Gustilo–Anderson Classification of Open Fractures

Classification

Key memory point: The distinction between IIIA, IIIB, and IIIC depends on soft tissue cover adequacy and vascular status, NOT wound size alone.

Clinical Example — Type I (inside-out puncture wound)

Clinical Example — Type III (massive soft tissue disruption)

Infection Risk by Grade

Management

1. Emergency / Initial

• ATLS primary survey — manage life-threatening injuries first
• Wound: bedside irrigation of gross contamination, loose sterile dressing, splint; avoid repeated inspection in the ED to minimise contamination
• Fracture reduction and splinting
• Mark NPO; arrange theatre

2. Antibiotics (Most Important Intervention)

Aminoglycoside caveat: Dose-dependent nephrotoxicity and ototoxicity have led some institutions to omit aminoglycosides — use is declining. Check local protocols.

3. Tetanus Prophylaxis

4. Debridement and Irrigation

• Perform within 6–24 hours of injury
• Thorough excision of all devitalised muscle, bone, and contaminated tissue
• Pulsed lavage irrigation (normal saline); low-pressure irrigation is as effective as high-pressure and avoids driving bacteria deeper into tissue
• Counter-incisions to improve wound access reduce flap rates (especially medial ankle)
• Repeat debridement every 48–72 hours if needed until wound is clean
• Antibiotic bead pouch (methylmethacrylate + tobramycin ± vancomycin): useful for highly contaminated wounds as local antibiotic delivery

5. Fracture Stabilisation

• Reduces further soft tissue damage and facilitates wound management
• Options:
  • External fixator — preferred for heavily contaminated/unstable wounds, temporary stabilisation before definitive fixation
  • Intramedullary nail — suitable for Type I–IIIA fractures once adequately debrided (widely used for tibial shaft fractures)
  • Plate fixation (ORIF) — selected cases, requires good soft tissue coverage
  • Spanning external fixator — periarticular open fractures

6. Wound Coverage

• Proximal third → Gastrocnemius muscle flap
• Middle third → Soleus muscle flap
• Distal third → Fasciocutaneous flap or free-tissue transfer (microvascular)

7. Vascular Injury (Type IIIC)

• Requires urgent vascular surgery consultation
• Temporary vascular shunt → skeletal stabilisation → definitive vascular repair (preferred sequence)
• Warm ischaemia time: revascularisation should be complete within 6 hours to avoid irreversible muscle necrosis
• Amputation rates for IIIC historically up to 50%; early multidisciplinary approach improves limb salvage

8. Compartment Syndrome Monitoring

Limitations of G-A Classification

1. Designed originally for open tibia fractures only — validity for other bones is extrapolated
2. Poor interobserver reliability (42–94%)
3. Final grade can only be assigned intraoperatively, not at presentation
4. Treatment-based rather than anatomy-based (type of wound closure defines IIIB)

OTA Open Fracture Classification (OTA-OFC)

• Skin (laceration size/complexity)
• Muscle (degree of loss)
• Arterial injury
• Contamination
• Bone loss

Developmental Dysplasia of the Hip (DDH)

Spectrum of Disease

Incidence & Risk Factors

• Neonatal instability: ~20 per 1,000 live births; true dislocation ~2 per 1,000
• Many hips stabilise spontaneously within the first 2–3 weeks

1. Breech presentation (especially extended breech) — 30–50× increased risk
2. Female sex — 4–5× more common; oestrogen-related peripartum ligamentous laxity
3. Positive family history — ≥20% incidence with affected first-degree relative
4. Firstborn child — tight primigravid uterus, left occipito-anterior position → 67% left hip
5. Oligohydramnios — restricts fetal movement
6. Swaddling with hips in extension — postnatal risk factor

Diagnosis

Clinical Examination — Neonate

Is the hip dislocated? If so, is it reducible (Ortolani +) or irreducible? If not dislocated, is it dislocatable (Barlow +)?

Figure: (a) Ortolani test — elevation and abduction of the femur causes a palpable clunk as the dislocated femoral head reduces. (b) Barlow test — adduction and posterior depression causes a palpable clunk as the hip dislocates.

Bilateral dislocation may be missed — abduction is symmetrically limited and may appear normal in low-tone infants.

