Background

Introduction

• Open fractures represent a spectrum of injuries sharing a common feature which is disruption of the skin and underlying subcutaneous tissues by the fracture bone causing communication to the environment.
• Ranges from small inside-out puncture wounds to more extensive, high energy injuries.
• Involves a high risk of infection to a variety of environmental factors.
• Infection rate is reported to be up to 38% which increases over time for as long as the wound is exposed.

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Epidemiology

• Incidence of 30.7/100,000/year
  • 69.1% occurs in males, average age of 40.8 years old
  • 30.9% occurs in females, average age of 56 years old
• Location of injury
• 45.7% for finger phalanges
  • 11.2% for tibia and fibula – most common long bone fracture, the infection rate in this area is 10 to 20 times higher
  • 7.1% distal radius
  • 7.1% toe phalanges
  • 5.3% ankles
  • Others account for 23% which include metacarpus, proximal ulna, metatarsus, etc.

Incidence Rate using the Gustilo-Anderson Classification System
Type I Fracture	0-2% of Open Fractures
Type II Fracture	2-12% of Open Fractures
Type III Fracture	10-50% of Open Fractures
Type IIIA Fracture	4% of Type III Fractures
Type IIIB Fracture	52% of Type III Fractures
Type IIIC Fracture	42% of Type III Fractures

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Etiology

Mechanisms of injury are categorized as follows:

I. Low-energy trauma (~100 foot-pounds of energy)

• Torsional injuries
• Fall from standing

II. Moderate-energy trauma (~300 – 500 foot-pounds of energy)

• Skiing injury
• Bicycling injury

III. High-energy trauma (greater than 2000 foot-pounds of energy)

• Motor vehicle accident
• Fall from height
• Firearm

•Most common cause of open fractures includes crash injuries, falls, and road traffic accidents.

•Type III open fractures are 7 times more likely to develop an infection

•Type IIIC fractures are 25-90% likely to need amputation.

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Gustilo-Anderson Classification System

• This is a grading system for the identification of open fractures and its severity.
• Fractures are designated as one of these three types and subtypes based on:

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Gustilo-Anderson Classification System
Type I Fracture	Open fracture with clean wound <1cm long
Type II Fracture	Open fracture with laceration >1cm long without extensive soft tissue damage
Type III Fracture	Open segmental fracture, open fracture with extensive soft tissue damage, or traumatic amputation
Type IIIA Fracture	Adequate soft tissue coverage of a fractured bone despite extensive soft tissue laceration or flaps, or high energy trauma irrespective of the size of the wound
Type IIIB Fracture	Extensive soft tissue injury loss with periosteal stripping and bone exposure, usually associated with massive contamination
Type IIIC Fracture	Open fracture associated with arterial injury repair

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Reliability of the classification and a collective understanding and agreement of observers remains an issue. With Gustilo-Anderson Classification, here are its limitations:

1. Does not take tissue viability or tissue necrosis into account.
2. Moderate to poor inter-observer reliability.
3. Wound size and outward appearance may not accurately identify the true extent of the injury.

• Under-classifications has occurred on several accounts in the Emergency Department admission.
• Classification can only be made most precisely by surgeon in the OR following wound exploration and debridement.

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