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A better staging system for pressure ulcers.

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.


(1.) Grace SM, Stulberg DL. A disfigured foot with ulcer. J Fam Pract. 2008;57:321-324.

Suellywn Stewart, MD, Clinical Assistant Professor

Family Medicine, The Ohio State University Primary Care Network, The Ohio State University Comprehensive Wound Center

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.


(1.) Oyibo SO, Jude EB, Tarawneh I, Nguyen HC, Harkless LB, Boulton AJM. A comparison of two diabetic foot ulcer classification systems. The Wagner and the University of Texas wound classification systems. Diabetes Care. 2001;24:84-88.

(2.) Lavery LA, Armstrong DG, Murdoch DP, Peters EJG, Lipsky BA. Validation of the Infectious Diseases Society of America's diabetic foot infection classification system. Clin Infect Dis. 2007;44:562-565.

(3.) Smith RG. Validation of Wagner's classification: a literature review. Ostomy Wound Manage. 2003;49:54-62.

Daniel L. Stulberg, MD, FAAFP

Associate Professor, Department of Family and Community Medicine, University of New Mexico


The Wagner grading system is more useful for the surgical foot

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Title Annotation:LETTERS
Author:Stewart, Suellywn; Stulberg, Daniel L.
Publication:Journal of Family Practice
Article Type:Letter to the editor
Date:Jul 1, 2008
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