LITERATURE REVIEW
Tissue Destruction Classification Systems Holly Korzendorfer, PhD, PT, CWS, FACCWS; Pamela Scarborough, DPT, MS, PT, CDE, CWS, CEEAA; and Heather Hettrick, PhD, PT, CWS, FACCWS, MLT, DAPWCA
ABSTRACT
Table 1.
Assessing the level of tissue destruction in wounds can be a confusing challenge. This important task is frequently accompanied by questions and the need for clarification to accurately classify the level of damage seen in wounds. The purpose of this article was to present several known classification systems to help clarify this issue for the clinician. KEYWORDS: tissue destruction, wound classification, wound assessment
CLASSIFICATION OF WOUND BY THICKNESS OF TISSUE DESTRUCTION Partial thickness
Extends through the epidermis (first layer of skin), but not through the dermis (second layer)
Full thickness
Extends through the epidermis and dermis; may involve subcutaneous tissue, muscles, joint capsule, bone
ADV SKIN WOUND CARE 2013;26:499Y503
INTRODUCTION As wound care clinicians are aware, accurately assessing the level of tissue destruction in wounds can be a daunting task. Several classification systems have been developed to assist the clinician; however, some systems are specific to the wound etiology. Thus, documenting the levels of tissue destruction correctly is critical for communication between clinicians. In addition, the Centers for Medicare & Medicaid Services (CMS) regulatory mandates require accurate staging for reimbursement purposes and tracking of pressure ulcers (PrUs) in the different healthcare settings. For example, the CMS requires the use of accurate staging for the MDS 3.0 M-section for the long-term-care setting, for the OASIS M-1300 section for home health, and the G-section of the upcoming C.A.R.E. tool for acute care. The purpose of this article was to help clarify how to assess the level of tissue destruction by presenting several classification systems.
Lampe KE. The general evaluation. In: McCulloch JM, Kloth LC, eds. Wound healing: evidence-based management. 4th ed. Philadelphia, PA: FA Davis Company; 2010:65-93. Photos/courtesy Holly Korzendorfer, PhD, PT, CWS, FACCWS.
descriptions in the Payne-Martin revision define each category as a partial-thickness wound. Both systems define a skin tear as ‘‘a traumatic wound occurring principally on the extremities of older adults, as a result of friction alone or shearing and friction forces, which separate the epidermis from the dermis (partial-thickness wound) or which separate both the epidermis and the dermis Table 2.
PAYNE-MARTIN CLASSIFICATION SYSTEM
ALL WOUNDS All wounds, regardless of etiology, can be assessed as either partial or full thickness (Table 1).
Category I
Category II
SKIN TEARS Among the earlier published classification systems for skin tears are the Payne-Martin Classification System (Table 2) and the STAR Classification System (Table 3). The STAR system was developed and validated in Australia in 2006, whereas the Payne-Martin system was published in 1990 and revised in 1993. The expanded
Category III
Skin tears without tissue loss Linear type (no tissue loss, resembles an incision) Flap type (epidermal flap covers the dermis to within 1 mm of skin tear edge) Skin tears with partial tissue loss Scant tissue loss type (e25% epidermal flap lost, covers 975% of the dermis) Moderate to large tissue loss type (Q25% epidermal flap lost, 925% dermis exposed) Skin tears with complete tissue loss
Adapted from Payne and Martin.1 Used with permission.
Holly Korzendorfer, PhD, PT, CWS, FACCWS, is Vice President of Business and Clinical Development at DermaRite Industries, LLC, Paterson, New Jersey. Pamela Scarborough, DPT, MS, PT, CDE, CWS, CEEAA, is Director of Public Policy and Education at American Medical Technologies, Irvine, California. Heather Hettrick, PhD, PT, CWS, FACCWS, MLT, DAPWCA, is Associate Professor at Nova Southeastern University, Ft. Lauderdale, Florida. The authors have disclosed they have no financial relationships related to this article. Submitted January 18, 2012; accepted March 1, 2012. WWW.WOUNDCAREJOURNAL.COM
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LITERATURE REVIEW
ment, and treatment of skin tears and included the Payne-Martin and STAR systems.
Table 3.
