Accepted Manuscript

Title: Unified Classification of Open Fractures: Based on

Gustilo and OTA Classification Schemes

Author: Agrawal Anuj

PII: S0020-1383(18)30278-X
DOI: https://doi.org/10.1016/j.injury.2018.06.007
Reference: JINJ 7709

To appear in: Injury, Int. J. Care Injured

Accepted date: 2-6-2018

Please cite this article as: Agrawal A, Unified Classification of Open

Fractures: Based on Gustilo and OTA Classification Schemes, Injury (2018),
https://doi.org/10.1016/j.injury.2018.06.007

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 Unified Open Fracture Classification

ORIGINAL ARTICLE

UNIFIED CLASSIFICATION OF OPEN FRACTURES: BASED ON GUSTILO AND OTA

CLASSIFICATION SCHEMES

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Running title: Unified Open Fracture Classification

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Author Information:
First/Corresponding author Agrawal Anuj MBBS, MS (ortho), MCh (ortho)

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Consultant, Dept. of Orthopaedics,
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Kamineni Hospitals, King Koti Road, Hyderabad, India
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e-mail: anuj_aiims@yahoo.co.in Ph: +91-78989-16210
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Fax: 040-24762727
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No. of pages: 16

No. of photographs: 0
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Word count: Abstract - 152, Text – 2,886

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Abstract
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Background: The Orthopaedic Trauma Association (OTA) classification scheme for open fractures

has improved precision, validity and reliability over the modified Gustilo classification system.

However, it needs to be modified into a simple and practical classification system to gain

widespread acceptance and application.

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 Unified Open Fracture Classification

Material and methods: We devised a new “unified” classification of open fractures based on the

Gustilo and OTA classification systems. The new classification was tested for interobserver

reliability on five different fractures classified by 15 surgeons each using the Krippendorff’s alpha.

Preference of surgeons for the Gustilo, OTA and unified classifications was assessed.

Results: The new classification showed excellent interobserver reliability (α = 0.93). A

significantly higher number of surgeons expressed preference for the new over the Gustilo and OTA

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classifications for routine clinical use.

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Conclusion: The new “unified” classification of open fractures has good validity, reliability and

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acceptability, and has the potential to replace all other existing classification systems.

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Keywords: classification; Gustilo; open fractures; Orthopaedic Trauma Association; unified

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Introduction
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Even after 40 years since Gustilo and Anderson1 first proposed a classification of open fractures, a
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universally acceptable, valid and reliable classification system of open fractures remains elusive.
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The Gustilo classification has been shown to have only a moderate interobserver reliability.2,3 The

Classification Committee of the Orthopaedic Trauma Association (OTA) proposed a scientifically

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derived pathoanatomic classification scheme of open fractures.4 It allows a comprehensive

stratification of injury characteristics under five essential categories, and is applicable across
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anatomic regions and age groups. However, the ideal way of using this scheme as a classification
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remains to be determined5 and it is currently used only in conjunction with other popular
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classification systems.

We propose a new “unified” classification of open fractures based on the scientifically validated

OTA classification scheme and the universally acceptable Gustilo format. In this study, we

determined the interobserver reliability of the new classification and surgeons’ preferences between

the three open fracture classification systems.

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 Unified Open Fracture Classification

Current classification systems for open fractures

We reviewed and compared the various popular schemes and classifications of open fractures.

Gustilo classification remains the universally accepted system, with the Tscherne classification6

enjoying limited popularity in Europe. Gustilo and Anderson were the first to stratify open fractures

into types I, II and III with worsening severity and prognosis (particularly infection), mainly for

tibial fractures. Gustilo modified the classification in 19847, dividing the type III fractures into

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further subtypes finding them “too inclusive” of a diverse array of injuries. A further expansion of

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the classification was published by Gustilo in 19908 (Table 1) with no precise definitions given for

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terms like “minimal soft tissue damage”, “moderate contamination” and “extensive lacerations”.

