Gustilo open fracture classification

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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.[1][2][3]

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.[4]


Gustilo open fracture Classification
Gustilo Grade Definition
I Open fracture, clean wound, wound <1 cm in length
II Open fracture, wound > 1 cm but < 10 cm in length[4] without extensive soft-tissue damage, flaps, avulsions
IIIA Open fracture with adequate soft tissue coverage of a fractured bone despite extensive soft tissue laceration or flaps, or high-energy trauma regardless of the size of the wound[5][6]
IIIB Open fracture with extensive soft-tissue loss and periosteal stripping and bone damage. Usually associated with massive contamination.[5][6] Will often need further soft-tissue coverage procedure (i.e. free or rotational flap)
IIIC Open fracture associated with an arterial injury requiring repair, irrespective of degree of soft-tissue injury.


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%).[7][8]

Another important issue of this classification system is the ability to predict outcome. For this purpose, other classification systems, like Mangled Extremity Severity Score (MESS) and Limb Salvage Index (LSI) have been devised.[9][10]

Gustilo type I open fracture
Gustilo type II open fracture


  1. ^ Rüedi, etc. all; Thomas P. Rüedi; Richard E. Buckley; Christopher G. Moran (2007). AO principles of fracture management, Volume 1. Thieme. p. Page 96. ISBN 3-13-117442-0. 
  2. ^ Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: Retrospective and prospective analyses. J Bone Joint Surg Am. 1976;58:453–8
  3. ^ Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: A new classification of type III open fractures. J Trauma. 1984;24:742–6.
  4. ^ a b
  5. ^ a b Kim, Paul H.; Leopold, Seth S. (2012-11). "Gustilo-Anderson Classification". Clinical Orthopaedics and Related Research. 470 (11): 3270–3274. doi:10.1007/s11999-012-2376-6. ISSN 0009-921X. PMC 3462875Freely accessible. PMID 22569719.  Check date values in: |date= (help)
  6. ^ a b "Ovid: Externer Link". Retrieved 2017-11-10. 
  7. ^ Brumback RJ, Jones AL. Interobserver agreement in the classification of open fractures of the tibia: The results of a survey of two hundred and forty-five orthopaedic surgeons. J Bone Joint Surg Am. 1994;76:1162–6
  8. ^ Cross WW, Swiontkowski M. Treatment principles in the management of open fractures.Indian J Orthop. 2008 Oct-Dec; 42(4): 377–386.
  9. ^ Johansen K, Daines M, Howey T, Helfet D, Hansen ST., Jr Objective criteria accurately predict amputation following lower extremity trauma. J Trauma. 1990;30:568–72
  10. ^ MacKenzie EJ, Bosse MJ, Kellam JF, Burgess AR, Webb LX, Swiontkowski MF, et al., editors. Factors influencing the decision to amputate or reconstruct after high-energy lower extremity trauma. J Trauma. 2002;52:641–9

See also[edit]