The Photo Rounds article (“A disfigured foot with ulcer,” May 2008) depicting an ulcer on a rocker bottom foot of a woman with diabetes caught my attention.1 As a wound care physician, I would suggest the better staging system for diabetic leg and foot conditions would be the Wagner grading system, with the following categories:
| Grade 0: | Pre-ulcerative lesions; healed ulcers; presence of bony deformity |
| Grade 1: | Superficial ulcer without subcutaneous tissue involvement |
| Grade 2: | Penetration through the subcutaneous tissue: may expose bone, tendon, ligament, or joint capsule |
| Grade 3: | Osteitis, abscess, osteomyelitis |
| Grade 4: | Gangrene of digit |
| Grade 5: | Gangrene of the foot requiring disarticulation. |
Using the Wagner system, the stage of the pictured pressure ulcer would be a Grade 2 diabetic ulceration.
Suellywn Stewart, MD,
Clinical Assistant Professor
Family Medicine, The Ohio State University Primary
Care Network, The Ohio State University
Comprehensive Wound Center
Suellywn.Stewart@osumc.edu
Reference
1. Grace SM, Stulberg DL. A disfigured foot with ulcer. J Fam Pract. 2008;57:321-324.
Dr. Stulberg responds
My thanks to Dr. Stewart for the input. Pressure ulcers—and this article was intended to be an aid for the treatment of pressure ulcers in general—are most commonly “staged.” Podiatrists commonly utilize the Wagner grading system for diabetic foot ulcers. As outlined by Dr. Stewart, the Wagner system is more useful for the surgical foot.
Other diabetic foot classifications are available, including the University of Texas San Antonio wound classification and the Infectious Diseases Society of America’s diabetic foot infection classification system.1,2 I double-checked with one of our wound care specialists, who noted that they do not typically use the Wagner classification, but find a descriptive assessment to be more useful for diabetic ulcers.
Using the Wagner grading system (reportedly derived from Meggitt’s work)3 would be useful in the locales and fields that utilize that system as their option among other systems of nomenclature.
In hospital and long-term care settings where I have worked, and in terms of pressure ulcer management, the staging system developed by the National Pressure Ulcer Advisory Panel is what we have used for pressure ulcers in general.
Daniel L. Stulberg, MD, FAAFP
Associate Professor,
Department of Family and Community Medicine, University of New Mexico