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Consequently, the classification has been variably interpreted with studies showing only a moderate

interobserver agreement.2,3 It is also criticised by being determined by the treatment (e.g. the need

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of vascular repair or soft-tissue flap) rather than the injury pathoanatomy.
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Tsherne and Oestern, around the same time, proposed a classification of soft tissue injuries for both
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open and closed fractures. It too suffers from lack of precision based on subjective criteria like
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“moderate contamination” and “distinct soft tissue damage”. Also, the classification is too inclusive
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like the original Gustilo classification, with the type III (O3) fractures including a vast array of

fractures of varying severity and prognosis.

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AO-ASIF group devised a “soft tissue grading system” for both closed and open fractures.9 It is a

comprehensive system based purely on injury pathoanatomy, omitting wound contamination and
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fracture severity from the classification. It consists of three categories of open fracture assessment
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(with a fourth category for closed fractures) with five characteristics each, making a total of 15
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characteristics. It is too complex for routine clinical application and never got popular outside

research settings, though it is based on precise scientific criteria.

To address the shortcomings of current classification systems (validity, reliability and complexity),

the OTA Classification Committee proposed a new classification scheme4 in 2010. It identified five

essential categories of open fracture severity assessment (skin injury, muscle injury, arterial injury,
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 Unified Open Fracture Classification

contamination and bone loss), and defined three precise grades of increasing severity for each

category, making a total of 15 characteristics like the AO-ASIF system. The classification included

several improvements over the previous systems. Fracture severity (as in Gustilo classification) was

replaced by bone loss. Wound size (as in Gustilo and Tsherne classifications) was not considered

and replaced by skin defect, to make the scheme applicable across anatomic regions and age groups.

Some special conditions like compartment syndrome (as in AO-ASIF system) were removed from

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the main classification, recognizing them as “add-ons”. Logistic (e.g. delay in presentation, warm

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ischemic time), physiological (e.g. age, smoking status) and psychosocial factors (e.g. occupation,

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socioeconomic status) were excluded from the classification to avoid undue complexity.

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Classification timing was clearly defined to be applied at the ‘time of the initial debridement’.

However, the OTA-OFC still suffers from similar limitations as the AO-ASIF system- that of being

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perceived as a complex scoring system rather than a practical classification suitable for day-to-day
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communication.10 It needs to be presented in a simplified and familiar fashion to gain widespread
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acceptance and popularity amongst clinicians.
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 Unified Open Fracture Classification

New unified classification of open fractures

Format: The five types (I-II-IIIA-IIIB-IIIC) of the Gustilo classification are deeply engraved in

orthopaedic literature and clinicians’ minds alike, and we set out to retain this popular format, only

replacing the characteristics with more precise and validated ones. Also, the fracture types in the

new classification would reflect a similar progression of severity as the Gustilo types, and not

radically depart from them.

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Categories/ groups: The five essential categories of open fracture severity identified in the OTA

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classification are appropriate and form a part of other classification systems as well (Tables 1, 2).

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These categories were retained in the new classification, arranging them in a logical order according

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to progression of injury (from superficial to deep) and impact on outcomes, in agreement with their

order of appearance in other systems (Tables 1, 2). We renamed the category “skin” in OTA

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classification to “integument” (as in AO-ASIF system), so that the five categories, and their order,
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can be easily memorized by the acronym “CIMBA” (Table 3).
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Characteristics/ subgroups: We defined the characteristics in our classification similar to the

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OTA scheme, except for the integumentary system. The number of characteristics is similarly
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limited to three for each category. We have made minor changes in the description of the

characteristics (Table 3), removing some unnecessary (e.g. compartment excision) or ambiguous
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(e.g. “some muscle injury”) terms and adding a few others (e.g. human/ animal bites). Though the

OTA Study Group stated the objective of “parallel construction in the subgrouping”4, this was not
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truly followed for the stratification of skin injury. We found a few shortcomings in the skin injury
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subgrouping of OTA classification as follows:

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1. Only skin lacerations have been mentioned in the OTA classification, and other common wound

types like puncture wounds and skin avulsions (flaps, degloving) have been excluded. Full-

thickness abrasions and contusions are also commonly associated with lacerations in open

fractures, requiring debridement and contributing to skin loss. These too should be mentioned, as

in the AO-ASIF system.

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 Unified Open Fracture Classification

2. The first subgroup of ‘wounds that can be approximated’ is too inclusive, including fractures

otherwise classified upto the third type (Gustilo type IIIA-B or AO-ASIF IO3) in other systems.

