The Orthopaedic Trauma Association (OTA) Open Fracture Study Group has published a proposal for an updated system for classification of open fractures. So far, I don’t know of anyone who is actually using the new system, but I wanted to publicize it for your comments. Today, I’ll discuss the current classification standard in most trauma centers. Tomorrow, I’ll review the newly proposed one.
The most widely used system was developed by Gustilo and Anderson (G&A), with work starting in 1969. A number of modifications have been made over the years. Here’s the current classification system:
- Grade I: Clean wound, <1cm in length
- Grade II: Wound >1cm, but no extensive soft tissue injury, flaps or avulsions
- Grade III: Extensive soft tissue laceration or damage, or open segmental fracture. Three subtypes were later developed:
- Grade IIIa: Adequate periosteal coverage of the fracture
- Grade IIIb: Extensive soft tissue loss, periosteal stripping, bone damage. Usually includes massive contamination.
- Grade IIIc: Vascular injury requiring repair, regardless of degree of soft tissue injury
A few minor modifications have been made by others over the years, but they are not in general use.
So what’s the problem with G&A? Here are a few. Is the injury classified before or after debridement? Preop classification or intraop? Can you use this system for treatment when it is already based on treatment? How reproducible is it? Is there good data on outcomes? Do outcomes rely on other factors, such as the level of trauma hospital treating the fracture? To name a few. In it’s favor, it is in widespread use and nearly all orthopaedic surgeons are well versed in it.
Tomorrow I’ll discuss how the new OTA system addresses some of the shortcomings in the G&A system.
- 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 58:453–8, 1976.
- Problems in the management of type III (severe) open fractures: A new classification of type III open fractures. J Trauma 24:742–6, 1984.