e152(1)

the
Orthopaedic
forum
The Evolution and Interpretation of the Gustilo
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and Anderson Classification

Guang H. Yim, MSc, MRCS, and Joseph T. Hardwicke, PhD, FRCS(Plast)

Background: The Gustilo classification is the most established system for classifying open fractures. Despite this, the
classification has changed in how it has been described and interpreted. We have traced how this classification has
slowly evolved throughout the literature over the past 4 decades.
Methods: A systematic search of the literature was undertaken with the MEDLINE, Embase, and PubMed databases to
source relevant articles that have evolved the interpretation of the Gustilo classification. The references from these
articles were consecutively hand-searched to find other articles that describe the Gustilo classification.
Results: There was a total of 393 results from the Healthcare Databases Advanced Search (HDAS): 95 from MEDLINE,
49 from Embase, and 249 from PubMed. Fifty-six articles were initially selected; an additional 67 articles were retrieved
through reference checking and further checking of relevant articles until no additional relevant articles could be found.
Conclusions: The original Gustilo and Anderson classification initially was modified by Gustilo before subtle changes
were made to the descriptors in the 1990s. Some authors have used the Gustilo classification to create alternative
classifications, but these have not gained traction. Other contemporaneous literature has modified the Gustilo-IIIB
subtypes to better stratify functional and reconstructive outcomes following vascular injury. The impact and longevity of
such recent modifications are yet to be known.

Open tibial fractures are one of the most common types of
open fractures that are encountered, accounting for 11.2% of
all open fractures1. They can be challenging to manage2 and are
associated with substantial morbidity because of patients’ low
return-to-work rates3-5 and high health-care costs6-8. To facili-
tate communication between clinicians, provide prognostica-
tion, plan the type of soft-tissue reconstruction or method of
bone fixation, facilitate research, or help decide whether to
amputate or salvage, many open-fracture classification systems
have been developed9-16. While a variety of open-fracture clas-
sification systems have been proposed15,17,18, they have not
gained much traction. The Gustilo classification remains the
most widely used classification of open fractures19 and is one of
the most well-known classification systems in surgery. In 1976,
Gustilo and Anderson published a retrospective review of 1,025
open fractures (before and after the introduction of the open-

Disclosure: The authors indicated that no external funding was received for any aspect of this work. The Disclosure of Potential Conflicts of Interest forms
are provided with the online version of the article (http://links.lww.com/JBJS/F16).

Contains public sector information licensed under the Open Government Licence v3.0.

J Bone Joint Surg Am. 2018;100:e152(1-8) d http://dx.doi.org/10.2106/JBJS.18.00342