Clinical Examination — Older Infant/Child

Investigations

1. Ultrasound (< 4–6 months)

A: Graf type IV hip (dislocated). B: After Pavlik harness — α angle 62° (Graf type I — normalised). C: Follow-up X-ray at 6 months showing recurrent acetabular dysplasia (AI = 28°). D: After abduction bracing — AI normalised to 20°.

• Breech presentation
• Positive family history
• Abnormal clinical examination

2. Plain Radiograph (≥ 4–5 months)

Right hip normal; left hip dislocated. The ossific nucleus should lie in the inferomedial quadrant.

3. Arthrography

• Confirm concentric reduction before casting
• Identify blocks to reduction (the "thorn sign" indicates normal labral position)
• Assess medial dye pool width (> 8 mm suggests inadequate reduction)

4. CT / MRI

• Post-reduction confirmation of concentric reduction in the spica cast
• MRI preferred (no radiation) for post-reduction assessment
• CT used where MRI unavailable

Blocks to Concentric Reduction

Structures blocking reduction: iliopsoas tendon (hourglass constriction), pulvinar (fibrofatty tissue), redundant ligamentum teres, transverse acetabular ligament, contracted inferomedial capsule, inverted/everted labrum.

Treatment

Age 0–6 Months: Pavlik Harness

The anterior strap controls hip flexion (~100°). The posterior strap limits adduction and encourages abduction.

• First-line treatment for all Ortolani-positive and Barlow-positive hips (reducible and dislocatable)
• Maintains hips in the "human position" — ~100° of flexion, mild abduction (Salter position)
• Worn 23 hours/day for at least 6 weeks after reduction achieved, then part-time (nights/naps) for a further 6–8 weeks
• Reduction confirmed by ultrasound after fitting; repeat US to monitor

• AVN — from excessive abduction (compresses posterosuperior retinacular branch of medial femoral circumflex artery)
• Femoral nerve palsy — from excessive flexion (transient)
• "Pavlik disease" — if reduction is not achieved within 3 weeks, continued harness use causes erosion of the pelvis superior to the acetabulum, making subsequent closed reduction more difficult → discontinue at 3 weeks if not reduced

• Age > 7 weeks at initiation
• Bilateral dislocations
• Absent Ortolani sign (irreducible hip)
• Teratologic dislocation (absolute contraindication)

Age 6–18 Months: Closed Reduction + Spica Cast

1. Examination under anaesthetic
2. Hip arthrography — assess reduction and blocks
3. Adductor ± psoas tenotomy if tight
4. Closed reduction — gentle traction + flexion + abduction
5. Hip spica cast in the stable zone of abduction (hips ≥ 90° flexion)
6. Post-reduction CT or MRI to confirm concentric reduction

Age 6–18 Months (failed closed) / Age ≥ 18 Months: Open Reduction

• Medial approach (Ferguson/Ludloff): 6–24 months; allows direct access to medial obstacles; does not permit simultaneous capsulorrhaphy
• Anterior (Smith-Petersen) approach: preferred from 9–12 months onwards; allows capsulorrhaphy; lower risk to medial femoral circumflex artery than medial approach at older ages

• Adductor longus tenotomy
• Iliopsoas release
• Pulvinar excision
• Transverse acetabular ligament division
• Labrum repositioning
• Capsulorrhaphy (tightening of capsule) to maintain reduction

Pelvic Osteotomies (for residual acetabular dysplasia)

Summary Treatment Algorithm

Birth → Neonatal exam (Ortolani / Barlow)
│
├─ Unstable / dislocated → Observe 2–3 weeks (many resolve spontaneously)
│        Still abnormal at 4–6 weeks → Ultrasound + Pavlik harness
│
├─ 0–6 months → Pavlik harness (23 h/day x 6–8 weeks)
│        Reduced → Continue until US/XR normal
│        Not reduced in 3 weeks → Stop harness → EUA + closed reduction + spica
│
├─ 6–18 months → EUA + arthrogram + closed reduction + spica cast
│        Failure → Open reduction (medial or anterior approach) ± adductor tenotomy
│
├─ 18 months–3 years → Open reduction + femoral shortening + possible pelvic osteotomy
│
├─ 3–8 years → Open reduction + pelvic osteotomy (Salter/Pemberton/Dega)
│
├─ Older child / adolescent → Triple/PAO osteotomy ± femoral osteotomy
│
└─ Adult → PAO (if reducible), Chiari/shelf (salvage), or THA when arthritic

Complications