This neither maintains parallelism with the first subgroup of other categories (no contamination/

muscle necrosis/ bone loss/ arterial injury), nor with the first type of other classifications. In early

reports of clinical experience with the OTA classification11,12, considerable floor effect is evident

for the skin injury, with 70-80% fractures falling under the first subgroup, leaving a truncated

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second subgroup with only around 8-12% fractures. Such a wide difference in distribution is not

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seen in any other category, except arterial injury which is uncommon. In the study by Agel et

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al11, 62 of the 72 patients with Gustilo type IIIA femoral or tibial fractures fell under the first

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subgroup of skin injury of OTA-OFC, clearly showing a large floor effect.

3. The third subgroup of ‘extensive degloving’ is a particularly severe one (IO5 in AO-ASIF

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classification), whereas such severe characteristics of other categories (e.g. compartment
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syndrome [MT5], amputations [NV5]) are kept out of the main classification, recognizing them
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as ‘add-ons’. This again makes the skin injury category non-parallel with other categories, with a
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higher ceiling. Such an effect is evident in clinical reports11,12, wherein the skin involvement is
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found to have a strong predictive influence on most outcomes, at each level of the variable.

Johnson et al12 reported the skin injury to be the most significant predictor of amputation in
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OTA-OFC, more significant than even arterial injury!

To address the high floor and ceiling of the integumentary category, we redefined its subgroups as
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follows:
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I1: Wounds with healthy edges- These include inside-out puncture wounds and lacerations with

healthy edges. Even outside-in sharp injury can cause such wounds.
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I2: Wounds that can be approximated- These include lacerations with contused or devitalized edges,

that can be approximated after debridement. Small avulsion flaps and full-thickness abrasions/

contusions that can be closed after debridement are also included in this.

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 Unified Open Fracture Classification

I3: Wounds that cannot be approximated- These include similar types of wounds as in I2 above, but

are more severe/ larger and cannot be approximated (without undue tension) after adequate

debridement. Degloving injuries are high-energy injuries with a grave prognosis for the avulsed

skin (even if apparently viable during first debridement) and are also included in this type.

Special situations: The OTA Study Group decided to keep devastating conditions like

compartment syndrome as separate ‘add-ons’ rather than merging them in the main classification, in

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order to cut down upon the number of subgroups within a category, yet recognizing these severe

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conditions. We further identified such special conditions under each category (Table 4), which have

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a striking presentation and/or prognosis, and deserve separate consideration:

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 High-risk contamination (C): Wounds with high-risk contamination like farmyard injuries, dirty

water/ fecal contamination and human/animal bites run a particularly high risk of infection,

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often with unusual organisms like Clostridia, Pseudomonas, Vibrio, Aeromonas etc. These
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require special antibiotics according to the injury environment and likely organism.
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 Circumferential degloving (I): These are striking injuries with a high rate of complications.
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These require specialized plastic surgery care with excision of degloved skin and primary/
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secondary coverage with skin grafts, or reattachment of the avulsed flap itself as a full-thickness

skin graft.13 Amputations are rarely required in these in the presence of adequate expertise.
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 Compartment syndrome (M): This is a limb-threatening condition needing urgent fasciotomies

with secondary closure/ coverage. Amputations are frequently required in these if not timely
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diagnosed and treated. Crush syndrome is more of a systemic disorder with regional
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implications similar to compartment syndrome, and hence is not mentioned separately.

 Critical bone loss (B): Certain injuries involving indispensable loss of bone, such as talar
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extrusions and extensive segmental extrusions, require different treatment strategies like bone

replantation, even retrieving the lost bone from the injury site, if required.14,15

 Subtotal/total amputation (A): These are the most devastating injuries requiring advanced

microsurgical expertise for replantation and limb salvage.

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 Unified Open Fracture Classification

Unified classification: The new classification (Table 3) thus devised is comparable to the modified

Gustilo classification as follows:

 Type I fractures have small puncture wounds or lacerations, without any visible contamination,

muscle necrosis, bone loss or arterial injury. The wound margins are healthy, not requiring a

formal surgical debridement. Even the routine use of antibiotics would be questionable in these,

subject to further study.

