Answer:
A system for describing the extent of soft tissue injury in open tibial fractures:
Gustilo classification of open fractures of the tibia:
Type Description
I Open fracture with a wound < 1 cm
II Open fracture with a wound > 1 cm without extensive soft tissue damage
III Open fracture with extensive soft tissue damage
IIIA III with adequate soft tissue coverage
IIIB III with soft tissue loss with periosteal stripping and bone exposure
IIIC III with arterial injury requiring repair
Plastic surgeons by definition are consulted on an open tibial fracture only when the grade is a Gustilo grade IIIB or IIIC. This limits our classification system to two categories. A type IIIA injury is an open fracture with extensive soft tissue damage. However, because it has adequate soft tissue coverage it rarely requires plastic surgical consultation. A type IIIB injury involves an open fracture with periosteal stripping and bone exposure. A type IIIC injury is an open fracture associated with an arterial injury requiring repair.
Although this is the most commonly quoted classification, it remains woefully inadequate to describe the injury or evaluate the prognosis of an open tibial fracture for which the plastic surgeon is involved. An open tibial fracture with 3 cm of periosteal stripping and exposed bone is not the same as an open tibial fracture with an 8-cm bone gap, 12 cm of exposed bone, and necrosis of 16 cm of all four compartment muscles, though they would be both classified as IIIB injuries. Similarly, the phrase “arterial injury requiring repair” in the classification of a IIIC injury is ambiguous. Some surgeons may believe it is necessary to repair a second vessel in a one-vessel leg, while others may think a single vessel is an adequate blood supply to the foot. In the first case the injury would be classified as a IIIC and in the latter a IIIB. The classification also makes no note of nerve injury, which is crucial in the assessment of prognosis.
In an attempt at a better classification, the Mangled Extremity Syndrome Index, Mangled Extremity Severity Score, Predictive Salvage Index, and Limb Salvage Index have been created. Even these indices have often proved unhelpful in predicting outcome. A more precise classification system must be developed to help predict the outcome of salvage efforts for mangled extremities.