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fracture classification system in 1969) and new treatment
guidelines relative to the type of injury encountered. The orig-
inal Gustilo and Anderson classification categorized open frac-
tures into 3 types16:
 Type I: An open fracture with a wound <1 cm long and
clean
 Type II: An open fracture with a laceration >1 cm long
without extensive soft-tissue damage, flaps, or
avulsions
 Type III: Either an open segmental fracture, an open
fracture with extensive soft-tissue damage, or a trau-
matic amputation. Special categories in type III were
gunshot injuries, any open fracture caused by a farm
injury, and any open fracture with accompanying
vascular injury requiring repair
Their study demonstrated that the wound infection rate
dropped to 2.4% in the prospective group compared with 6.4%
in the retrospective group following the changes to the classi-
fication system. For type-III fractures, the prospective group
had a 9.9% infection rate compared with 44% in the retro-
spective group, although the authors did not state how they
retrospectively classified the type-III injuries. The study was
confounded by the heterogeneity of the upper and lower-limb
open fractures because open lower-limb fractures tend to be
more severe than open upper-limb fractures1. The study did
create the foundation of modern open-fracture management
by advocating early and adequate debridement, closure of type-
I and type-II open fractures, delayed closure of type-III injuries
with use of specialized techniques, and prophylactic antibiotic
treatment. Some of their other recommendations (e.g., the use
of skeletal traction for arterial injuries requiring repair) have
since been superseded.As Gustilo’s experience developed, he
observed that there were varying degrees of prognosis within
the type-III classification depending on the associated injuries.
In 1984, Gustilo et al. divided type-III injuries into 3 subtypes20:
 Type IIIA: Adequate soft-tissue coverage of a fractured
bone despite extensive soft-tissue laceration or flaps, or
high-energy trauma irrespective of the size of the
wound;
 Type IIIB: Extensive soft-tissue injury with periosteal
stripping and bony exposure. This is usually associated
with massive contamination; and
 Type IIIC: Open fracture associated with arterial injury
requiring repair.
A progressively worsening prognosis was seen within
these subtypes, as type-IIIA injuries had a 4.4% infection rate
with no amputations; type-IIIB injuries had a 52% infection
rate, with 16% leading to amputation; and type-IIIC injuries
had a 42% infection rate with a 42% amputation rate20. While
the use of the Gustilo classification is virtually ubiquitous, the
senior author (J.T.H.) had observed the changes in the descrip-
T H E E VO LU T I O N A N D I N T E R P R E TAT I O N OF THE G U S T I LO AND
A N D E R S O N C L A S S I F I C AT I O N
tors of the Gustilo classification while examining the literature.
In this study, we sought to trace how the descriptors of the
Gustilo classification have evolved since its original publication
in 1976.
Materials and Methods
To trace the evolution of the Gustilo classification, a systematic
search of the literature was undertaken with use of the National
Institute for Health and Care Excellence (NICE) Healthcare
Databases Advanced Search (HDAS). Keywords (“Gustilo” AND
“classification” AND “open fracture”) were searched in the title
and abstract fields in the Medline, EMBASE, and PubMed data-
bases. We limited the search to English-language literature with
human subjects. There were no limits on the time frame of the
published literature. We reviewed the titles and the abstracts. At
the first level of screening, full articles that were available in the
English language were retrieved if they related to the tibia, if they
mentioned infective complications, or if they proposed a new
method of classification. Articles were excluded if they were case
reports, if they related only to children, if the trauma was sports-
related or combat/military-related, if the fractures did not involve
the tibia, or if the aim of the article was to introduce/assesses/
validate a surgical and/or fixation technique. Once the full-text
articles had been retrieved, the articles were screened to obtain the
relative definitions or modifications of the Gustilo classification. If
the articles did not contain definitions or modifications of the
Gustilo classification, the references cited within the article were
screened using our first-level criteria to obtain any additional
