This document discusses the classification of open fractures. It begins with a brief history, noting that open fractures were first recognized by Egyptians and Hippocrates advocated debridement. It then details several classification systems for open fractures. The most widely used system is the Gustilo-Anderson classification, which considers wound size, soft tissue damage, and contamination. Type III fractures are further divided into subclasses A, B, and C based on severity. Other classification systems discussed include MESS, GHOISS, and Oestern and Tschernes. Complications of open fractures include shock, compartment syndrome, and infection.

1. OPEN FRACTURES: HISTORICAL PERSPECTIVE AND
CLASSIFICATION.
• Presented By:
-Dr. Punit Gaurav
1st year Post Graduate Trainee.
Department of Orthopaedics.

2. INTRODUCTION
 Open fractures are those in which a bone
or joint structure is exposed to the
external environment.
 Due to disruption of the soft tissues and
overlying skin.

3. Usually high energy injuries with severe bone and soft
tissue involvement.
Often associated with decreased vascular supply,
contamination,degloving of skin and a variable degree
of soft tissue damage.

4. HISTORICAL ASPECTS :
Egyptians 1st time recognised need for
coverage over fracture wounds to
minimise morbidity.
 Hippocrates favoured the debridement
of purulent material.

5. • In 1895, Stanley Boyd
said “The most
important divisions of
fractures - simple,
compound and
complicated - are
based upon the
condition of the soft
parts.”

6. • Last century, high mortality with
open fractures of long bones.
• During WWI, mortality of open
femur fractures > 70%.
• By the WWI the main principle of
treatment was debridement &
stabilization, and healing by
secondary intention.

7. • 1939 Trueta -“closed treatment of
war fractures”
– Included open wound
treatment and then enclosure of
the extremity in a cast.
• During the WW-II use of local
antibiotics like sulfonamides was
started for wound treatment.

8. • Advances shifted the focus
– Preservation of life and limb
→preservation of function and
prevention of complications.
• However, amputation rates still
exceed 50% in the most severe open
tibial fractures associated with
vascular injury.

9. EPIDEMIOLOGY
• More than 4.5 million open fractures occur
per year in India. (IJO)
• Can involve significant morbidity and are
inherently worrisome, as the body's
protective skin barrier broken and the
potential for contamination is high.
• Correct and timely management of these
injuries can benefit our patients and lead to
more favorable outcomes.

10. • Diaphyseal fractures are
more common than
metaphyseal fractures.
• Highest rate of diaphyseal
fractures are seen in tibia
(21.6%) >femur(12.1%)>
radius >ulna(9.3%)>
humerus(5.7%)

11. MODE OF INJURY:
• Result of high energy trauma → Greater soft
tissue disruption → Leaves wound more
susceptible to infection by contaminating
bacteria.
• Energy stored in soft and hard tissues until the
strength of respective material is exceeded.
• Comminuted pieces acquire high velocity →
Propel into the surrounding soft tissues →
Additional damage.

12. • More severe injury, limb absorbs
energy →releases in explosion → tears
the skin→ momentary vacuum sucks
foreign material into the wound
depth.
• Soft tissue damage→ enormous
muscle swelling→compartment
syndrome (more in open injuries) of
the intact compartments

13. OPEN FRACTURE CLASSIFICATION:
• Purpose of any fracture classification system in the
clinical setting is to allow communication that infers
fracture morphology and treatment parameters.
• In the setting of open fractures, there are four
classification systems that surgeons treating these
injuries should be familiar with.

14. 1. GUSTILO AND ANDERSON CLASSIFICATION
• Most widely used system and is
generally accepted as the primary
classification system for open fractures.
• Takes into consideration- energy of the
fracture, soft-tissue damage, and the
degree of contamination.

15. TYPE I :
• WOUND SIZE :
Small ≤ 1cm, Clean, Punctured, a
Bone spike protruded.
• SOFT TISSUE DAMAGE :
Little, No crsushing.
• ENERGY OF TRAUMA :
Low Velocity.
• FRACTURE PATTERN :
Simple Fracture.

16. TYPE I :
• CONTAMINATION :
Mild.
• PERIOSTEAL STRIPPING :
Absent.
• VASULAR INJURY :
Absent.
• SKIN COVERAGE:
Local Coverage.

17. TYPE II :
• WOUND SIZE :
Small 1-10 cm, No skin flaps or
avulsion.
• SOFT TISSUE DAMAGE :
Moderate Crushing, Not extensive.
• ENERGY OF TRAUMA :
Moderate Velocity.
• FRACTURE PATTERN :
Simple fracture pattern with minimal
comminution

18. TYPE II :
• CONTAMINATION :
Moderate.
• PERIOSTEAL STRIPPING :
Absent.
• VASULAR INJURY :
Absent.
• SKIN COVERAGE:
Local Coverage.

