A 28-year-old man sustains a crush injury to his right leg in a motor vehicle accident. On examination, there is a 3 cm laceration over the fracture site with bone ends visible, minimal contamination, and the fracture is comminuted. Soft tissue damage is moderate. According to the Gustilo classification, what is the grade of this open fracture?

Question

Accepted Answer

C. Gustilo Grade II. ## Gustilo Classification of Open Fractures

The Gustilo-Anderson classification system stratifies open fractures by wound size, degree of contamination, soft tissue damage, and fracture complexity. This patient's features are consistent with **Grade II**.

### Classification Criteria

| Grade | Wound Size | Contamination | Soft Tissue Damage | Fracture Type |
|-------|-----------|----------------|-------------------|---------------|
| I | <1 cm | Minimal | Minimal | Simple |
| II | 1–10 cm | Moderate | Moderate | Simple or comminuted |
| III A | >10 cm | High | Extensive, but adequate soft tissue coverage | Comminuted/segmental |
| III B | >10 cm | High | Severe periosteal stripping; requires flap coverage | Comminuted |
| III C | Any size | Any | Any | Any + arterial injury requiring repair |

**Key Point:** Grade II is defined by a wound **1–10 cm** in length with **moderate** soft tissue damage and **moderate** contamination. Comminution alone does NOT automatically upgrade a fracture to Grade III A.

### Analysis of This Case

1. **Wound size:** 3 cm — falls squarely in the 1–10 cm range → Grade II criterion met
2. **Contamination:** Minimal (motor vehicle accident, not agricultural/marine/heavily contaminated) → consistent with Grade II
3. **Soft tissue damage:** Moderate — no periosteal stripping, no requirement for flap coverage → consistent with Grade II
4. **Fracture pattern:** Comminuted — comminution can occur in Grade II; it does not mandate Grade III A

**Why NOT Grade III A?** Grade III A requires a wound **>10 cm** with **extensive** soft tissue damage (though adequate coverage remains possible). The wound here is only 3 cm and soft tissue damage is described as moderate, not extensive. The explanation that "comminution alone elevates to Grade III A" is **not standard teaching** per Gustilo & Anderson (1976) or Rockwood & Green's Fractures in Adults.

**Clinical Pearl:** The key differentiator between Grade II and Grade III A is wound size (>10 cm) and the degree of soft tissue stripping/damage, not fracture comminution alone. A comminuted fracture with a 3 cm wound and moderate soft tissue injury = **Grade II**.

**High-Yield:** Grade III B differs from III A by requiring soft tissue reconstruction (flap coverage) due to periosteal stripping. Grade III C involves an arterial injury requiring repair regardless of wound size.

*Reference: Gustilo RB, Anderson JT. JBJS 1976; Rockwood & Green's Fractures in Adults, 9th ed.*

Answer

A. Gustilo Grade III A

Answer

B. Gustilo Grade III B

Answer

D. Gustilo Grade I

Explanation

Gustilo Classification of Open Fractures

Classification Criteria

Analysis of This Case

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Grade	Wound Size	Contamination	Soft Tissue Damage	Fracture Type
I	<1 cm	Minimal	Minimal	Simple
II	1–10 cm	Moderate	Moderate	Simple or comminuted
III A	>10 cm	High	Extensive, but adequate soft tissue coverage	Comminuted/segmental
III B	>10 cm	High	Severe periosteal stripping; requires flap coverage	Comminuted
III C	Any size	Any	Any	Any + arterial injury requiring repair