relevant full texts; this technique of reference checking was cas-
caded until no additional relevant articles could be found.
Results
There was a total of 393 results from the HDAS search: 95 from
MEDLINE, 49 from Embase, and 249 from PubMed. Fifty-six
articles initially were selected for full-text review, and 29 of
those were selected for an in-depth review of the references.
An additional 67 references were retrieved with the cascading
review. A summary timeline and diagram of how the Gustilo
classification system has evolved since its inception is shown in
Figure 1. The variations in the descriptions of the Gustilo clas-
sification are provided in Table I, which demonstrates how the
interpretation of the classification system has evolved.
The early variations of the Gustilo classification sought to
create alternative ways of classifying injury. In 1981, Byrd et al.
provided an early modification of the Gustilo classification
that created 4 types of injury to better describe the injury
velocity, the fracture configuration, and the associated soft-
tissue injury18. In 1985, Byrd et al. further modified the classi-
fication following Gustilo’s 1984 update. This modification
essentially changed type IIIB to type IV to reflect the increasing
degree of bone and soft-tissue devascularization21.
There have been interpretations that make seemingly
small but noteworthy omissions to the descriptions of the
Gustilo classification (e.g., the omission of bone exposure for
type-IIIB injuries22 or not stating the requirement for vascular
repair in type-IIIC injuries23). The loss of a small segment of the
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Fig. 1
A flow diagram describing the evolution of the Gustilo classification and the relationships of the publications.
descriptors can change the “essence” of how injuries are clas-
sified, particularly for readers who have not read Gustilo’s orig-
inal articles.
The “index” publication that made a substantial modifi-
cation to the Gustilo classification descriptors was by Trabulsy
et al. in 199424; they introduced the concept of wounds being
1 to 10 cm long for type-II injuries and “usually” >10 cm for all
type-III injuries24. They undertook a prospective review of both
the management of skeletal fixation and the soft-tissue recon-
struction in 45 consecutive patients who were treated under
their protocol. They did not observe any difference in time
to union between use of external fixation and unreamed
intramedullary nailing. Their success rate with soft-tissue
reconstruction was impressive, with 34 (97%) of 35 free flaps
surviving, although the local flaps had a lower success, with 11
(85%) of 13 surviving. Trabulsy et al. felt that successful closure
of the wounds contributed to the union rate of 98%. It is
interesting that the authors chose to include a case report of
a type-IIIB injury with vascular injury because the importance
of such an injury would be recognized by later authors. The
introduction of the wound-size threshold of 10 cm between
type-II and type-III descriptors has since propagated through
the literature; many publications have incorrectly omitted the
T H E E VO LU T I O N A N D I N T E R P R E TAT I O N OF THE G U S T I LO AND
A N D E R S O N C L A S S I F I C AT I O N
“usually” descriptor or attributed the 10-cm threshold to Gus-
tilo’s original works25-27.
Some authors have used the Gustilo classification as the
basis to create newer classifications to help guide clinicians
toward either limb salvage or amputation14, but the latest mod-
ifications are based on the influence of vascular injuries. In
1995, Dickson et al. proposed modifying the Gustilo classifica-
tion to better describe the effects of arterial injury on fracture-
healing and infection28. This was based on a retrospective
review of open tibial fractures involving 114 patients who
had undergone arteriography for suspected arterial injuries.
Patients who had penetrating trauma, traumatic amputation,
or Gustilo type-IIIC injuries were excluded. In their series, 62
(54%) of the patients had a normal arteriogram, whereas 52
(46%) had disruption of 1 or 2 tibial arteries. Their results
demonstrated substantially higher rates of nonunion or de-
layed union (10 versus 24, respectively) and osteomyelitis (4
versus 9, respectively) in patients with normal versus abnormal
arteriograms. Unfortunately, their modification of the Gustilo
classification did not gain any traction.
It was not until nearly 20 years later that the Gustilo
classification would be remodified to account for vascular
injuries by Chummun et al.29. Their retrospective review