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 Type II fractures are of intermediate severity with surface contamination and/or tissue (skin/

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muscle/ bone) loss or devitalization. There is no severe injury such as ischaemic arterial injury,

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skin defects, loss of muscle function or segmental bone loss. Surgical debridement is indicated

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to remove the dead, devitalized and/or foreign material.

 Type IIIA fractures include those with severe contamination (deep or high-risk) and/or severe

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injury to the integumentary system. Urgent, aggressive debridement is required, delivering the
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fractured bone ends into the wound for cleansing the medullary cavities. Wound closure may
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require skin grafts, muscle flaps (to cover exposed bone without periosteum, tendons or
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neurovascular structures), vacuum-assisted closure or tissue expansion techniques.

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 Type IIIB fractures include those with severe injury to deep tissues, leading to functional

muscle loss and/or segmental bone loss. These are usually, but not necessarily, associated with
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severe contamination and skin injury too. These frequently require reconstructive soft-tissue and

bony procedures, such as regional/distant myocutaneous flaps, muscle transfers, vascularized/

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non-vascularized bone grafting, bone transport or Masquelet technique.

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 Type IIIC fractures are the most devastating with an ischaemic arterial injury, similar to the
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modified Gustilo classification. Emergency vascular repair is needed to attempt limb salvage in

these.

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 Unified Open Fracture Classification

Material and methods

The new unified classification was tested for interobserver reliability on a group of 15 practicing

orthopaedic surgeons of varying experience. Five open fractures of different regions (femur, tibia,

humerus, forearm, hand) and severity (types I-IIIC), in patients of any age, were classified by each

surgeon. The surgeons had the new classification explained in detail and were given handouts

(Table 3) for reference. They were provided with a brief history (e.g. high-risk environment for

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contamination), examination findings (e.g. presence of distal pulses and/or ischaemia), clinical

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pictures (for assessment of contamination and wound margins), radiographs (for assessing bone

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loss) and intraoperative notes of surgical debridement (regarding deep contamination, skin/ muscle

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necrosis, skin cover/ muscle integrity after debridement and bone loss/ devitalization). No further

information regarding treatment plan was provided, such as the type of fixation (internal versus

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external), additional soft tissue reconstructive procedures (skin grafting, muscle flap) or vascular
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repair. The fractures were classified into individual categories (C1-3 I1-3 M1-3 B1-3 A1-3) as a first step,
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before arriving at the final open fracture type (I-IIIC). The interobserver reliability was assessed
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only for the fracture type and not individual categories. At the end of the study, the surgeons were
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asked to give their feedback regarding which of the three classification systems (Gustilo, OTA,

unified) would they prefer to apply for day-to-day clinical practice.

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Krippendorff’s alpha for ordinal data was used16 to measure interobserver reliability, with a desired

α > 0.80017. ‘N-1’ chi-squared test was used for the significance of proportions (for surgeon
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preference), with a p-value < 0.05 being considered as significant.18

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Results

The interobserver agreement (α = 0.93) was found to be excellent for the new classification. Ten,

four and one of the fifteen surgeons participating in the study preferred the new, modified Gustilo

and OTA classification systems respectively for routine clinical use, with preference for the unified

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classification being significantly higher than the other two (p < 0.05 and < 0.01 for Gustilo and

OTA classifications respectively).

Discussion

Open fractures include a wide array of injuries with a variable involvement of the integument,

muscles, neurovascular structures and bone, ranging from puncture wounds to subtotal amputations.

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A standardized classification is needed for documentation and communication of the pathoanatomy,

planning the treatment and comparing the outcomes of open fractures. Several treatment decisions

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and controversies19 are involved in open fracture management, such as the timing of treatment

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(emergency versus urgent), plan (limb salvage versus amputation), type of fixation (internal versus

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external), antibiotic coverage (Gram-positive versus Gram-negative coverage) and need for
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additional procedures (antibiotic cement beads, VAC dressings), etc. Studies examining these
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factors have reported conflicting results19, partly due to the lack of a validated and reliable
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classification system to grade open fractures.