19. TYPE III :
• Either an open segmental fracture, an open
fracture with extensive soft tissue damage, or a
traumatic amputation.
• Variation in severity, etiology, and prognosis of
Type III injuries made a single classification
insufficiently specific for the task at hand.

20. • Frequency of these injuries (>60% of
open fractures are Type III, according
to one epidemiologic study), made
that issue even more pressing.
• In response to that problem, these
high-energy open fractures were
further subclassified by Gustilo et al.
into A, B, and C.

21. TYPE III A :
• WOUND SIZE :
Usually >10cm, skin flaps or
avulsion
• SOFT TISSUE DAMAGE :
Extensive.
• ENERGY OF TRAUMA :
High Velocity.
• FRACTURE PATTERN :
Severe comminution or segmental
fractures.

22. TYPE III A :
• CONTAMINATION :
Extensive.
• PERIOSTEAL STRIPPING :
Present.
• NEUROVASULAR INJURY :
Present.
• SKIN COVERAGE :
Local Coverage.

23. TYPE III B :
• WOUND SIZE :
Usually >10cm, skin flaps or
avulsion
• SOFT TISSUE DAMAGE :
Extensive.
• ENERGY OF TRAUMA :
High Velocity.
• FRACTURE PATTERN :
Severe comminution or segmental
fractures.

24. TYPE III B :
• CONTAMINATION :
Extensive.
• PERIOSTEAL STRIPPING :
Present.
• NEUROVASULAR INJURY :
Present.
• SKIN COVERAGE :
Requires free tissue flap or rotational
flap coverage.

25. TYPE III C :
• WOUND SIZE :
Usually >10cm
• SOFT TISSUE DAMAGE :
Extensive.
• ENERGY OF TRAUMA :
High Velocity.
• FRACTURE PATTERN :
Severe comminution or segmental
fractures.

26. TYPE III C :
• CONTAMINATION :
Extensive.
• PERIOSTEAL STRIPPING :
Present.
• NEUROVASULAR INJURY :
Exposed fracture with arterial
damage that requires repair
• SKIN COVERAGE :
Typically requires flap coverage.

27. MANGLED EXTREMITY SEVERITY SCORE
• Second classification system, the MESS, originally designed as an
objective tool to assist the surgeon in decision-making for
amputation vs limb salvage in complex lower extremity trauma
• Given by Johansen in 1990.
• Strong weightage given for the presence of warm ischemia time and
an age >30 years.
• Johansen reported that a score of 7 or more predicted amputation
with 100% accuracy

28. Components
Skeletal and soft-tissue injury
• Low energy (stab; simple fracture civilian gunshot wound) 1
• Medium energy (open or multiple fractures, dislocation) 2
• High energy (close-range shotgun or military gunshot wound, crush injury) 3
• Very high energy (same as above plus gross contamination, soft tissue avulsion) 4
Limb ischemia (score is doubled for ischemia >6 h)
• Pulse reduced or absent but perfusion normal 1
• Pulselessness; paresthesias, diminished capillary refill 2
• Cool, paralyzed, insensate, numb 3
Shock
• Systolic blood pressure always >90 mm Hg 0
• Hypotensive transiently 1
• Persistent hypotension 2
Age (years)
• <30 0
• 30–50 1
• >50 2

29. GANGA HOSPITAL OPEN INJURY SEVERITY
SCORE
• GHOISS was proposed by Rajasekaran in 2006 as a score
specifically to assess severe Grade IIIB limb injuries without a
vascular injury.

32. • Injuries with a score of 14 and below should be attempted for
salvage.
• 17 and above should be considered for primary amputation,
in between(15,16) must be assessed by an experienced team
on a case-to-case basis

33. OESTERN AND TSCHERNE CLASSIFICATION
Grade 0
• Open fractures with a small puncture
wound without skin contusion.
• Negligible bacterial contamination.
• low energy fracture pattern.

34. Grade 1
• Open injuries with small skin and
soft tissue contusions.
• Moderate contamination.
• Variable fracture patterns.

35. Grade 2
• Open fractures with heavy contamination
• Extensive soft tissue damage
• Often, associated arterial or neural injuries

36. Grade 3
• Open fracture with incomplete
or complete amputations.

37. COMPLICATIONS
• Hypovolemic shock
• Compartment syndrome
• Fat embolism
• ARDS
• Neurovascular injuries
• Infection

38. REFRENCES
• Rockwood & Green’s fractures in Adults. Fifth Edition.
• Koval's handbook of fractures.
• Campbell’s Operative Orthopaedics Ninth Edition, Edited by
Terry Canale.
• Apleys and solomon texbook of trauma 10th edition.
• William W Cross et al - Indian Journal of Orthopaedics
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2740354/)
• Sudhir Babhulkar et al - Indian Journal of Orthopaedics
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2740363/)