There are a number of classifications of the severity of diabetic ulcers. These were reviewed by Strauss (2005), although this was in the context of demonstrating the need for yet another score. Most scores are based on size, site and depth of ulcer, degree of contamination and the presence of deep infection and ischaemia. Probably the most popular wound score, and the one most likely to be asked in exams, is that described by Meggitt (1976) and Wagner (1982):
- grade 0 - intact skin
- grade 1 - superficial ulcer
- grade 2 - deep ulcer to tendon, bone or joint
- grade 3 - deep ulcer with abscess or osteomyelitis
- grade 4 - forefoot gangrene
- grade 5 - whole foot gangrene
Note that infection only enters at grade 3 and ischaemia at grade 4.
Superficial toe ulcer
Ulcer penetrating to joint capsule
Partial forefoot gangrene
A more comprehensive scale has been developed by Armstrong and colleagues at the University of Texas, which includes risk stratification and expresses tissue breakdown, infection and gangrene separately (Lavery et al 1996). The University of Texas scale has been shown to be reproducible and to correlate with prognosis, especially risk of amputation (Armstrong et al 1998, Treece et al 2004).
- grade 0 - pre-ulcerative site, or healed ulcer.
- grade 1 - ulcer through the epidermis +/- dermis, but not to tendon, capsule or bone
- 1A without infection or ischaemia
- 1B with infection but no ischaemia
- 1C with ischaemia
- 1D with ischaemia and infection
- grade 2 - ulcer to capsule or tendon
- 2A without infection or ischaemia
- 2B with infection but no ischaemia
- 2C with ischaemia
- 2D with ischaemia and infection
- grade 2 - ulcer to bone or joint
- 3A without infection or ischaemia
- 3B with infection but no ischaemia
- 3C with ischaemia
- 3D with ischaemia and infection
Current comparative studies do not give sufficient evidence to mandate the use of one of these (or other) scores.