STAR SKIN TEAR CLASSIFICATION SYSTEM Category 1a
Category 1b
Category 2a
Category 2b
A skin tear where the edges can be realigned to the normal anatomical position (without undue stretching) and the skin or flap color is not pale, dusky, or darkened. A skin tear where the edges can be realigned to the normal anatomical position (without undue stretching) and the skin or flap color is pale, dusky, or darkened. A skin tear where the edges cannot be realigned to the normal anatomical position and the skin or flap color is not pale, dusky, or darkened. A skin tear where the edges cannot be realigned to the normal anatomical position and the skin or flap color is pale, dusky, or darkened.
PRESSURE ULCERS Pressure ulcers are most commonly classified according to the staging guidelines from the National Pressure Ulcer Advisory Panel (Table 4). The guidelines were designed uniquely for PrUs and should not be used for wounds of other etiologies.
DIABETIC FOOT ULCERS
Carville K, Lewin G, Newall N, et al. STAR: a consensus for skin tear classification. Primary Intention 2007;15(1):18-28. Reproduced with permission.
from underlying structures (full-thickness wound).’’1,2 However to date, neither system is widely used in practice despite the need for standardized assessment language. More recently, LeBlanc et al3 published an International Skin Tear Advisory Panel Skin Tear Classification System (Figure 1). In 2011, LeBlanc and Baranoski2 also published comprehensive consensus statements relating to the prevention, prediction, assess-
There are 2 commonly accepted classification systems for diabetic foot ulcers that were developed to guide future surgical treatment and protocols. The Wagner scale, which was developed first, incorporates depth, presence of cellulitis/abscess formation/ osteomyelitis, and aspects of arterial circulation by assessing gangrene levels. The scale includes grades and their descriptions, such as Grade 0: preulcerous lesion, healed ulcer, bony deformity; Grade 1: superficial ulcer without subcutaneous tissue involvement; Grade 2: Deep ulcer, penetration through the subcutaneous tissue (may have exposed bone, tendon, or ligament or joint capsule); Grade 3: deep ulcer with cellulitis, abscess formation, or osteomyelitis; Grade 4: localized gangrene of digit; and Grade 5:
Figure 1. ISTAP SKIN TEAR CLASSIFICATION
Source: Leblanc et al.3 Reprinted with permission. ADVANCES IN SKIN & WOUND CARE & VOL. 26 NO. 11
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LITERATURE REVIEW
Table 4.
NATIONAL PRESSURE ULCER ADVISORY PANEL STAGING ILLUSTRATIONS AND DEFINITIONS Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. Further description: The area may be painful, firm, soft, warmer, or cooler as compared with adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones; may indicate ‘‘at risk’’ persons (a heralding sign of risk).
Category/Stage I: Nonblanchable Erythema Partial-thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Further description: Presents as a shiny or dry shallow ulcer without slough or bruising. *This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration, or excoriation. *Bruising indicates suspected deep tissue injury. Category/Stage II Full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Further description: The depth of a Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus does not have subcutaneous tissue and Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Stage III pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage III Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. Further description: The depth of a Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus does not have subcutaneous tissue, and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (eg, fascia, tendon, or joint capsule), making osteomyelitis possible. Category/Stage IV Full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed. Further description: Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as ‘‘the body’s natural (biological) cover’’ and should not be removed. Unstageable Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared with adjacent tissue. Further description: Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. Suspected Deep Tissue Injury *National Pressure Ulcer Advisory Panel, 2007. Used with permission.
extensive gangrene involving whole foot.4 Use of the Wagner scale is required for reimbursement by some managed care insurance companies and Medicare when billing for the management of diabetic foot wounds. The University of Texas system stages diabetic foot wounds based on the depth of the ulcer and whether the wound is inWWW.WOUNDCAREJOURNAL.COM
fected, ischemic, or both. This system uses both grades and classes to distinguish these types of wounds.5
VENOUS ULCERS The CEAP (Clinical-Etiology-Anatomy-Pathophysiology) Classification (Table 5) of venous ulcer disease is a consensus statement,
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LITERATURE REVIEW
Table 5.