The modified Gustilo classification7 remains the most popular classification of open fractures,
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though the classes are not precisely defined, resulting in variable interpretation and limited

reliability. The OTA-OFC4 is based upon precisely defined characteristics, but is a complex system
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with too many potential combinations.5 Moreover, improved reliability of the OTA-OFC over
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Gustilo classification has been recently questioned20, with a similar interobserver agreement
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reported for both OTA and Gustilo classifications, citing the need to further develop the

classification.
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We devised a new open fracture classification that essentially unifies the OTA and Gustilo

classifications, retaining the precise categorization of the former and the familiar format of the

latter. The five categories of open fracture characterization were arranged in a logical order, easily

memorized by the acronym CIMBA. Only the subclassification of the skin injury was modified to

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maintain construct parallelism with other classes and classifications. Particularly severe injuries

continue to be identified as add-on 'special situations'. The new classification was preferred by a

majority of the surgeons in our study, due to its simplified and familiar format. OTA-OFC is

perceived as a complex scoring system rather than a simple classification.10

The unified classification was found to have an excellent interobserver reliability in our study. In a

video-based reliability study, Agel et al21 reported a moderate to substantial level of interrater

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agreement for most categories, though more recently, Ghoshal et al20 reported only a moderate

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agreement for most categories of OTA-OFC. We attribute the high interobserver agreement in our

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study to a more simplified classification and provision of key intraoperative notes to the

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participating surgeons. The distinction between the moderate and severe classes in most categories

is based upon intraoperative factors, such as presence of deep contamination or the extent of muscle

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debridement. The classification cannot be meaningfully done without provision of such details. In
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our experience, the type I and IIIC fractures can be reliably identified with clinical data and wound
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inspection/ photographs when a patient presents as an emergency. The distinction between types II
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and III A/B can be reliably done only at the time of initial debridement, as reiterated in the OTA-
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OFC. This serves the clinical purpose, as the most severe type IIIC fractures need to be immediately

identified for emergency vascular repair whereas identification of the least severe type I fractures
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allows one to treat them less aggressively, with possible casting in children.

Further multi-centre studies will be required to assess the impact of the unified classification on
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treatment and outcome of open fractures, and more importantly, usability and acceptability in day-
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to-day practice and communication. Once the classification is universally accepted, we might find

answers to the yet unanswered questions in open fracture management.

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Conclusion

We have devised a new “unified” classification of open fractures based on the Gustilo and OTA

classifications. It has good validity, reliability and acceptability, and could potentially replace all

other existing classification systems of open fractures.

Conflicts of interest None

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Source of funding None

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Acknowledgements
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We hereby thank all the surgeons who participated in the study and provided their valuable
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feedbacks on the classifications.
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References
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1. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-
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five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am.

1976;58:453–458.
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2. Horn BD, Rettig ME. Interobserver reliability in the Gustilo and Anderson classification of open
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fractures. J Orthop Trauma. 1993;7:357–360.

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3. Brumback RJ, Jones AL. Interobserver agreement in the classification of open fractures of the

tibia. The results of a survey of two hundred and fortyfive orthopaedic surgeons. J Bone Joint

Surg Am. 1994;76:1162–1166.

4. Orthopaedic Trauma Association: Open Fracture Study Group. A new classification scheme for

open fractures. J Orthop Trauma. 2010;24:457–65.

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5. Editorial. The classification of open fractures: Are we there yet? Injury, Int. J. Care Injured. 2013;

44:403–405.

6. Tscherne H, Oestern HJ. A new classification of soft-tissue damage in open and closed fractures.

Unfallheilkunde. 1982;85(3):111–5.

7. Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open

fractures: A new classification of type III open fractures. J Trauma.1984;24(8):742–6.

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8. Gustilo R, Merkow R, Templeman D. Current concepts review: the management of open

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fractures. J Bone Joint Surg Am. 1990;72:299–304.

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9. Muller ME, Allgower M, Schneider R, Willenegger H. Manual of Internal Fixation: Techniques

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recommended by the AO-ASIF group. 3rd ed. Berlin: Springer-Verlag; 1991.

10. Rehan UH, Jain A. A new classification scheme for open fractures. J Orthop Trauma. 2011

Jun;25(6):e59. [Letter to the Editor] U

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11. Agel J, Rockwood T, Barber R, Marsh JL. Potential Predictive Ability of the Orthopaedic
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Trauma Association Open Fracture Classification. J Orthop Trauma. 2014;28:300–306.
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12. Johnson JP, Karam M, Schisel J, Agel J. An evaluation of the OTA-OFC System in clinical
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practice: a multi-center study with 90 days outcomes. J Orthop Trauma. 2016;30:579–584.

