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Diabetic Foot Ulcer Classification Systems

July 4, 2016 21 Comments

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Diabetic Foot Ulcer

Diabetic Foot Ulcer – Wagner Grade 2

It is crucial to apply a standardized measurement system to evaluate whether a diabetic foot ulcer is responding to care, as a result several classification systems have been proposed.

At the present time no specific system has been universally accepted.  Even so, most clinicians use one of the available systems when assessing and documenting a diabetic ulcer.

In this article we will discuss two commonly used classification systems;  The Wagner diabetic foot ulcer grade classification system and the University of Texas diabetic foot ulcer classification system.

The Wagner Diabetic Foot Ulcer Grade Classification System

The Wagner diabetic foot ulcer classification system assesses ulcer depth and the presence of osteomyelitis or gangrene by using the following grades:

  • Grade 0 – intact Skin
  • Grade 1 – superficial ulcer of skin or subcutaneous tissue
  • Grade 2 – ulcers extend into tendon, bone, or capsule
  • Grade 3 – deep ulcer with osteomyelitis, or abscess
  • Grade 4 – partial foot gangrene
  • Grade 5 – whole foot gangrene

Note:  While the wound shown in the above image may appear to be a grade 3 ulcer, upon assessment no abscess or osteomyelitis was found.  Beneath the superficial necrotic tissue was exposed tendon.

The University of Texas Diabetic Foot Ulcer Classification System

The University of Texas system grades diabetic foot ulcers by depth and then stages them by the presence or absence of infection and ischemia:

  • Grade 0 – pre-or postulcerative site that has healed
  • Grade 1 – superficial wound not involving tendon, capsule, or bone
  • Grade 2 – wound penetrating to tendon or capsule
  • Grade 3 – wound penetrating bone or joint

Within each wound grade there are four stages:

  • Stage A – clean wounds
  • Stage B – non-ischemic infected wounds
  • Stage C – ischemic noninfected wounds
  • Stage D – ischemic infected wounds

Additional Diabetic Foot Ulcer Classification Systems

The following chart from Wounds International highlights additional classifications systems.

diabetic foot ulcer classification systems

Source: wounds international.com

For detailed information on the above chart refer to “Best Practice Guidelines:  Wound Management in Diabetic Foot ulcers”

Conclusion

While each system uses a different approach to classify a wound,  similarly each system classifies the wound according to depth, presence of ischemia, and presence of infection.

Regardless of which classification system is used, it is essential that the system be used consistently across the healthcare team and be recorded appropriately in the patient’s records.

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Categories: Diabetic ulcers, Wound Assessment and Documentation

About the Author

Laurie Swezey's avatar

Laurie Swezey, founder and president of WoundEducators.com, has been a Registered Nurse for more than a quarter century, with most of those years dedicated to wound treatment. Ms. Swezey is a Certified Wound Care Nurse and a Certified Wound Specialist.

Reader Interactions

Comments

  1. Jaque Christo says

    December 6, 2017 at 12:27 pm

    Thank you for the information on Diabetic foot ulcer classification systems. I had no idea that diabetic foot ulcers could get so bad they reach tendons or even the bone. I wonder how you catch an ulcer early, or how to treat one that’s gone so deep it affects a tendon or bone.

    Reply
  2. Dr dilip kumar kandar,india says

    January 18, 2018 at 1:56 pm

    I good number of case recorded for diabetic foot
    Where tight glycaemic controlled is very very importent

    Reply
    • Laurie Swezey says

      January 18, 2018 at 2:42 pm

      So true!! Tight glycemic control is essential to diabetic wound healing. Thanks for your input.

      Reply
  3. Matthew Powers says

    May 19, 2018 at 9:11 am

    A diabetic has a heel ulcer completely covered by eschar. Should this be “Staged” or “Graded” according to the Wagner Grading Scale. If “Graded”, what would be the Grade ?