CEAP CLASSIFICATION Class
Descriptors
CVClinical signs 6 Grades, supplemented by (S) for symptomatic or (A) for asymptomatic presentation Symptoms: Pain, aching, tightness, skin irritation, heaviness, muscle cramps, or other complaints due to venous dysfunction Example: C3A
C0: No visible or palpable signs of venous disease C1: Telangiectasias or reticular veins C2: Varicose veins; distinguished from reticular veins by having Q3-mm diameter C3: Edema C4: Changes in skin and subcutaneous tissue C4a: Pigmentation or eczema C4b: Lipodermatosclerosis or atrophie blanche C5: Healed venous ulcer C6: Active venous ulcer Ec: Congenital Ep: Primary Es: Secondary (postthrombotic) En: No venous cause identified As: Superficial veins Ap: Perforator veins Ad: Deep veins An: No venous location identified Pr: Reflux Po: Obstruction Pr,o: Reflux and obstruction Pn: No venous pathophysiology identifiable
EVEtiologic factors
AVAnatomic distribution
PVPathophysiologic dysfunction
Eklo¨f B, Rutherford RB, Bergan JJ, et al. Revision of the CEAP classification for chronic venous disorders: consensus statement. J Vasc Surg 2004;40:1248-52. Sibbald RG, Williamson D, Contreras-Ruiz J, et al. Venous leg ulcers. In: Krasner DL, Rodeheaver GT, Sibbald RG, eds. Chronic Wound Care: A Clinical Source Book for Healthcare Professionals. 4th ed. Malvern, PA: HMP Communications; 2007:429-42.
of which the C, or clinical signs component, is most frequently used. The C is based on examination, whereas the other components (E, A, P) require noninvasive vascular testing. The venous clinical severity score (Table 6) augments the CEAP classification by assessing a patient’s health-related quality of life as a result of the symptoms of chronic venous insuf-
ficiency. Scoring is based on 10 clinical attributes that are ranked from 0 to 3.
PERIPHERAL ARTERY DISEASE There are 2 classification methods by which peripheral artery disease (PAD) is clinically classified. The Fontaine classification (Table 7)
Table 6.
VENOUS CLINICAL SEVERITY SCORE (VCSS) Attribute
Absent = 0
Mild = 1
Moderate = 2
Severe = 3
Pain
None
Varicose veins
None
Occasional, not restricting activity or requiring pain medication Few scattered
Venous edema
None
Evening ankle swelling
Daily moderate activity limitation; occasional pain medication Multiple; great saphenous veins, confined to calf and thigh Afternoon swelling, above ankle
Skin pigmentation
None
Daily, severe, limiting activities or requiring regular use of pain medication Extensive: thigh and calf or great and small saphenous distribution Morning swelling above ankle and requiring activity change, elevation Wider distribution (above lower third) plus recent pigmentation Severe cellulitis (lower third and above) or significant Entire lower third of leg or more 92 Not healed 91 y 96 cm Full compliance, stockings + elevation
Inflammation Induration No. of active ulcers Active ulcer duration Active ulcer diameter Compression therapy
Diffuse, but limited in area and old (brown) None Mild cellulitis, limited to marginal area around ulcer None Focal, circummalleolar 0 1 None G3 mo None G2 cm Not used or patient Intermittent use of stockings not compliant
Diffuse over most of gaiter distribution (lower third) or recent pigmentation (purple) Moderate cellulitis, involves most of gaiter (lower third) Medial or lateral, less than lower third of leg 2 93 mo, G1 y 2-6 cm Wears elastic stocking most days
Ricci MA, Emmerich J, Callas PW, et al. Evaluating chronic venous disease with a new venous severity scoring system. J Vasc Surg 2003;38:909-15. Used with permission. https://openaccess. leidenuniv.nl/bitstream/1887/1578/1/303_071.pdf. Last accessed June 11, 2013. (For complete description, see reference Rutherford RB, Padberg FT, Comerota AJ, Kistner RL, Meissner MH, Moneta GL. Venous severity scoring [an adjunct to venous outcome assessment]. J Vasc Surg 2000;31:1307-12).
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Table 7.
FONTAINE CLASSIFICATION FOR PAD Stage I
Stage II
Stage III
Stage IV
Asymptomatic Of note: Fontaine Stage I does, in fact, describe patients who are for the most part asymptomatic. Careful history may actually reveal subtle and nonspecific symptoms such as paresthesias. Physical examination may reveal cold extremities and other signs of ‘‘subclinical’’ peripheral artery disease. More examples include bruits over blood vessels and lack of normal pulses. Intermittent claudication This stage takes into account the fact that patients usually have a very constant distance at which they have pain: Stage IIaVIntermittent claudication after 9200 m of pain-free walking. Stage IIbVIntermittent claudication after G200 m of walking Rest pain Rest pain is especially troubling for patients during the night. The reason for this is 2-fold: First, the legs are usually raised up on to a bed at night, thus diminishing the positive effect gravity may have had during the day when the legs were dependent. Second, during the night, the lack of sensory stimuli allows patients to focus on their legs. Ischemic ulcers or gangrene (which may be dry or humid).
