Wagner’s Classification vs. Texas University Classification for Diabetic Foot Ulcer

Foot ulcer complicating 5-10% patient suffered from diabetes mellitus with up to 3% of them will need lower limb amputation. [Samson O. Oyibo et al]

Below is the grading of this two system.

1. Wagner’s classification

Grade 0 (Pre or post ulcerative lesion)

Grade 1 (partial/ full thickness ulcer, i.e. superficial ulcer)

Grade 2 (Probing to tendon or capsule, i.e. deep ulcer)

Grade 3 (Presence of osteomyelitis)

Grade 4 (Partial foot gangrene)

Grade 5 (Whole foot gangrene)

2. University Texas Classification

Grade 0 (pre or post ulcerative ulcer that has healed)

Grade 1 (Superficial wounds not involving tendon, capsule or bone)

Grade 2 (Wound penetrating to tendon or capsule)

Grade 3 (Wound penetrating bone or joint.

Within each grade, it got 4 stages

A (Clean wounds)

B (Non ischemic infected wounds)

C (Ischemic non infected wounds)

D (Ischemic infected wounds)

Conclusion:

1) Increasing stage regardless of grade is associated with increased risk of amputation and prolongs healing ulcer time.

2) UT system’s inclusion of stage makes it a better predictor of outcome.

Extract from

1) Samson O. Oyibo, Edward B. Jude, Ibrahim Tarawneh, et al, “ A Comparison of Two Diabetic Foot Ulcer Classification Systems”, Diabetes Care 24:84-88, January 2001

Approach to an ulcer

1) Explain the abnormalities seen in the picture (4m)

2) Give one most possible causes of the abnormality and the Pathophysiology for the condition (3m)

3) Name one complication of the abnormality (1m)

4) Outline the management for this patient. (2m)

Ok friends! First of all please try to answer the above questions first. I post the answer below. Approach to an ulcer also being posted below

Anwer

1)

a) Grade one single ulcer

b) Plantar surface of big toe

c) Healing margin

d) Punched edge

e) Floor filled with granulation tissue

2)

a) Trophic ulcer due to uncontrolled diabetis mellitus

b) Uncontrolled DM --> peripheral neuropathy -->motor damage + sensory damage + autonomic damage --> ulcer formation without realizing it --> will extend and complicate the ulcer.

3) Osteomyelitis

4)

a) Debridement

b) Relieve the pressure

c) Antibiotic if present with infection.

Approach to an ulcer

Basically it is divided into 3 steps. Inspection, palpation and focal examination.

Inspection
1) Size and shape
2) Number
3) Location
4) Margin (Healing, Inflammed, Fibrosed)
5) Edge (Sloping, punched, everted, undermined, everted, raised)
6) Floor (Granulation tissue, slough, discharge)
7) surrounding skins (inflammation, pigmentation, scars&puckering, hypopigmentation)

Palpation
1) Surrounding skins (Temperature, tenderness)
2) Edge of the ulcer (soft: healing ulcer, firm: non healing, hard:malignant)
3) Floor of ulcer (Consistency, underlying structure)
4) Test the fixity (skin, muscle, bone)

Focal examination
1) Lymph node
2) Arteries, venous circulation, nerves
3) Movement of neighboring joint

******Grading of ulcer (especially for ulcer foot)
Grade 0 — No ulcer in a high risk foot.
Grade 1 — Superficial ulcer involving the full skin thickness but not underlying tissues
• Grade 2 — Deep ulcer, penetrating down to ligaments and muscle, but no bone involvement or abscess formation
• Grade 3 — Deep ulcer with cellulitis or abscess formation, often with osteomyelitis
• Grade 4 — Localized gangrene.
• Grade 5 — Extensive gangrene involving the whole foot.