Abridged version Type I wound ≤1 cm, minimal contamination or muscle damage Type II wound 1-10 cm, moderate soft tissue injury Type IIIA wound usually >10 cm, high energy, extensive soft-tissue damage, contaminated adequate tissue for flap coverage farm injuries are automatically at least Gustillo IIIA Type IIIB extensive periosteal stripping, wound requires soft tissue coverage (rotational or free flap) Type IIIC vascular injury requiring vascular repair, regardless of degree of soft tissue injury Most accurate way to grade open fratures is by intra-operative examination Complete version Gustilo Classification I II IIIA IIIB IIIC Images Energy Low Moderate High High High Wound size ≤ 1 cm 1-10 cm usually >10 cm usually >10 cm usually >10 cm Soft tissue damage Minimal Moderate Extensive Extensive Extensive Contamination Clean Moderate Extensive Extensive Extensive Fracture Comminution Minimal Moderate Severe Severe Severe Periosteal Stripping No No Yes Yes Yes Skin Coverage Local coverage Local coverage Local coverage Free tissue flap or rotational flap coverage Typically requires flap coverage Neurovascular Injury Normal Normal Normal Normal Exposed fracture with arterial damage that requires repair Antibiotics based on Gustilo Classification Grade I and II Grade IIIA, IIIB and IIIC Special considerations Antibiotics 1st generation cephalosporin (e.g. cefazolin) 1st generation cephalosporin for gram positive coverage Aminoglycoside (such as gentamicin) for gram negative coverage Penicillin should be added if concern for anaerobic organism (farm injury) Flouroquinolones (e.g. ciprofloxacin) should be used for fresh water wounds or salt water wounds (can be used if allergic to cephalosporins or clindamycin Doxycycline and 3rd or 4th-generation cephalosporin (e.g. ceftazidime) can be used for salt water wounds Antibiotic Indications for Open Fractures Gustillo type I and II 1st generation cephalosporin Gustillo type III 1st generation cephalosporin + aminoglycoside traditionally recommended, but there is controversy about this regimen With farm injury / bowel contamination 1st generation cephalosporin + aminoglycoside + PCN add PCN for clostridia Duration initiate as soon as possible increased infection rate when antibiotics are delayed > 3 hours from time of injury continue for 24-72 hours after I&D Tetanus booster if not up to date (no booster in last 5 years)