Diabetic foot ulcers: Classification, risk factors and management

Table 1 Wagner classification system

Grade	Ulcer depth
0	Pre-ulcerative area without open lesion
1	Superficial ulcer (partial/full thickness)
2	Ulcer creep to tendon, capsule, bone
3	Stage 2 with abscess, osteomyelitis, or joint sepsis
4	Localized gangrene
5	Global foot gangrene

Table 2 University of Texas classification system[21]

	Grade 0	Grade 1	Grade 2	Grade 3
	Pre- or post- ulcerative site	Superficial wound not involving tendon, capsule, or bone	Wound penetrating to tendon or capsule	Ulcer penetrating to bone of joint
Lesions without infection or ischemia
Infected/non-ischemic lesions
Ischemic noninfected lesions
Ischemic infected lesions

Table 3 Size (area, depth), sepsis, arteriopathy, denervation system

Grade	Size
	Area	Depth	Sepsis	Arteriopathy	Denervation
0	Skin intact	Skin intact	None	Pedal pulses present	Pin pricks intact
1	< 1 cm2	Superficial (skin and subcutaneous tissue)	Surface	Pedal pulses reduced or one missing	Pin pricks reduced
2	1-3 cm2	Tendon, periosteum, joint capsule	Cellulitis	Absence of both pedal pulses	Pin pricks absent
3	> 3 cm2	Bone or joint space	Osteomyelitis	Gangrene	Charcot

Table 4 Site, ischemia, neuropathy, bacterial infection, area, depth system[13]

Category	Definition	Score
Site	Forefoot	0
	Midfoot and hindfoot	1
Ischemia	Pedal blood flow intact: At least one palpable pulse	0
	Clinical evidence of reduced pedal flow	1
Neuropathy	Protective sensation intact	0
	Protective sensation lost	1
Bacterial infection	None	0
	Present	1
Area	Ulcer < 1 cm2	0
	Ulcer ≥ 1 cm2	1
Depth	Ulcer confined to skin and subcutaneous tissue	0
	Ulcer reaching muscle, tendon or deeper	1
Total possible score		6

Table 5 Wound, Ischemia, and foot Infection system

Grade	Wound	Ischemia			Foot infection system
	Clinical features	ABI (mmHg)	ASP (mmHg)	Toe pressure, TcPO2 (mmHg)	Clinical manifestations
0	No ulcer no gangrene	≥ 0.80	> 100	≥ 60	No symptoms or signs of infection. Infection present, as defined by the presence of at least two of the following items: (1) Local swelling or induration; (2) Erythema 0.5 cm-2 cm around the ulcer; (3) Local tenderness or pain; (4) Local warmth; and (5) Purulent discharge (thick, opaque to white, or sanguineous secretion)
1	Small, shallow ulcer(s) on the distal leg or foot; no exposed bone, unless limited to the distal phalanx	0.6-0.79	70-100	40-59	Local infection involving only the skin and the subcutaneous tissue exclude other causes of an inflammatory response of the skin (e.g., trauma, gout, acute Charcot neuro-osteoarthropathy, fracture, thrombosis, and venous stasis)
2	Deeper ulcer with exposed bone, joint, or tendon generally not involving the heel; shallow heel ulcer without calcaneal involvement, gangrenous changes limited to digits	0.4-0.59	50-70	30-39	Local infection with erythema > 2 cm, or involving structures deeper than skin and subcutaneous tissues (e.g., abscess, osteomyelitis, septic arthritis, and fasciitis), and no systemic inflammatory response signs
3	Extensive, deep ulcers involving forefoot and/or midfoot; deep, full-thickness heel ulcers with or without calcaneal involvement, extensive gangrene involving the forefoot and/or midfoot; full-thickness heel necrosis with calcaneal involvement	≥ 0.39	< 50	< 30	Local infection with signs of SIRS, as manifested by two or more of the following: (1) Temperature > 38 °C or < 36 °C; (2) Heart rate > 90 beats/min; (3) Respiratory rate > 20 breaths/min or PaCO2 < 32 mmHg; and (4) White blood cell count > 12000 or < 4000 cu/mm or 10% immature bands

ABI: Ankle-brachial index; ASP: Ankle systolic pressure; TcPO2: Transcutaneous oxygen pressure; SIRS: Systemic inflammatory response syndrome.