13. Sakai G, Suzukia T, Hishikawaa T, Shiraia Y, Kurozumia T, Shindoa M. Primary reattachment

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of avulsed skin flaps with negative pressure wound therapy in degloving injuries of the lower

extremity. Injury. 2017;48:137–141.

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14. Smith CS, Nork SE, Sangeorzan BJ. The extruded talus: results of reimplantation. J Bone Joint
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Surg Am. 2006;88(11):2418-24.

15. Shanmuganathan R, Chandra Mohan AK, Agraharam D, Perumal R, Jayaramaraju D, Kulkarni

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S. Succcessful reimplantation of extruded long bone segments in open fractures of lower limb- a

report of 3 cases. Injury. 2015;46(7):1389-92.

16. Freelon D. ReCal OIR: Ordinal, Interval and ratio intercoder reliability as a web service.

International Journal of Internet Science. 2013;8(1):10-16.

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17. Krippendorff K. Reliability in content analysis.Human Communication Research. 2004;30(3):

411-433.

18. Campbell I. Chi-squared and Fisher-Irwin tests of two-by-two tables with small sample

recommendations. Stat Med. 2007 Aug 30;26(19):3661-75.

19. Ryan SP1, Pugliano V2. Controversies in initial management of open fractures. Scand J Surg.

2014 Jun;103(2):132-137. Epub 2014 Apr 15.

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20. Ghoshal A1, Enninghorst N2, Sisak K1, Balogh ZJ2. An interobserver reliability comparison

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Anderson classification. Bone Joint J. 2018 Feb;100-B(2):242-246. doi: 10.1302/0301-

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Jul;27(7):379-84; discussion 384-5. doi: 10.1097/BOT.0b013e3182820d31.
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Classification of Gustilo-Anderson Modified Gustilo Expanded Gustilo

open fractures (1976) (1984) (1990)
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Type I Clean (C) Clean (C) Minimal contamination (C)

< 1 cm (I) < 1 cm (I) Puncture wounds < 1 cm (I)
Minimal soft-tissue damage (M)
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Low-energy fracture (B)

Type II Lacerations Lacerations Moderate contamination (C)

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> 1cm (I) > 1cm (I) Lacerations > 1cm (I)
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Moderate soft-tissue damage (M)

Medium-energy fracture (B)

Type III Extensive lacerations Extensive lacerations or Severe contamination (C)

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or avulsions (I) avulsions (I) Extensive lacerations or avulsions (I)

Extensive soft-tissue Extensive soft-tissue damage (M) Extensive soft-tissue damage (M)
damage (M) High-energy trauma (B) High-energy fracture (B)
Segmental fracture (B) Farmyard injury (C)

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Type III Special categories Subtypes Subtypes

(special/ Farm injury (C) IIIA- adequate soft-tissue coverage IIIA- adequate soft-tissue coverage
subtypes) Gunshot injuries (B) of bone (I, M) of bone (I, M)
Vascular injury (A) IIIB- exposed bone (I, M) (without IIIB- exposed bone (I, M) (without
(ischaemic) periosteal or soft-tissue coverage) periosteal or soft-tissue coverage)
IIIC- vascular injury (A) IIIC- vascular injury (A)

Abbreviations: C- contamination, I- integument, M- muscle, B- bone, A- artery

Table 1. Evolution of Gustilo classification of open fractures

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Tscherne & Oestern AO/ ASIF Unified
(1982) (2007) (2018)

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O1 IO1: Inside-out skin lesion (I) C1: Clean

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Minimal contamination (C) MT1: No muscle injury (M) I1: Wounds with healthy edges
Inside-out wounds with no/ NV1: No neurovascular injury (A) M1: No muscle necrosis
minimal contusion (I) B1: No bone loss

U A1: No major arterial injury

O2
Moderate contamination (C)
Wounds with
circumscript contusions (I)
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IO2: Outside-in wound <5 cm, laceration C2: Surface contamination
with contused edges (I) I2: Wounds that can be
A
MT2: One muscle compartment injured (M) approximated after debridement
NV2: Only nerve lesion (A) M2: Localized muscle necrosis
M