Adapted with permission from Weinberg I. Fontaine Classification. http://www.angiologist.com/arterial-disease/fontaine-classification.
is useful for research purposes, and the Rutherford classification (Table 8) is commonly used in the clinical setting.
SUMMARY This article presented the most common classification system for all wounds in general, and specifically for skin tears, PrUs,
diabetic foot ulcers, venous ulcers, and arterial ulcers in order to improve awareness for clinicians treating chronic wounds. Understanding wound classification by depth of tissue destruction of various wound types is important for developing treatment plans and clear communication among medical professionals caring for individuals with wounds.
&
Table 8.
RUTHERFORD CLASSIFICATION FOR PAD Stage 0 Stage 1 Stage 2
Stage Stage Stage Stage
3 4 5 6
Asymptomatic Mild claudication Moderate claudication The distance that delineates mild, moderate, and severe claudication is not specified in the Rutherford classification, but is mentioned in the Fontaine classification as 200 m. Severe claudication Rest pain Ischemic ulceration not exceeding ulcer of the digits of the foot Severe ischemic ulcers or frank gangrene
Adapted with permission from Weiner I. Rutherford Classification. http://www.angiologist. com/arterial-disease/rutherford-classification.
REFERENCES 1. Payne RL, Martin ML. Defining and classifying skin tears: need for a common language. Ostomy Wound Manage 1993;39(5):16-26. 2. LeBlanc K, Baranoski S. Skin tears: state of the science: consensus statements for the prevention, prediction, assessment, and treatment of skin tears. Adv Skin Wound Care 2011; 24(9)(Suppl 1):2-15. 3. LeBlanc K, Baranoski S, Holloway S, Langemo D. Validation of a new classification system for skin tears. Adv Skin Wound Care 2013;26:263-5. 4. Wagner FW. The dysvascular foot: a system for diagnosis and treatment. Foot Ankle 1981; 2(2):64-122. 5. Armstrong DG, Lavery LA, Harkless LB. Validation of a diabetic wound classification system. Diabetes Care 1998;21(5):855-8.
CALL FOR PAPERS Advances in
SKIN& ® WOUND CARE
Advances in Skin & Wound Care is soliciting manuscripts on a variety of topics, including original investigations, clinical concepts, and literature reviews. Consult the journal’s Web site, www.woundcarejournal.com, for the Author Guidelines.
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Tissue Destruction Classification Systems Holly Korzendorfer, PhD, PT, CWS, FACCWS; Pamela Scarborough, DPT, MS, PT, CDE, CWS, CEEAA; and Heather Hettrick, PhD, PT, CWS, FACCWS, MLT, DAPWCA
ABSTRACT
Table 1.
Assessing the level of tissue destruction in wounds can be a confusing challenge. This important task is frequently accompanied by questions and the need for clarification to accurately classify the level of damage seen in wounds. The purpose of this article was to present several known classification systems to help clarify this issue for the clinician. KEYWORDS: tissue destruction, wound classification, wound assessment
CLASSIFICATION OF WOUND BY THICKNESS OF TISSUE DESTRUCTION Partial thickness
Extends through the epidermis (first layer of skin), but not through the dermis (second layer)
Full thickness
Extends through the epidermis and dermis; may involve subcutaneous tissue, muscles, joint capsule, bone
ADV SKIN WOUND CARE 2013;26:499Y503
INTRODUCTION As wound care clinicians are aware, accurately assessing the level of tissue destruction in wounds can be a daunting task. Several classification systems have been developed to assist the clinician; however, some systems are specific to the wound etiology. Thus, documenting the levels of tissue destruction correctly is critical for communication between clinicians. In addition, the Centers for Medicare & Medicaid Services (CMS) regulatory mandates require accurate staging for reimbursement purposes and tracking of pressure ulcers (PrUs) in the different healthcare settings. For example, the CMS requires the use of accurate staging for the MDS 3.0 M-section for the long-term-care setting, for the OASIS M-1300 section for home health, and the G-section of the upcoming C.A.R.E. tool for acute care. The purpose of this article was to help clarify how to assess the level of tissue destruction by presenting several classification systems.
Lampe KE. The general evaluation. In: McCulloch JM, Kloth LC, eds. Wound healing: evidence-based management. 4th ed. Philadelphia, PA: FA Davis Company; 2010:65-93. Photos/courtesy Holly Korzendorfer, PhD, PT, CWS, FACCWS.
descriptions in the Payne-Martin revision define each category as a partial-thickness wound. Both systems define a skin tear as ‘‘a traumatic wound occurring principally on the extremities of older adults, as a result of friction alone or shearing and friction forces, which separate the epidermis from the dermis (partial-thickness wound) or which separate both the epidermis and the dermis Table 2.
