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Given that ulcers are a common complication for patients with diabetes, it is important to understand the various ulcer grading systems and how they can aid in treatment. This author reviews common classification systems and how to apply them in a clinical setting.
Continuing Education Course #161 March 2008 | - I am pleased to introduce the latest article, “Pertinent Pearls On Grading Diabetic Foot Ulcers,” in our CE series. This series, brought to you by the North American Center for Continuing Medical Education (NACCME), consists of complimentary CE activities that qualify for one continuing education contact hour (.1 CEU). Readers will not be required to pay a processing fee for this course.
Grading systems for diabetic foot ulcers can help facilitate improved documentation of wound healing progress and foster appropriate treatment. Accordingly, Ronald A. Sage, DPM, discusses the pros and cons of established diabetic ulcer grading systems including the Wagner classification and the University of Texas classification. He also reviews pressure ulcer staging as well.
At the end of this article, you’ll find a 10-question exam. Please mark your responses on the enclosed postcard and return it to NACCME. This course will be posted on Podiatry Today’s Web site (www.podiatrytoday.com) roughly one month after the publication date. I hope this CE series contributes to your clinical skills.
Sincerely,
Jeff A. Hall
Executive Editor
Podiatry Today
INSTRUCTIONS: Physicians may receive one continuing education contact hour (.1 CEU) by reading the article on pg. 94 and successfully answering the questions on pg. 98. Use the enclosed card provided to submit your answers or log on to www.podiatrytoday.com and respond via fax to (610) 560-0502.
ACCREDITATION: NACCME is approved by the Council on Podiatric Medical Education as a sponsor of continuing education in podiatric medicine.
DESIGNATION: This activity is approved for 1 continuing education contact hour or .1 CEU.
DISCLOSURE POLICY: All faculty participating in Continuing Education programs sponsored by NACCME are expected to disclose to the audience any real or apparent conflicts of interest related to the content of their presentation.
DISCLOSURE STATEMENTS: Dr. Sage has disclosed that he has no significant financial relationship with any organization that could be perceived as a real or apparent conflict of interest in the context of the subject of his presentation.
GRADING: Answers to the CE exam will be graded by NACCME. Within 60 days, you will be advised that you have passed or failed the exam. A score of 70 percent or above will comprise a passing grade. A certificate will be awarded to participants who successfully complete the exam.
TARGET AUDIENCE: Podiatrists
RELEASE DATE: March 2008
EXPIRATION DATE: March 31, 2009
LEARNING OBJECTIVES: At the conclusion of this activity, participants should be able to:
• cite the five ulcer grades of the Wagner classification;
• discuss which ulcer grades in the Wagner classification would require vascular consultation;
• review the documentation of wound depth, ischemia and infection within the UTHSCSA Diabetic Wound Classification System;
• describe the different pressure ulcer stages as per the National Pressure Ulcer Advisory Panel System; and
• review other considerations in documenting ulcer severity.
Sponsored by the North American Center for Continuing Medical Education.
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The Centers for Disease Control and Prevention (CDC) estimated in 2003 that over 18 million people in the United States have diabetes mellitus. The number is now probably closer to 20 million. Approximately 60 to 70 percent suffer some form of neuropathy, which is a leading risk factor for lower extremity amputation. Each year, there are 82,000 non-traumatic amputations in the U.S. that are related to diabetes.1 Researchers have estimated that cutaneous ulceration and faulty wound healing contribute to 85 percent of these amputations.2 In regard to the management of diabetic ulcers and other ulcerations in the lower extremity, there are a number of grading systems one can use to help facilitate proper care of these wounds. These ulcer classification systems also enable podiatrists to provide a quick description of the seriousness of the ulceration, which they can easily document in the patient record. Further, grading the ulcer at each visit can help document the progress or lack thereof toward healing.
There are several systems physicians can use to grade or stage ulcers, particularly diabetic ulcerations. The Wagner classification is the oldest and may be the most widely known of the classification systems. This system was based on the experiences of physicians who were among the first to initiate an aggressive limb salvage program for patients with diabetes in the late 1970s.3 Wagner’s work thoroughly describes the various stages of diabetic foot ulcer, infection and necrosis. However, he cites no case series or evidence aside from his own expert opinion that this is a workable system. A Closer Look At The Wagner Classification
|  | | Here one can see a Wagner grade 4 ulcer. According to the author, part of the foot is likely salvageable with an acceptable ABI. This ulcer is graded as a 3-D ulcer in the UTHSCSA system. In this system, grade 3 ulcers are those that penetrate to bone. |
The Wagner classification is based on the depth of the ulceration and the extent of infection or necrosis. The system describes five grades of ulceration and a 0 grade that indicates a diabetic foot at risk for ulceration. The premise of this classification is that with proper treatment, physicians should be able to convert all but grade 5 feet to grade 0 if adequate circulation is present to sustain healing.
