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Open fractures — Gustilo classification and management
An open fracture communicates with the outside through a wound; the dangers are infection and non-union, so care rests on antibiotics within one hour, tetanus cover, a sterile dressing and temporary splinting, followed by surgical debridement, stabilisation and early soft tissue cover.
Why it matters in the exam
Questions present a wound over a fracture and ask for the right order of actions or the classification. The first rule: any wound over or near a fracture is an open fracture until proven otherwise. In the emergency department give intravenous antibiotics as soon as possible, ideally within one hour of injury, check tetanus cover, photograph the wound, remove only gross contamination, cover with a saline-soaked dressing and splint — without repeatedly exploring the wound in the department. The Gustilo-Anderson grade is set finally only in theatre after debridement, because it depends on tissue damage and not only on wound size. High energy, farm or sewage contamination and comminution make any fracture type III even when the wound is small. Under the British standards of care, debridement is done immediately for gross contamination or vascular injury, within 12 hours for high-energy fractures and within 24 hours for others, and definitive soft tissue cover is ideally within 72 hours. In questions about a limb with arterial injury (type IIIC), think of rapid revascularisation, fasciotomy and compartment syndrome, which can also occur with an open fracture. In a badly mangled limb, the choice between reconstruction and amputation is made by a combined team of orthopaedic and plastic surgeons.
Key points
- Any wound over a fracture — open fracture until proven otherwise.
- Antibiotics within one hour and tetanus cover.
- Gustilo I, II, IIIA, IIIB, IIIC by tissue damage.
- Timed surgical debridement by severity; cover within 72 hours.
- IIIC — arterial injury needing repair.
Summary table
| Type | Wound and tissue damage | Notes |
|---|---|---|
| I | Wound smaller than 1 cm, clean, little tissue damage | Usually a simple low-energy fracture |
| II | Wound of 1–10 cm, moderate tissue damage | No extensive periosteal stripping |
| IIIA | Extensive damage or high energy, but soft tissue cover possible | Includes farm contamination and comminution even with a small wound |
| IIIB | Extensive damage with periosteal stripping; a flap is needed for cover | High infection risk; cover within 72 hours |
| IIIC | Arterial injury needing repair | Urgent revascularisation and fasciotomy |
A free exam question
בן 32 נ פגע במשחק כדורגל וסובל משבר טיביה פתוח גוסטילו 2 . הוא מגיע לחדר מיון בשעה שתיים בלילה. מה עיתוי הניתוח הנכון? (the question as examined, in Hebrew)
- א. תוך 6 שעות מרגע הפציעה על מנת להפחית שיעור סיבוכים
- ב. בהקדם, אך רק כאשר יש חדר ניתוח זמין וצוות כשיר
- ג. ניתן להתייחס אליו כשבר סגור ולתאם לו מועד בעוד מספר ימים
- ד. אין חשיבות לעיתוי כל עוד משתמשים במקבע חיצוני
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Sources
- BOA/BAPRAS Standards for the Management of Open Fractures, 2020 — Open Fractures
- Rockwood and Green's Fractures in Adults, 9th ed. (2019) — Initial Management of Open Fractures
- Gustilo RB, Anderson JT, J Bone Joint Surg Am (1976; modified 1984) — Classification of open fractures
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.