開放骨折のGustilo分類

ガスティロ分類

専門医試験的には

• Type I: 1cm未満、結構きれい
• Type II: 1cm以上、それなりの汚染
• Type III: 不安定骨折、かなりの汚染
  • Type IIIA: 骨折部被覆可能
  • Type IIIB: 被覆無理
  • Type IIIC: 動脈再建が必要

Gustilo classification (原著的には)

• Type I: the wound is less than one centimeter long. It is usually a moderately clean puncture, through which a spike of bone has pierced the skin. There is little soft-tissue damage and no sign of crushing injury. The fracture is usually simple, transverse, or short oblique, with little comminution.
• Type II: the laceration is more than one centimeter long, and there is no extensive soft-tissue damage, flap, or avulsion. There is a slight or moderate crushing injury, moderate comminution of the fracture, and moderate contamination.
• Type III is characterized by extensive damage to soft tissue, including muscles, skin, and neuromuscular structures, and a high degree of contamination. The fracture is often caused by high-velocity trauma, resulting in a great deal of comminution and instability.
  • Type IIIA: soft tissue coverage of the fractured bone is adequate, despite extensive laceration, flaps, or high-energy trauma. This subtype includes segmental or severely comminuted fractures from high-energey trauma, regardless of the size of the wound.
  • Type IIIB: extensive injury to or loss of soft tissue, with periosteal stripping and exposure of bone, massive contamination, and severe comminution of the fracture from high-velocity trauma. After debridement and irrigation is completed, a segment of bone is exposed and a local or free flap is needed for coverage.
  • Type IIIC: any open fracture that is associated with an arterial injury that must be repaired, regardless of the degree of soft tissue injury.

参照（原著）：Gustilo RB, et al. The management of open fractures. J Bone Joint Surg Am. 1990

感染率は？

わざわざ分類するのは、重傷だなーと感心するためではもちろん無くて、それぞれで感染率が違うから。Type I, IIとType IIIでは治療を別に考える必要がある。Type IIIにセフェム単剤使用はやめましょう。破傷風予防も忘れずに。

感染率from原著

• Type I: 0-2%
• Type II: 2-7%
• Type III: 10-25%
  • Type IIIA: 7%
  • Type IIIB: 10-50%
  • Type IIIC: 25-50%

（感染しちゃったら骨髄点滴iMAP?）

個人的には

Type IIIB以上には、願わくば出会いたくないですね。昔同僚の当番日に、トイレで転んだおばあちゃんが木が腕に刺さったと言って救急搬送されてきたようだが、木が刺さってたのではなくて、骨が突き出ていたという痛い話も。刺さった木を必死に引き抜こうとしていたおばあちゃんのガッツに恐れ入るしかない。

原著：Gustilo RB, et al. The management of open fractures. J Bone Joint Surg Am. 1990

参考：Patzakis MJ, et al. Prospective, randomized, double-blind study comparing single-agent antibiotic therapy, ciprofloxacin, to combination antibiotic therapy in open fracture wounds. J Orthop Trauma. 2000

その他：秀逸な紹介があったけど、存在していないのでアーカイブから。