Open fractures : Mnemonics

Gustilo Anderson Classification

1. Parameters: ABCD’S (Area, Bone, Circulation, Dirt, Soft tissue)
2. Classification: I, II, III then A, B, C

Progression for grade I to III C implies a higher degree of energy involved in the injury, higher soft tissue and bone damage, and higher potential for complications.

open fracture gustilo anderson

Type I: 1 cm or smaller wound, Grade I injury (minimal energy trauma, soft tissue damage, contamination or comminution)

Type II: 2 cm or larger wound, Grade II injury (moderate energy trauma, soft tissue injury, contamination or communition)

Type III: >10 cm; Severe/extensive energy trauma, soft tissue injury, contamination or communition or segmental fractures

  • III A: Adequate soft tissue coverage of bone
  • III B: Bony exposure
  • III C: Compromise of neurovascular status

These are automatically Type III open fractures:

  1. Fractures >8 hours old
  2. Farmyard injuries
  3. Gunshot injuries
  4. Traumatic amputation
gustilo anderson type III

Infection rate:
Class I: 0-2%
Class II: 2-5%
Class IIIA: 5-10%
Class IIIB: 10-50%
Class IIIC: 25-50%

Swanson, Szabo and Anderson Classification for Open fractures of Hand

Mnemonic: ABCD’S
1. Animal bite
2. Barnyard injury
3. Comorbidities (Diabetes, hypertension, rheumatoid arthritis, hepatitis, asthma, etc.)
4. Dirt/Debris
5. Delay in treatment of 1 Day (>24 hours)
6. Stream (warm lake/river) injury

All of the above are absent: Type I (infection rate – 1.4%; primary closure suitable)

Any of the above present: Type II (infection rate – 14%; delayed closure suitable)

Mangled Extremity Severity Score (MESS) to Predict Eventual Amputation

Mnemonic: MESS

1. Maturity (Age):

  • <30 years: 0
  • 30-50 years: 1
  • >50 years: 2

2. Extremity ischemia:

  • Pulse reduced or absent but perfusion normal: 1
  • Pulseless (by doppler), paresthesia, diminished capillary refilling, diminished motor activity: 2
  • Pulseless, cool, paralysed, insensate, numb, without capillary refill: 3

3. Skeletal and soft tissue injury:

  • Low energy: 1
  • Medium energy: 2
  • High energy: 3
  • Very high energy (crush): 4

4. Shock:

  • Normotensive: 0
  • Transient hypotension: 1
  • Persistent hypotension: 2


  • Score is doubled for ischemia >6 hours.
  • MESS >7 predicts eventual amputation.

Rule of 3 for Open fractures


3 possible antibiotics:

  • 1st generation cephalosporin +/-
  • Aminoglycoside (for grade III) +/-
  • Metronidazole (for possible anaerobic contamination)

Initiate antibiotics as early as possible (within 3 hours)

Continue antibiotics for atleast 3 days after last debridement.

Irrigation fluid volume

Gustilo-Anderson Class I = 1 X 3 L = 3 L

Gustilo-Anderson Class II = 2 X 3 L = 6 L

Gustilo-Anderson Class III = 3 X 3 L = 9 L

Tetanus Prophylaxis


1. You don’t need to think of HTIG if the wound is clean or if the patient has received 3 or more doses of TT.

2. If <3 doses of TT – TT needs to be given

3. If 3 or more doses of TT – HTIG is not needed; TT is needed if last dose as taken 5-10 yrs ago in clean wound and more than 10 yrs ago in dirty wound.

tetanus prophylaxis

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