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TABLE I A Summary of the Evolution and Changes in the Gustilo Classification Descriptors
Authors I II
Gustilo and An open fracture with a
Anderson wound loss of <1 cm long
16
(1976) and clean
Gustilo et al.
20
(1984)
Georgiadis et al.
23
(1993)
Trabulsy et al. <1 cm long, clean, minimal
24
(1994) soft-tissue injury, simple/
minimal comminution
Dickson et al. I1: Wound <1 cm from a
28
(1995) puncture wound from in to
out; the fracture is usually
simple, transverse, or
short oblique, with little
comminution; little soft-
tissue damage without
signs of crushing. I2: Same
as I1 with 1 artery damaged
(peroneal, anterior tibial, or
posterior tibial artery)
45
Olson (1996) A low-energy injury with
minimum soft-tissue
damage and a small (<1-
cm) wound; the fracture
typically occurs as an
inside-to-out puncture from
an underlying spike of
bone; typically, there is
slight comminution of the
bone
Parrett et al. <1 cm
47
(2006)
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Gustilo Classification Descriptors
An open fracture with a
laceration >1 cm long
without extensive soft-
tissue damage, flaps, or
avulsions
>1 cm long, moderate
contamination, moderate
soft-tissue injury with some
muscle damage, moderate
bone comminution
II1: Laceration >1 cm long
with mild-to-moderate
evidence of crushing to the
soft tissues; the bone can
have moderate
comminution. II2: Same as
II1 with 1 artery damaged
Represents a transition
between the low-energy
type-I and the high-energy
type-III fracture; type-II
fractures may have
associated soft-tissue
lacerations that are 1 to
10 cm long, slight or
moderate comminution,
and no or slight periosteal
stripping of the bone
fragments
1 to 10 cm with moderate
tissue damage
T H E E VO LU T I O N A N D I N T E R P R E TAT I O N
A N D E R S O N C L A S S I F I C AT I O N
IIIA
No subdivision into IIIA, IIIB,
and IIIC. Type III: An open
segmental fracture, an open
fracture with extensive soft-
tissue damage, or a traumatic
amputation. Special categories
include gunshot injuries, any
open fracture caused by a farm
injury, and any open fracture
with accompanying vascular
injury requiring repair
Adequate soft-tissue coverage of
a fractured bone despite
extensive soft-tissue laceration
or flaps, or high-energy trauma
irrespective of the size of the
wound
Usually >10 cm long, high
contamination, severe soft-
tissue injury with crushing,
usually comminuted, soft-
tissue coverage of bone
possible
IIIA1: Extensive soft-tissue
damage with instability of the
fracture; soft-tissue coverage is
adequate; segmental fractures
despite wound size. IIIA2: Same
as IIIA1 with 1 artery damaged
Those having adequate
coverage with soft tissue
despite extensive soft-tissue
lacerations or flaps or injuries
reflecting high-energy trauma,
such as extensive osseous
comminution, a segmental
fracture pattern, or extensive
soft-tissue injury (irrespective
of the size of the wound), or a
combination of any of these;
open fractures that occur in an
environment that predisposes
to extensive bacterial
contamination, such as a
barnyard setting or a public
waterway, are also classified
as type IIIA
>10 cm with extensive tissue
damage, making it difficult to
cover exposed bone or
hardware.
Sufficient soft tissue for bone
coverage, but after serial
debridement, such coverage
may not exist
OF THE
III B
Same
Extensive soft-tissue injury
with periosteal stripping
and bony exposure. This is
usually associated with
massive contamination
Open fractures associated
with a large open wound and
an intact blood supply to the
foot
Usually >10 cm long, high
contamination, very severe
loss of coverage, bone
coverage poor, usually
requires soft-tissue
reconstructive surgery
IIIB1: Same as IIIA1 with
lack of soft-tissue
coverage that requires a
flap of some kind to gain
wound closure. IIIB2: Same
as IIIB1 with 1 artery
damaged
Originally defined as
fractures with extensive
soft-tissue injury,
periosteal stripping, and
exposed bone; we prefer
to define type-IIIB open
fractures as those that
necessitate local or
distant flap coverage of
areas of exposed bone;
these fractures are
commonly associated with
extensive periosteal
stripping
>10 cm with extensive
tissue damage, making it
difficult to cover exposed
bone or hardware.
Extensive tissue damage
with periosteal stripping
making local soft tissue
coverage not possible.
G U S T I LO AND
IIIC
Same
Open fracture associated
with arterial injury requiring
repair
Associated with not only a
large open wound but also
a vascular disruption
Usually >10 cm long, high
contamination, very severe
loss of coverage plus
vascular injury requiring
repair, bone coverage
poor, usually requires soft-
tissue reconstructive
surgery
IIIC: Fracture requires an
arterial repair
A type-IIIC fracture is
associated with a vascular
injury that requires repair
for survival of the limb; a
tibial fracture with only an
isolated injury of the
anterior or posterior tibial
artery should not be
considered type IIIC
>10 cm with extensive
tissue damage, making it
difficult to cover exposed
bone or hardware.
Vascular injuries requiring
repair
continued
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A N D E R S O N C L A S S I F I C AT I O N

