Ulcer Classification Systems

Wagner Ulcer Classification System
UTSA Ulcer Classification System

There are several ways that have been devised to classify diabetic ulcers over the years.  Perhaps the system most commonly used today is the Wagner system described below:  

Wagner Classification System

Grade 0:  Skin intact, but deformity present.  Foot is "at risk". 

Grade I:  Localized superficial ulcer.

Grade II:  Deep ulcer extending to tendon, joint and bone.

Grade III:  Ulcer involving infection of bone.  

Grade IV:  Ulcer involving gangrene of toes or forefoot.

Grade V:  Gangrene beyond forefoot. 

It's an easy system, but the Wagner Classification System has its faults.  First, the vast majority of ulcers will fall in one of two classes, either Grade I or Grade II, so it doesn't differentiate well between the majority of ulcers.  Second, there is no predictive value in formulating a prognosis with this system.  

UTSA Classification System

A new and more comprehensive system has been developed by podiatrists at the University of Texas at San Antonio (abbreviated  here as "UTSA").

Wounds in this classification system are graded as follows:

First, the patient's medical condition is graded. 

  • Grade A refers to a clean, non-infected wound in a patient with adequate blood supply. 

  • Grade B refers to patients with infected wounds but have adequate blood supply.

  • Grade C refers to patients with no infection in the wound, but has poor circulation.

  • Grade D refers to patients with an infected wound and poor circulation.

Next, the wound is graded. 

  • Grade 0 refers to pre- or post-ulcerative lesion that is completely healed.

  • Grade 1 refers to patients with a superficial wound not involving tendon, capsule or bone.

  • Grade 2 refers to wounds penetrating to tendon or capsule.

  • Grade 3 refers to wounds extending to the bone or joint. 

Example Patients:

So, let's say a patient with good circulation has an infected ulcer extending down to the tendon.  You'd classify this patient as Grade 2B.

Next you have a patient with poor circulation and a non-infected ulcer extending only superficially--not to tendon, capsule or bone, you'd classify this patient as Grade 1C.

So what's the point of all this classification? 

Well, it makes it easy for the podiatric physician to accurately discuss both the patient's ulcer and overall medical condition with a colleague, it better differentiates between the types of ulcers, it gives us an idea of the prevalence of the patient's type of wound, and most importantly perhaps, it implies a prognosis for the patient's wound. 

For example, the prevalence of each type of wound is listed as the first percentage, and the number percentage of patients in that category who'll go on to have an amputation within 6 months is the second percentage listed:

Grade 0A wounds:         4.2%                0%
Grade 1A wounds:       25.8%                0%
Grade 2A wounds:       10.0%                0%
Grade 3A wounds:         5.6%                0%

Grade 0B wounds:        2.2%                12.5%
Grade 1B wounds:      13.1%                  8.5%
Grade 2B wounds:        7.8%                28.6%
Grade 3B wounds:      20.8%                92.0%

Grade 0C wounds:        1.1%                25.0%
Grade 1C wounds:        2.8%                20.0%
Grade 2C wounds:        1.1%                25.0%
Grade 3C wounds:        0.8%              100.0%

Grade 0D wounds:        0.6%                50.0%
Grade 1D wounds:        0.6%                50.0%
Grade 2D wounds:        0.6%              100.0%
Grade 3D wounds:        3.1%              100.0%

So now let's return to our example patients above.  The first patient classified as 2B represents 7.8% of the diabetic wounds, and the odds of his having an amputation within 6 months is a little more than one out of four.  The second patient in our example who was classified as 1C represents 2.8% of diabetic wounds, and there is a one in five chance that the patient will go on to have an amputation within 6 months. 

In that diabetic wounds may now be given a prognosis based on their classification, this system represents a major advance in how wounds are considered. 





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The Achilles Foot Health Centre
S. A. Schumacher, D.P.M., F.A.C.F.A.S., F.A.C.F.A.O.M.  
Dr. S. A. Schumacher, Podiatric Corporation  

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