Open Fracture Classification &

Limb Salvage in Trauma

 Gustilo-Anderson Classification
Class I Wound <1cm. Low energy with minimal soft tissue damage.
Simple fracture pattern with minimal comminution.

Class II Wound 1-10cm. Moderate energy, soft tissue damage, and

comminution.

Class IIIA Wound >10cm. High energy. Adequate soft tissue cover of bone
despite extensive soft tissue damage. Severe comminution or
segmental fractures. Extensive contamination.

Class IIIB Wound >10cm. Inadequate soft-tissue cover requiring tissue flap.
Periosteal stripping and bone exposure.
Class IIIC Wound >10cm. Vascular injury requiring repair.
Gustilo-Anderson Classification
Management of open fractures
• ABCDE
• Tourniquet- arterial and venous occlusion
• Radiology: X-rays, CT scans
• Consults: ortho, neuro, vascular, plastics
• Stabilization and reduction of fracture
• Antibiotics, tetanus prophylaxis
• Irrigation and debridement
• Surgery within 6 hours of injury
 Antibiotics

• Start ASAP and continue until 24 hrs after final closure

• Grade I and II: first generation cephalosporin (cefazolin)
• Grade III: add aminoglycoside (gentamycin)
• Penicillin is added to cover anaerobes (C. perfringens)
which can lead to gas gangrene.
injuries with contamination of dirt/soil
 Tetanus Shot
Tetanus Immunization status Recommended dosing

Tetanus booster within last 5 years No further treatment

>5 years since booster or not completed Tetanus toxoid (+/- human tetanus
immunization series immunoglobulin (HTIG))

>10 years since booster or Tetanus toxoid and HTIG

immunocompromised
Limb Salvage
• Reconstruction to save use and appearance of a limb
• Preservation of bone, tendon, nerves, and blood
vessels as best as possible
• Flaps and bone grafts used for reconstruction
• Amputation in war due to high risk of infection
before microsurgical techniques were advanced and
optimized
Example of limb salvage

Ong, Y. S., & Levin, L. S. (2010)

 Indications
Salvage Amputation
• Limb injury in children • Crush injuries with warm
• Bony and soft tissue loss ischemia >6 hours
with intact sensibility • Open tib-fib fractures with
complete anatomical
disruption of posterior tibial
nerve in adults

Scales/assessments often used to help clinicians determine

whether to attempt salvage or choose primary amputation
Mangled Extremity Severity Scale (MESS)

Cross, W. W., & Swiontkowski, M. F. (2008).

 Predictive Scales
• Mangled extremity severity scale(MESS)
• Predictive salvage index
• Limb salvage index
• Hanover fracture scale – 97
• Nerve Injury, Ischemia, Soft-Tissue Injury, Skeletal
Injury, Shock, and Age of Patient Score(NISSSA)

• Low scores could be used to predict limb-salvage

potential, but high scores are not good predictors
of amputation.
 Limb salvage versus amputation
• Saddawi-Konefka et al. screened over 1900 citations
from three large databases, ultimately extracting data
from 28 articles that collectively examined over 1300
distinct patients.
• No difference in length in hospital stay in patients who
undergo limb salvage versus primary amputation for IIIB
and IIIC open tibial fractures
• Pain, long-term quality-of-life and limb function do not
differ greatly between the patient groups
• Limitation of the study excluded unfavorable patients
with co-morbid conditions or severe injuries. Also,
available studies did not use standardized evaluation
tools.
References
• Kanakaris, NK, Giannoudis, PV. “Open Fractures.” Trauma and Orthopaedic
Classifications: A Comprehensive Overview, 2014: 487-493.
• Cross, W. W., & Swiontkowski, M. F. (2008). Treatment principles in the
management of open fractures. Indian Journal of Orthopaedics, 42(4), 377–386.
• Jedlicka, N., Summers, N. J., & Murdoch, M. M. (2012). Overview of Concepts and
Treatments in Open Fractures. Clinics in Podiatric Medicine and Surgery, 29(2),
279-290.
• Ong, Y. S., & Levin, L. S. (2010). Lower Limb Salvage in Trauma. Plastic and
Reconstructive Surgery, 125(2), 582-588.
• Kadam, D. (2013). Limb salvage surgery. Indian Journal of Plastic Surgery, 46(2),
265. doi:10.4103/0970-0358.118603
• Saddawi-Konefka, D., Kim, H. M., & Chung, K. C. (2008). A Systematic Review of
Outcomes and Complications of Reconstruction and Amputation for Type IIIB and
IIIC Fractures of the Tibia. Plastic and Reconstructive Surgery, 122(6), 1796–1805.
• Bosse, M. J., Mackenzie, E. J., Kellam, J. F., Burgess, A. R., Webb, L. X.,
Swiontkowski, M. F., . . . Cyril, J. K. (2001). A Prospective Evaluation of the Clinical
Utility of the Lower-Extremity Injury-Severity Scores. The Journal of Bone and Joint
Surgery-American Volume, 83(1), 3-14. doi:10.2106/00004623-200101000-00002