TABLE I (continued)

Gustilo Classification Descriptors

Authors I II IIIA III B IIIC

Choudry et al. IIIB fractures have open

26
(2008) wounds >10 cm in size
with severe soft-tissue loss
but no vascular injury
requiring repair; these
fractures are grossly
displaced and
contaminated and may
include segmental bone
loss; the remaining soft
tissue is inadequate for
wound closure, so regional
and/or distant flaps are
required for coverage
Bhattacharyya A Gustilo grade-IIIB
25
et al. (2008) fracture is a wound >10
cm that cannot be closed
primarily
2 2 2 2 2
Parrett and Pribaz Open wound <1 cm ; Wound 1 to 10 cm , no Wound >10 cm with extensive Wound >10 cm with Wound >10 cm with
27
(2010) simple bone fracture with extensive soft-tissue tissue damage, making it extensive tissue extensive tissue damage,
minimal comminution damage; minimal crushing, difficult to cover exposed bone damage, making it making it difficult to cover
moderate comminution, or hardware; bone difficult to cover exposed exposed bone or hardware;
and contamination comminution. bone or hardware; bone bone comminution.
comminution.
Sufficient soft tissue for bone Extensive tissue damage Grade-IIIB injuries with
coverage with periosteal stripping, major vascular injury
making local soft-tissue requiring repair
coverage not possible;
flap closure needed
Chummun et al. IIIB: An injury that
29
(2013) requires vascularized
soft-tissue
reconstruction, with all 3
vessels intact. IIIB1:
Has a vascular injury, but
has ‡1 axial vessel that
is patent and keeps the
limb vascularized
Sagi et al. Open wound <1cm Open wound 1 to 10 cm Open wound >10 cm, high- Open wound requiring soft- Open wound with vascular
48
(2015) energy injury, heavy tissue reconstruction injury requiring repair
contamination
Soltanian et al. Open fracture, clean Open fracture, wound >1 Open fracture with extensive Same Same
54
(2015) wound, wound <1 cm in cm in length without soft-tissue laceration,
length extensive soft-tissue damage, or loss or an open
damage, flaps, or segmental fracture; this type
avulsions also includes fractures that
have been open for 8 hr
before treatment.
Type-III fracture with periosteal Type-III fracture, extensive Type-III fracture associated
coverage of the fracture, soft-tissue loss, periosteal with an arterial injury
extensive soft-tissue laceration stripping and bone requiring repair
or damage damage; associated with
massive contamination;
often needs soft-tissue
coverage
Stranix et al. <1 cm, simple fracture >1 cm, moderate fracture Extensive soft-tissue damage; Extensive soft-tissue Open fracture with arterial
30
(2017) pattern, normal vascular pattern, normal vascular adequate local tissue for bone damage; regional or free injury requiring emergent
status status coverage; severe comminution flap required for bone repair, devascularized limb
or segmental fractures; normal coverage, IIIA fracture (0-vessel runoff)
vascular status. pattern plus periosteal
stripping.
IIIB sub-classification:
•IIIB-3 has 3-vessel runoff
•IIIB-2 has 2-vessel runoff
•IIIB-1 has 1-vessel runoff
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compared 18 type-IIIB injuries with an associated vascular
injury to 50 type-IIIB injuries with no vascular injury; they
reviewed functional outcomes with the Enneking score. The
Enneking score was used as an objective tool to assess the
return of limb function. The type-IIIB injuries associated with
a vascular injury had a significantly lower mean Enneking score
of 24.4 compared with 29.8 for type-IIIB injuries without a
vascular injury (p = 0.004). Therefore, Chummun et al. pro-
posed the Gustilo type-IIIB1 injury to denote the presence of
vascular injury not requiring repair in an otherwise vascular-
ized leg.
Stranix et al. took a different strategy30. They reviewed the
effect of vascular injury on free-flap outcomes by stratifying the
complications of return to the operating room (OR) and flap
failure according to the number of vessels that were damaged in
type-IIIB injuries. There were increasing free-flap complication
rates involving return to the OR and flap failure as the number
of damaged vessels increased. The rate of return to the OR
increased from 17% to 26% to 41% as vessel runoff was
reduced from 3 to 2 to 1, respectively (p = 0.007 on regression
analysis). Flap failure demonstrated a similar trend, with failure
rates of 34%, 50%, and 60% as vessel runoff was reduced from
3 to 2 to 1, respectively (p = 0.02 on regression analysis). When
only type-IIIB injuries were controlled for age, sex, time from
injury, and the number of venous anastomoses, there was a
significantly higher rate of complications for limbs with only a
single vessel (p = 0.01). Stranix et al. generated the latest evo-
lution of the Gustilo classification by proposing the following
subclassification of type-IIIB injuries:
 Type IIIB-3 has 3-vessel runoff.
 Type IIIB-2 has 2-vessel runoff.
 Type IIIB-1 has 1-vessel runoff.
Discussion
The Gustilo classification system remains the most widely used
open-fracture classification system19. This was exemplified with
a survey of 753 senior orthopaedic and plastic surgeons in the
United Kingdom; only 20 surgeons did not use the Gustilo
classification system29. Part of the appeal of the Gustilo classi-
fication has been its correlation with the complications of
infection and nonunion; contemporaneous literature con-
tinues to support the view that the Gustilo classification has a
role in stratifying these complications16,20,31-35.
Over the past 4 decades, the Gustilo classification has
been subject to various interpretations to help clinicians better
understand how to apply the classification system. Gustilo rec-
ognized that soft-tissue injury is a very important factor in
classifying open fractures and that type-IIIB injuries require
flap coverage36. Because the Gustilo classification is used to
communicate clinical information between clinicians, its level
of interobserver agreement is important, and studies showing
low values have led some authors to question its “accuracy.”37-39
The largest evaluation was conducted by Brumback and Jones,
