The purpose of this observational study was to evaluate the accuracy of Gustilo's classification of open
tibial fractures in children. Pre- and post-
debridement (using the parameters of Gustilo's classification)
wound gradings in 27 children with a mean age of 10 years (3 to 15 years) who had sustained an open
tibial fracture were compared. Pre-operative Polaroid photographs of the
wound were taken of all these patients in the accident and emergency department. In every case, the fracture was treated with prophylactic intravenous
antibiotic administration,
wound debridement and lavage. Following
wound exploration in the operating theater, the
wound was classified using Gustilo's parameters again; this was different from the initial grading. We compared post-
debridement classification according to Gustilo to the new classification which we propose. The latter classification is a peroperative assessment of the extent of soft tissue damage and it addresses bone stability. According to this classification, the majority of open
tibial fractures were stable, requiring no skin graft or flap and had a good outcome. Only five patients were treated by initial external fixation of the tibia; the remainder were treated by cast immobilization.
Wounds were treated as appropriate. The clinical outcome study included the assessment of
wound and fracture healing and the incidence of complications. The mean period for follow-up was 8 months (6 to 24 months). There were no cases of nonunion or deep
wound infection and the
wounds healed in all these patients. We conclude that Gustilo's classification is not specific and does not reflect the extent of soft tissue and skeletal damage. Factors such as the degree of soft tissue damage and periosteal stripping that are noticed following
wound debridement and velocity of injury are far more important than the
wound size. Our proposed peroperative classification covers the extent of
soft tissue injury and skeletal stability, thus predicting the outcome more than the Gustilo classification.