The system accounts for infection only at grades three, four and five. This classification also does not account for the presence or absence of good circulation. Wagner recommended the use of Doppler exams to evaluate perfusion and determine the indication for vascular clinic referral.
Grade 0. This foot has no open lesions but one may see hammertoes, prominent metatarsals or other deformities that, in the presence of neuropathy, could lead to pressure induced ulcerations from walking, standing or ill-fitted footgear.
|  | | This ulcer probes to bone and the X-ray changes are consistent with osteomyelitis. It is a Wagner grade 3 ulcer and UTHSCSA grade 3-B ulcer. |
Grade 1. This foot presents with superficial ulceration through the skin only. One would apply this grade to a wound with a viable or a necrotic base. There is no significant wound depth and there is no evidence of penetrating infection. The use of this grade does not include or rule out surrounding cellulitis, which one should describe separately.
Grade 2. This type of lesion is deeper and may slough to tendon, ligament or joint. In treating these ulcers, Wagner recommended utilizing the ischemic index or ankle brachial artery index to determine the need for a peripheral vascular referral. If the ratio of ankle systolic pressure (which one can measure with a Doppler probe) to brachial systolic blood pressure (or ABI), is less than 0.45, this indicates the need for a vascular referral. The ulcer is not likely to heal without improved perfusion.
Sage and Doyle completed a study applying this criterion to 48 cases. The findings supported the assertion that healing of diabetic ulcers or surgical wounds usually occurred at or above an ischemic index of 0.45.4 One can apply the ischemic index without regard to ulcer grade. There is no indication in the Wagner grading system itself of whether the ulcer is ischemic.
Grade 3. A grade 3 wound occurs when deep infection progresses to abscess or osteomyelitis. Such a wound requires incision, drainage and debridement of all infected soft tissue or bone. Again, if the ABI is above 0.45, one can expect the wound to heal. If not, physicians should obtain a vascular consultation.
Grade 4. When it comes to grade 4 ulcerations, gangrene affects some portion of the forefoot. Although some type of amputation will be necessary, this may be limited to the toes, metatarsals or midfoot level, assuming there is adequate vascular perfusion. In regard to grade 4 ulcerations, part of the foot is likely salvageable with an acceptable ABI.
Grade 5. Wagner applied grade 5 to those feet presenting with extensive necrosis, infection or gangrene to the point where salvage of the foot is not possible, and amputation at trans-tibial or higher level is necessary.
Understanding The UTHSCSA Diabetic Wound Classification
In 1998, Armstrong, Lavery and Harkless from the University of Texas Health Science Center at San Antonio (UTHSCSA) published a grading system that not only indicated the depth of the ulceration, but also included infectious and ischemic components.5 They demonstrated this system as an effective predictor of the likelihood of amputation in a strong case series. Although the UTHSCSA classification is currently less popular than the Wagner system, we will likely see an upsurge in its use as more practitioners become familiar with the classification.
The work of Armstrong, Lavery and Harkless takes into account the contributions of wound depth, infection and ischemia, and relates these factors to the risk of amputation.5 This system rates wound depth from 0 to 3. Grade 0 implies an at-risk foot without open ulceration. Grade 1 indicates superficial ulceration. Grade 2 applies to ulcers that penetrate to tendon or capsule. Grade 3 ulcers are those that penetrate to bone.
Then they classify each ulcer further according to the presence of infection or ischemia. The letter A indicates any ulcer grade without evidence of infection or ischemia. B indicates ulcers that are infected but not ischemic. C indicates ischemic but not infected ulcers. Lastly, D indicates when there are signs of infection and ischemia.
In an extensive case review, which validated the usefulness of this classification system, the UTHSCSA group found that the higher the number grade and the more advanced the letter grade, the more likely the patient was to require some form of amputation. One hundred percent of the patients in their study who had 3-D ulcerations to bone with infection and ischemia ultimately underwent some form of amputation. Key Insights On Pressure Ulcer Staging
|  | | Here one can see a necrotic forefoot ulcer and toe. There is ischemia but the patient has no ascending infection. In this case, the patient has a Wagner grade 4 ulceration and a UTHSCSA grade 3-C ulceration. |
The staging of pressure ulcerations has not been common in podiatry but it is useful in evaluating, treating and preventing decubitus ulcers of the heel or other bony prominences in the foot. Patients with decubitus ulcers may or may not have diabetes. Decubitus ulcers commonly occur among patients who are immobilized for prolonged periods of time. Indeed, the prevention of pressure ulceration in hospitalized or other institutionalized patients has become a national priority.