PAYNE-MARTIN CLASSIFICATION SYSTEM
ALL WOUNDS All wounds, regardless of etiology, can be assessed as either partial or full thickness (Table 1).
Category I
Category II
SKIN TEARS Among the earlier published classification systems for skin tears are the Payne-Martin Classification System (Table 2) and the STAR Classification System (Table 3). The STAR system was developed and validated in Australia in 2006, whereas the Payne-Martin system was published in 1990 and revised in 1993. The expanded
Category III
Skin tears without tissue loss Linear type (no tissue loss, resembles an incision) Flap type (epidermal flap covers the dermis to within 1 mm of skin tear edge) Skin tears with partial tissue loss Scant tissue loss type (e25% epidermal flap lost, covers 975% of the dermis) Moderate to large tissue loss type (Q25% epidermal flap lost, 925% dermis exposed) Skin tears with complete tissue loss
Adapted from Payne and Martin.1 Used with permission.
Holly Korzendorfer, PhD, PT, CWS, FACCWS, is Vice President of Business and Clinical Development at DermaRite Industries, LLC, Paterson, New Jersey. Pamela Scarborough, DPT, MS, PT, CDE, CWS, CEEAA, is Director of Public Policy and Education at American Medical Technologies, Irvine, California. Heather Hettrick, PhD, PT, CWS, FACCWS, MLT, DAPWCA, is Associate Professor at Nova Southeastern University, Ft. Lauderdale, Florida. The authors have disclosed they have no financial relationships related to this article. Submitted January 18, 2012; accepted March 1, 2012. WWW.WOUNDCAREJOURNAL.COM
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LITERATURE REVIEW
ment, and treatment of skin tears and included the Payne-Martin and STAR systems.
Table 3.
STAR SKIN TEAR CLASSIFICATION SYSTEM Category 1a
Category 1b
Category 2a
Category 2b
A skin tear where the edges can be realigned to the normal anatomical position (without undue stretching) and the skin or flap color is not pale, dusky, or darkened. A skin tear where the edges can be realigned to the normal anatomical position (without undue stretching) and the skin or flap color is pale, dusky, or darkened. A skin tear where the edges cannot be realigned to the normal anatomical position and the skin or flap color is not pale, dusky, or darkened. A skin tear where the edges cannot be realigned to the normal anatomical position and the skin or flap color is pale, dusky, or darkened.
PRESSURE ULCERS Pressure ulcers are most commonly classified according to the staging guidelines from the National Pressure Ulcer Advisory Panel (Table 4). The guidelines were designed uniquely for PrUs and should not be used for wounds of other etiologies.
DIABETIC FOOT ULCERS
Carville K, Lewin G, Newall N, et al. STAR: a consensus for skin tear classification. Primary Intention 2007;15(1):18-28. Reproduced with permission.
from underlying structures (full-thickness wound).’’1,2 However to date, neither system is widely used in practice despite the need for standardized assessment language. More recently, LeBlanc et al3 published an International Skin Tear Advisory Panel Skin Tear Classification System (Figure 1). In 2011, LeBlanc and Baranoski2 also published comprehensive consensus statements relating to the prevention, prediction, assess-
There are 2 commonly accepted classification systems for diabetic foot ulcers that were developed to guide future surgical treatment and protocols. The Wagner scale, which was developed first, incorporates depth, presence of cellulitis/abscess formation/ osteomyelitis, and aspects of arterial circulation by assessing gangrene levels. The scale includes grades and their descriptions, such as Grade 0: preulcerous lesion, healed ulcer, bony deformity; Grade 1: superficial ulcer without subcutaneous tissue involvement; Grade 2: Deep ulcer, penetration through the subcutaneous tissue (may have exposed bone, tendon, or ligament or joint capsule); Grade 3: deep ulcer with cellulitis, abscess formation, or osteomyelitis; Grade 4: localized gangrene of digit; and Grade 5:
Figure 1. ISTAP SKIN TEAR CLASSIFICATION
Source: Leblanc et al.3 Reprinted with permission. ADVANCES IN SKIN & WOUND CARE & VOL. 26 NO. 11
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Table 4.
