A Guide To Understanding The Various Wound Classification Systems

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Here is a non-infected, non-ischemic heel ulceration in a patient with diabetic neuropathy. Dr. Satterfield notes that the Wagner wound classification does not take the presence of diabetic neuropathy into account. (Photo courtesy of Jonathan Moore, DPM)
A 72-year-old male presented with a wound that had recently developed on his right great toe. His physician had been managing the wound until it developed a large eschar and infection with drainage. (Photo courtesy of Eric Espensen, DPM)
A Guide To Understanding The Various Wound Classification Systems
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Author(s): 
By Kathleen Satterfield, DPM
Indeed, these factors can have a pronounced effect on the treatment and potential outcome. That said, here are the basic tenets of the Wagner system. Grade 0: No open lesion but may have deformity or cellulitis Grade 1: Superficial ulcer, partial or full-thickness Grade 2: Ulcer extends to ligament, tendon, joint capsule or deep fascia without abscess/osteomyelitis Grade 3: Deep ulcer with abscess, osteomyelitis or joint sepsis Grade 4: Gangrene localized to forefoot or heel Grade 5: Extensive gangrene Reviewing Other Classification Systems The descriptive “S(AD) SAD” system builds upon the Wagner classification to include several additional categories: size (area, depth), sepsis, arteriopathy and denervation.3 Developed by an English group, the S(AD) SAD classification is a validated system that was reported in Diabetic Medicine. The system, with grades 0 to 3, includes a cross-sectional area but many clinicians believe this is too complicated and may result in confusion. At the other end of the spectrum is the RYB Color Classification, which was developed for the nursing literature.4 It initially appeared in the American Journal of Nursing in 1988 and has enjoyed considerable popularity. The system relies purely on a color scheme with no additional considerations. R/Red wounds are those that exhibit pale pink to beefy red granulation tissue and are deemed to be in the inflammatory or proliferative phase. Y/Yellow wounds are marked by pale ivory, yellowish green or brown color, slough of necrotic but moist tissue, and wound exudates. B/Black wounds are marked by black, brown or tan color, and desiccated eschar. The RYB classification is an easy and widely accepted system in the nursing literature and shows the continuum from acute to chronic wounds. Conversely, it is non-specific with no consideration of depth or size, and no consideration of the contributing factor of neuropathy. PEDIS, the most august of the systems, was developed by the International Working Group on the Diabetic Foot, a primarily European group. From its beginnings, the classification was designed as a system for the specific needs of research groups. PEDIS stands for P (perfusion), E (extent/size), D (depth of tissue loss), I (infection) and S (sensation). There are levels of 1 to 4 for each of these factors. The in-depth nature of this system is appropriate for the research community that desires this amount of detail.5 What About the DEPA Scoring System? When it comes to wound classification systems, the newcomer on the block is the DEPA Scoring System, which was previewed in The Journal of Foot and Ankle Surgery (JFAS) in 2004.1 DEPA stands for D (depth of the ulcer), E (extent of bacterial colonization), P (phase of ulcer) and A (associated etiology). Ascending scores, from 1 to 3, are assigned for increasing levels of intensity in each category. For instance, an ulcer involving soft tissue receives a 2. Contamination of this ulcer receives a 1. The ulcer is in the inflammatory phase, generating a 2 score, and has an underlying bony deformity, generating another 2 score. Accordingly, this ulcer has a total score of 7. Ulcers with a total score of 6 or less are considered “low grade” ulcers. Recommended treatment measures include oral antibiotics (if infected), blood sugar control (type not specified) and debridement. Those with a total score of 7 to 9 are deemed “moderate grade” wounds that one would treat with parenteral antibiotics, insulin, debridement, healing promoting agents and pressure relieving methods. The “high grade” lesions, those with a total score between 10 to 12, require a conservative trial including parenteral antibiotics, insulin, debridement, healing promoting agents and vascular reconstruction. The authors of the classification system offered acute ischemia patients a below-knee amputation at the time of presentation, a concept that may be foreign to this country’s practitioners who will usually offer revascularization or other interventions. The scores of 11 to 12 are prognostic for amputation and if these are heel ulcers, they were even more likely to lead to amputation. Scores of 10 or greater predict difficulty with healing while scores of 6 or less indicate probable healing.
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