The National Pressure Ulcer Advisory Panel, which included physicians and nurses, developed a system for grading pressure ulcers.
This system was updated in 2007.6 While this system is most applicable to heel decubiti, pressure ulcers can also occur over the malleoli and fifth metatarsal head or base if a patient is positioned with the lower extremity externally rotated for a prolonged period of time. By effectively using this system in collaboration with other healthcare workers, the podiatrist can play a significant role in reducing the morbidity associated with this problem. This system is based on wound depth. A stage 1 decubitus ulcer describes intact reddened skin over a bony prominence, indicating an “at-risk” patient. Ideally, observation for stage 1 decubiti and implementing protective measures should prevent more serious complications. Arguably, examination for stage 1 ulceration should be part of every podiatric consultation in the extended care setting.
Stage 2 pressure ulcerations involve a partial thickness loss of dermis that presents as a shallow ulceration. A stage 3 pressure ulceration is a full thickness loss of dermis without exposure of tendon or bone. In regard to stage 4 pressure ulcerations, one will note full thickness tissue loss and exposed bone, tendon or muscle. Eschar may be present in some of the stage 4 wound along with tunneling and slough.
Needless to say, the prognosis for healing becomes worse with each subsequent stage of the ulcer. There is no additional grade to account for infection or ischemia, which one should describe separately when using this system. Other Considerations In Documenting Ulcer Severity
|  | | This Wagner grade 1 ulcer is also labeled as a UTHSCSA grade 1-A ulcer. Both grading systems indicate a superficial infection. |
The clinician should name the grading system he or she is using to describe ulcers. This is especially useful when documenting charts that are likely to be read by non-podiatric providers. Use pre-ulcerative grades such as Wagner grade 0, UTHSCSA 0-A, or stage 1 pressure ulceration in bed-bound patients to indicate at-risk patients who require preventive interventions such as prescription shoes or pressure relief mattresses. Inform the patient and any caregivers that the patient is at risk for ulceration.
If ulceration occurs, document an ulcer grade. If you are using a system other than UTHSCSA system, you should add indications of ischemia or infection to the description of the ulcer. Other characteristics that physicians should note include: the amount and color of any drainage, odor, tunneling and surrounding or ascending erythema. Measure the wound before and after debridement. The measurements should include length, width and depth. Also document the presence or absence of granulation or non-viable tissue.
When following the patient, document each of these grades, measurements and characteristics. This allows the provider to evaluate progress or deterioration, and identify the need for continuation of the initial treatment plan, or the institution of more aggressive interventions.
Ideally, at each visit, one should see the size and grade of the ulcer decreasing along with the resolution of signs of infection. Ischemic changes require evaluation for vascular intervention, especially if an ulcer fails to show signs of improvement after one has initiated treatment. In Summary
The consistent application of an ulcer grading system allows the physician to efficiently document the seriousness of a foot ulceration at initial presentation. Grading at each follow-up visit provides a simple method of documenting and evaluating progress. This confirms success of the treatment regimen or indicates that present measures are failing to achieve improvement, and a change in the treatment plan may be needed. Ideally, in patients with adequate vascular and physiologic parameters, the clinician’s grading system should be able to demonstrate progress toward healing and achieving a grade 0 foot.
Dr. Sage is a Professor and Chief of the Section of Podiatry at the Department of Orthopaedic Surgery and Rehabilitation at the Loyola University Stritch School of Medicine. He is also a Staff Podiatrist at Edward Hines Jr. Veterans Affairs Hospital in Hines, Ill. References
1. Center for Disease Control and Prevention: National diabetes fact sheet, 2003. Available at: http://www.cdc.gov/diabetes/pubs/factsheet.htm.
2. Pecoraro RE, Reiber GE, Burgess EM: Pathways to diabetic limb amputation: basis for prevention. Diabetes Care 13: 513, 1990.
3. Mooney V, Wagner FW: Neurocirculatory disorders of the foot. Clin Orthop 122:53, 1977.
4. Sage R, Doyle D: Surgical treatment of diabetic foot ulcers: a review of forty-eight cases. JFS 23: 102, 1984.
5. Armstrong DG, Lavery LA, Harkless LB: Validation of a diabetic wound classification system. Diabetes Care 21:855, 1998.
6. National Pressure Ulcer Advisory Panel. Updated staging system. http://www.npuap.org/pr2.htm. (Accessed August 22, 2007). Editor’s note: For related articles, see “When Diabetic Foot Ulcers Can Be Managed At Home” in the October 2004 issue or “A Guide To Understanding The Various Wound Classification Systems” in the June 2006 issue.
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