who surveyed 245 orthopaedic surgeons regarding 12 video-
taped case presentations37. There was “moderate-to-poor inter-
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observer agreement,” with a mean of 60% (range, 42% to
94%). More recently, Ghoshal et al. undertook a study com-
paring the interobserver reliability of the Gustilo classification
with the Orthopaedic Trauma Association Open Fracture
Classification (OTA-OFC)39. Ninety-one long bone fractures
were assessed by 8 surgeons. The 2 best predebridement pho-
tographs, as well as radiographs and the description of the
mechanism of injury, the neurovascular status, and the demo-
graphics, were used to evaluate the use of both classification
systems. Despite the use of predebridement photographs by
Ghoshal et al., the kappa coefficient demonstrated only mod-
erate interobserver agreement, keeping with Horn and Rettig’s
findings in 199338. The comparison with the OTA-OFC dem-
onstrated only moderate interobserver reliability (k = 0.49) that
was marginally better than the Gustilo classification, which also
had a moderate reported agreement (k = 0.44), regardless of
experience39. The OTA-OFC has been lauded to potentially
supplant the Gustilo classification40. Agel et al. initially reported
the OTA-OFC as having moderate-to-excellent interobserver
agreement41; Agel et al. then published work indicating that it
was also predictive for early amputation, treatment using
negative-pressure wound therapy, and antibiotic bead place-
ment42. Although the OTA-OFC may be predictive for treat-
ment, infection is the key outcome that both patients and
clinicians want to be able to predict. Hao et al. reported that
the OTA-OFC was predictive for infection, the need for soft-
tissue coverage, and the need for amputation, albeit from a
retrospective analysis43. The OTA-OFC remains a new classifi-
cation system that was developed from expert consensus, but it
has not been fully validated; it may have too many combina-
tions that make it difficult to use in clinical practice, and the
OTA-OFC itself needs to grow and evolve40,44.
Because of the degree of subjectivity that is used to apply
the Gustilo classification, it is possible that introducing a mea-
surable threshold of 10 cm for the type-III classification
descriptors was intended to make the classification more objec-
tive or guide clinicians toward considering the use of local or
free-flap coverage. The 10-cm threshold subsequently has been
propagated as an absolute threshold through educational lec-
tures45 and in contemporary literature26,46-48. Despite attempts at
objectifying the classification, many wounds are still assessed
clinically rather than objectively and, therefore, wound classi-
fication remains inaccurate49.
With all of these various interpretations and the evolu-
tion of the original Gustilo descriptors, it is not surprising that
authors lose track of how they have been developed. At a more
fundamental level, authors need to be reminded of the care that
needs to be taken in how they attribute the various descriptors
to Gustilo’s work. The current classification that is commonly
used is a combination of work from Gustilo and Anderson
in 197616 and Gustilo, Mendoza, and Williams in 198420,50,51.
Unfortunately, many authors incorrectly attribute the 10-cm
threshold to Gustilo et al. rather than to Trabulsy et al.25-27,45,47,48.
The punctuation and conjunctions that are used with the
descriptors also can make small but potentially important
changes to the interpretation, particularly across the type-IIIA
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to type-IIIC injuries. As an example, type-IIIB injuries were
originally described as those with “extensive soft-tissue injury
with periosteal stripping and bony exposure. This is usually
associated with massive contamination.” There will be differ-
ences between an injury with “extensive soft-tissue injury and
periosteal stripping and bony exposure and massive contamina-
tion” and one involving “extensive soft tissue injury or periosteal
stripping or massive contamination.” The use of commas
between the descriptors also can make it unclear to the reader
whether the comma is intended as an “AND” or an “OR.” We feel
that paraphrasing of the descriptors should be done clearly to
maintain the “essence” of the original descriptors.
Just as Gustilo et al. refined the original classification in
1984, the medical community has been diligently evolving its
interpretation of the classification system. While it was not
explicitly stated in the earlier publications, Gustilo emphasized
that any grading was only provisional until surgical debride-
ment had been performed36; current standards in managing
open tibial fractures also recommend grading after surgical
debridement2.
In the classification, Gustilo incorporated what he felt
were 4 key factors that predisposed to open fracture complica-
tions: (1) massive soft-tissue damage with problems in bony
exposure, (2) severe wound contamination, (3) compromised
vascularity, and (4) fracture instability32. Because the Gustilo
type-IIIB grade encompasses a wide spectrum of injuries14,52,
authors have reviewed the outcomes of their own patient
cohorts to better define how vascular injury affects specific
outcomes and how this can be integrated into the Gustilo clas-
sification. Dickson et al. demonstrated that patients with an
associated vascular injury were more likely to encounter de-
layed union, nonunion, or osteomyelitis; however, although
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1
Guang H. Yim, MSc, MRCS
Joseph T. Hardwicke, PhD, FRCS(Plast)2,3
1
Department of Plastic Surgery, Derriford Hospital, Plymouth, United
Kingdom.
2
Department of Plastic Surgery, University Hospital Coventry, Coventry,
United Kingdom
3
Warwick Medical School, University of Warwick, Coventry, United
Kingdom
E-mail address for G.H. Yim: gyim@doctors.net.uk
ORCID iD for G.H. Yim: 0000-0003-3238-1808
ORCID iD for J.T. Hardwicke: 0000-0002-1756-0691
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