IO3: Outside-in wound >5 cm, devitalized B2: Partial bone loss

edges, circumscribed degloving (I) A2: Arterial injury (non-ischaemic)

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MT3: Two or more muscle compartments

injured (M)
NV3: Localized vascular lesion (A)
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O3 IO4: Full-thickness contusion/abrasion, C3: Deep/high-risk contamination

Distinct soft-tissue damage (I, skin loss (I) I3: Wounds that cannot be
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M) MT4: Muscle defect/ extensive contusion, approximated after debridement

Gunshot injuries (B) tendon laceration (M) M3: Non-functional muscle
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Farmyard injuries (C) NV4: Segmental vascular lesion (A) B3: Segmental bone loss
Vascular injury, ischaemic (A) A3: Arterial injury (ischaemic)
O4 IO5: Extensive degloving (I) Special situations*
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Subtotal or total MT5: Compartment syndrome/crush C*: High-risk contamination

Amputation (I,M.B,A) syndromes (M) I*: Circumferential degloving
NV5: Combined neurovascular M*: Compartment syndrome
injury (A) B*: Critical bone loss
A*: Subtotal or total amputation

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 Unified Open Fracture Classification

Abbreviations: C- contamination, I- integument, M- muscle, B- bone, A- artery

Table 2. Comparison of open fracture classification schemes

Fracture Contamination Integument Muscle Bone loss6 Arterial injury

type
I Clean Wound3 with healthy None None None
(C1) edges (I1) (M1) (B1) (A1)

T
II Surface Wound4 that can be Localized damage Partial Non-ischaemic
(C2) approximated (I2) (M2) (B2) (A2)

IP
IIIA Deep1 or Wound4 that cannot

R
high-risk2 (C3) be approximated (I3) M1/2 B1/2

SC
IIIB Non-functional Segmental
A1/2
5
muscle unit (M3) (B3)
C1/2/3 I1/2/3
IIIC
M1/2/3 U B1/2/3
Ischaemic
(A3)
N
Key:
A
1- reaching the deep soft tissues or bony surface (even if superficial, as in subcutaneous bones)
M

2- farmyard, fecal, dirty water, human/animal bites

3- puncture wounds, lacerations with healthy edges
4- lacerations with contused/devitalized edges, full-thickness abrasions/contusions, avulsions
ED

5- dead muscle, muscle defect that does not reapproximate after debridement, tendon laceration
6- loss or complete devascularization of an appreciable size of bone wedge/segment (even if retained/reimplanted)
Table 3. Unified classification of open fractures
E PT

Category Description Management strategies

CC

Severe (Type III) conditions

C3 Deep contamination Wound swab cultures, broad-spectrum antibiotics,

A

repeated debridement, delayed internal fixation, ABLC

beads/ blocks
I3 Skin defects Secondary healing, primary/ secondary closure with skin
grafts or muscle flaps, vacuum-assisted closure, tissue
expansion

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 Unified Open Fracture Classification

M3 Loss of muscle function Tendon repair, extensive debridement, muscle transfer/

flaps, tenodesis/arthrodesis
B3 Segmental bone loss Primary/ secondary bone grafting, vascularized bone
grafts, compression-distraction, bone transport, Masquelet
technique
A3 Ischaemic arterial injury Doppler ultrasound/ arteriography, anticoagulation,
fracture/ joint reduction, emergency vascular repair
Special situations*

T
C* High-risk contamination Antibiotics with coverage against unusual bacteria (e.g.

IP
Pseudomonas, Vibrios), microbiologist consultation
I* Circumferential degloving Flap excision, harvest of skin grafts from degloved skin

R
M* Compartment syndrome Emergent fasciotomy, secondary closure

SC
B* Critical bone loss Reimplantation, retrieval from site of trauma, allografts
A* Subtotal or total Replantation with neurovascular and tendon repairs, rigid
amputation fixation
U
N
Abbreviations: C- contamination; I- integument; M- muscle; B- bone; A- artery;
A
ABLC- antibiotic-loaded cement
M

Table 4. Management of severe/ special conditions in unified classification of open fractures

ED
E PT
CC
A

17