How are diabetic foot ulcers staged?

Updated: Oct 15, 2020
  • Author: Tanzim Khan, DPM; Chief Editor: Romesh Khardori, MD, PhD, FACP  more...
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Diabetic foot ulcers can be staged using the WIfi threatened-limb system. This system allows communication between providers and provides risk stratification for major amputation [5]

Wound classification is as follows:

  • Grade 0 – Rest pain; no wound, no ulcer, no gangrene.
  • Grade 1 – Small shallow ulcer(s) on distal leg or foot; any exposed bone is only limited to distal phalanx; no gangrene (ie, minor tissue loss: limb salvage possible with simple digital amputation [1 or 2 digits] or skin coverage)
  • Grade 2 – Deeper ulcer on distal leg or foot with exposed bone, joint, or tendon, or shallow heel ulcer without involvement of the calcaneus; gangrenous changes confined to the digits (ie, major tissue loss: salvageable with ≥3 digital amputations or standard transmetatarsal amputation [TMA] plus skin coverage)
  • Grade 3 – Extensive deep ulcer of the forefoot and/or midfoot or full-thickness heel ulcer with or without involvement of the calcaneus (ie, extensive tissue loss: salvageable only with complex foot reconstruction or nontraditional TMA [eg, Chopart or Lisfranc amputation])

Classification of Ischemia is as follows:

  • Grade 0 – ABI ≥0.8, ankle systolic pressure >100 mmHg, toe pressure (TP)/transcutaneous oxygen (TcPO2) ≥60
  • Grade 1 – ABI 0.6-0.79, ankle systolic pressure 70-100 mmHg, TP/TcPO2 40-59
  • Grade 2 – ABI 0.4-0.59, ankle systolic pressure 50-70 mmHg, TP/TcPO2 30-39
  • Grade 3 – ABI ≤0.39, ankle systolic pressure < 50 mmHg, TP/TcPO2 < 30

Classification of foot infection is as follows:

  • Grade 0 – No symptoms or signs of infection
  • Grade 1 – Infection is present, and at least two of the following are present: local swelling or induration, erythema >0.5 to ≤2 cm around ulcer, local tenderness or pain, local warmth, or purulent discharge; other causes of an inflammatory response of the skin have been excluded (eg, gout, fracture)
  • Grade 2 – Local infection is present as defined for grade 1 but extends >2 cm around ulcer or involves structures deeper than the skin and subcutaneous tissues (eg, abscess, osteomyelitis, septic arthritis, fasciitis); no clinical signs of systemic inflammatory response
  • Grade 3 – Local infection is present as defined for grade 2, but clinical signs of systemic inflammatory response are present as manifested by two or more of the following: temperature >38°C or < 36°C; heart rate >90 beats per minute, respiratory rate >20 breaths per minute or partial pressure of carbon dioxide (PaCO 2) < 32 mmHg; white blood cell count >12,000 or < 4000 (cu/mm) or 10% immature band forms present

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