap [ 5 ], possibly owing to the observer error [ 19 ]. Despite this, the Gustilo-Anderson classification has prognostic implications [ 610 ] with complication rates increasing as the severity of the injury increases [ 618 ]. Given that the classification system [ 1617 ] is easy to use and has prognostic and therapeutic implications, it is of value, but treatment recommendations based on the classification [ 1617 ] should be interpreted with caution owing to its limitations regarding interobserver reliability [ 519 ].

There is general agreement that more severe open fractures have a worse clinical prognosis for infection, nonunion, and other complications, although the magnitudes of these findings vary depending on numerous clinical factors [ 718 ].

A study of open fractures showed an overall infection rate of 4. In the original study by Gustilo and Anderson, an overall infection rate of 2.

Type III fractures, however, are not a homogeneous group; another study found a considerable range of infection rates among the subtypes of Type III injuries, with 1. The Gustilo-Anderson classification is widely used [ 6 ], and is the basic language with which many investigators communicate the results of open fracture treatment [ 5 ].

However, the Gustilo-Anderson classification is limited because it seeks to contain an almost limitless variety of injury patterns, classsification, and severities with a small number of discrete categories [ 32 ].

Another critical limitation is that the surface injury does not always reflect the amount of deeper tissue damage and the Gustilo-Anderson classification does not account for tissue viability and tissue necrosis, which tend to evolve with time after more severe injuries.

Because open fractures may be underclassified on initial evaluation in the emergency department, many investigators agree that definitive classification that is, the classification that will drive the eventual treatment decisions of open fractures is best made in the operating room [ 3 anderspn, 132223 ]. Gustilo and Anderson [ 16 ] emphasized the importance of debridement but Pollak et al.

Furthermore, Webb et al. Finally, Bowen and Widmaier found that the number of compromising comorbidities to be significant independent predictors of infection [ 4 ]. Studies such as these challenge the true prognostic ability of the Gustilo-Anderson classification.

Gustilo open fracture classification

Another limitation is the two studies [ 1617 ] were unbalanced in their numbers comparing the retrospective and prospective data without rigid statistical analysis; all long-bone open fractures were included despite different bones inherently having different risks of infection owing to their particular soft tissue envelope [ 16 ]. An area of controversy, at least earlier on [ 1617 ], pertained to the treatment of fractures in this spectrum of injury.

Gustilo and Anderson originally recommended against early fracture fixation for many Type III injuries. Newer evidence shows that stabilization of many of these fractures—even with internal fixation—reduces the risk of infection and malunion, promotes fracture healing, restores function, and expedites rehabilitation [ 4 ]. Finally, the nonmutual exclusive nature of the criteria for Type IIIB injuries imposes inherent difficulty in using this classification schema to predict which injuries need a muscle flap for coverage [ 6 ].

The Gustilo-Anderson classification, despite its inherent limitations, is prognostically valuable for predicting orthopaedic infection [ 41621 ]. It is widely accepted for research, communication, and training purposes, and its remains useful as a good, basic approach to manage open fractures. Goals of fracture treatment should be to prevent infection, promote fracture healing, and restore function. Open fractures are, by definition, contaminated; therefore, the use of antibiotics is therapeutic, not prophylactic, and is fundamental to the care of patients with these injuries [ 14 ].


Many of the principles outlined by Gustilo et al. Although the Gustilo-Anderson classification is useful, its interobserver reliability is limited [ 519 ] and it lacks the ability to comprehensively measure prognostic patient outcome [ 2830 ]; therefore, assessment of all open fractures should include the mechanism of injury, the appearance of the soft tissue envelope and its condition in the operating room [ 3132223 ], the level of likely bacterial contamination, and the specific characteristics of the fracture [ 133132 ].

To comprehensively measure prognosis, outcome measures such as the Sickness Impact Profile [ 2 ] can be used for more accuracy. The Gustilo-Anderson classification laid a foundation for management of open fractures, but the management of open fractures continues to evolve.

Delayed primary closure historically has been used, especially for Type III fractures, but consideration for earlier closure has been reported. Finally, adjunctive therapies such as rhBMP-2 have been found to significantly reduce secondary interventions, lower hardware failure, and promote faster fracture healing [ 15 ], but more recently Aro et al.

The Gustilo-Anderson classification system remains the preferred system for categorizing open fractures. Despite its limited interobserver agreement [ 519 ], good but imperfect prognostic ability, and somewhat dated treatment algorithms, no other classification is superior in terms of its popularity and common use, and because the Gustilo-Anderson schema correlates well with the risk of infection and other complications [ 52123 ].

National Center for Biotechnology InformationU. Clin Orthop Relat Res. Published online May 9. KimMD and Seth S.

Author information Article notes Copyright and License information Disclaimer. Gusgilo Dec 29; Accepted Apr This article has been corrected. See Clin Orthop Relat Res. This article has been cited by other articles in PMC.

History Open fractures usually are high-energy injuries. Purpose Like many classification systems, the purpose of the Gustilo-Anderson schema is to provide a prognostic framework that guides treatment and facilitates communication among surgeons and clinician-scientists.

Limitations The Gustilo-Anderson classification is widely used [ 6 ], and is the basic language with andersson many investigators communicate the results of open fracture treatment [ 5 ]. Recombinant human bone morphogenetic protein J Bone Joint Surg Am.

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Open tibial shaft fractures: Evaluation and initial wound management. J Am Acad Orthop Surg. Okike K, Bhattacharyya T.

Trends in the management of open fractures: Local antibiotic therapy for severe open fractures: The Orr method for wounds and compound fractures. Patzakis MJ, Wilkins J. Factors influencing infection rate in open fracture wounds.

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