    Reply
    • Matthew Powers says

      May 21, 2018 at 8:11 am

      I should mention that it developed as a result of pressure.

      Reply
      • Laurie Swezey says

        May 21, 2018 at 9:26 am

        Hi Matthew, That is a difficult question one that many professionals struggle will. The cause of the ulcer is clearly related to both disease processes and both pressure and diabetes will need to be addressed. For documentation purposes, the PRIMARY cause of the ulcer would be documented. If the ulcer was caused by pressure and is completely covered by eschar, it would be documented as an unstageable pressure ulcer with the comorbidity of diabetes. For more infomation refer to the following article: http://www.diabeticfootcanadajournal.ca/download/content/4588

        Reply
  4. Matthew Powers says

    May 21, 2018 at 10:29 am

    Thank you for that. Once the eschar is removed and is visualuzed, would the classification ever be converted to a Wagner Grade or does it remain “Staged” ?

    Reply
    • Laurie Swezey says

      May 21, 2018 at 12:56 pm

      If the primary cause of the wound was pressure it would remain a pressure ulcer.

      Reply
  5. Matthew Powers says

    May 24, 2018 at 12:35 pm

    Thank you so much. This topic at our wound center seems to raise more questions the more we talk about it. If we derermine that a diabetic foot ulcer should be graded and is completely covered by eschar, what Wagner Grade would it be ? Thanks

    Reply
    • Laurie Swezey says

      May 25, 2018 at 10:00 am

      The wound would need to be debrided in order to accurately stage. Following is a great article on staging: http://www.woundsresearch.com/article/8706

      Reply
  6. Kathy Rose says

    December 4, 2018 at 3:54 pm

    Can a Wagner classification be given to an infected below knee amputation residual limb or does it have to be a foot?

    Reply
    • Holly Hingle says

      December 18, 2018 at 11:46 am

      Kathy,

      Wagner classifications are given to diabetic foot ulcers and lesions, not limbs. Hope this helps!

      Reply
  7. Alex Webb says

    December 13, 2018 at 4:21 pm

    Can a Wagner grade 1 Ulcer also be considered a full thickness wound?

    Reply
    • Holly Hingle says

      December 18, 2018 at 11:44 am

      Hi Alex! Thanks for your inquiry. A Wagner grade 1 is considered a superficial ulcer, not a full thickness wound.

      Reply
      • Alex Webb says

        December 20, 2018 at 5:00 pm

        Thank you for the answer! I do have a followup question. If you have a diabetic wound that extends into the subcutaneous layers, lets say 2cm, but does not reach tendon, bone, or joint would that be considered a Wagner grade 1 or grade 2?

        Reply
        • Holly Hingle says

          January 6, 2019 at 2:27 am

          Alex,

          You can use this resource for more information and illustrations http://nhafp.org/pdf/intro-to-wound-care.pdf

          Reply
  8. Christine Wells says

    May 21, 2019 at 1:50 pm

    Is anybody aware of any licensing for the Wagner Diabetic Foot Ulcer Grade Classification System?

    Reply
  9. Gloria says

    April 30, 2020 at 4:15 am

    Thank you.. I found this information very valuable. Thank you

    Reply
  10. Lisa Woolery says

    June 8, 2020 at 7:07 am

    Are non-pressure ulcers “reverse-graded” as they heal – or are they reported at their deepest like pressure ulcers?

    Reply
  11. amir says

    February 1, 2022 at 3:33 pm

    i am doing research on diabetic foot ulcers dressings.I want to compare between papya dressing and povidone 10 % dressing.i need a criteria to declare diabetioc foot ulcer is healed .which is practical and can be documented .
    regards
    Dr amir rasool
    [email protected]

    Reply
    • WoundEducators.com says

      February 2, 2022 at 2:15 pm

      Hey Dr. Amir- our best recommendation would be to get the assistance of a wound certified professional in your area. You can find one through the ABWM’s website directory. Best of luck!

      Reply

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