NATIONAL PRESSURE ULCER ADVISORY PANEL STAGING ILLUSTRATIONS AND DEFINITIONS Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. Further description: The area may be painful, firm, soft, warmer, or cooler as compared with adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones; may indicate ‘‘at risk’’ persons (a heralding sign of risk).
Category/Stage I: Nonblanchable Erythema Partial-thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Further description: Presents as a shiny or dry shallow ulcer without slough or bruising. *This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration, or excoriation. *Bruising indicates suspected deep tissue injury. Category/Stage II Full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Further description: The depth of a Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus does not have subcutaneous tissue and Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Stage III pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage III Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. Further description: The depth of a Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus does not have subcutaneous tissue, and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (eg, fascia, tendon, or joint capsule), making osteomyelitis possible. Category/Stage IV Full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed. Further description: Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as ‘‘the body’s natural (biological) cover’’ and should not be removed. Unstageable Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared with adjacent tissue. Further description: Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. Suspected Deep Tissue Injury *National Pressure Ulcer Advisory Panel, 2007. Used with permission.
extensive gangrene involving whole foot.4 Use of the Wagner scale is required for reimbursement by some managed care insurance companies and Medicare when billing for the management of diabetic foot wounds. The University of Texas system stages diabetic foot wounds based on the depth of the ulcer and whether the wound is inWWW.WOUNDCAREJOURNAL.COM
fected, ischemic, or both. This system uses both grades and classes to distinguish these types of wounds.5
VENOUS ULCERS The CEAP (Clinical-Etiology-Anatomy-Pathophysiology) Classification (Table 5) of venous ulcer disease is a consensus statement,
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LITERATURE REVIEW
Table 5.
CEAP CLASSIFICATION Class
Descriptors
CVClinical signs 6 Grades, supplemented by (S) for symptomatic or (A) for asymptomatic presentation Symptoms: Pain, aching, tightness, skin irritation, heaviness, muscle cramps, or other complaints due to venous dysfunction Example: C3A
C0: No visible or palpable signs of venous disease C1: Telangiectasias or reticular veins C2: Varicose veins; distinguished from reticular veins by having Q3-mm diameter C3: Edema C4: Changes in skin and subcutaneous tissue C4a: Pigmentation or eczema C4b: Lipodermatosclerosis or atrophie blanche C5: Healed venous ulcer C6: Active venous ulcer Ec: Congenital Ep: Primary Es: Secondary (postthrombotic) En: No venous cause identified As: Superficial veins Ap: Perforator veins Ad: Deep veins An: No venous location identified Pr: Reflux Po: Obstruction Pr,o: Reflux and obstruction Pn: No venous pathophysiology identifiable
EVEtiologic factors
AVAnatomic distribution
PVPathophysiologic dysfunction
Eklo¨f B, Rutherford RB, Bergan JJ, et al. Revision of the CEAP classification for chronic venous disorders: consensus statement. J Vasc Surg 2004;40:1248-52. Sibbald RG, Williamson D, Contreras-Ruiz J, et al. Venous leg ulcers. In: Krasner DL, Rodeheaver GT, Sibbald RG, eds. Chronic Wound Care: A Clinical Source Book for Healthcare Professionals. 4th ed. Malvern, PA: HMP Communications; 2007:429-42.
of which the C, or clinical signs component, is most frequently used. The C is based on examination, whereas the other components (E, A, P) require noninvasive vascular testing. The venous clinical severity score (Table 6) augments the CEAP classification by assessing a patient’s health-related quality of life as a result of the symptoms of chronic venous insuf-
ficiency. Scoring is based on 10 clinical attributes that are ranked from 0 to 3.
PERIPHERAL ARTERY DISEASE There are 2 classification methods by which peripheral artery disease (PAD) is clinically classified. The Fontaine classification (Table 7)
Table 6.
VENOUS CLINICAL SEVERITY SCORE (VCSS) Attribute
Absent = 0
Mild = 1
Moderate = 2
Severe = 3
Pain
None
Varicose veins
None
Occasional, not restricting activity or requiring pain medication Few scattered
Venous edema
None
Evening ankle swelling
Daily moderate activity limitation; occasional pain medication Multiple; great saphenous veins, confined to calf and thigh Afternoon swelling, above ankle
Skin pigmentation
None
Daily, severe, limiting activities or requiring regular use of pain medication Extensive: thigh and calf or great and small saphenous distribution Morning swelling above ankle and requiring activity change, elevation Wider distribution (above lower third) plus recent pigmentation Severe cellulitis (lower third and above) or significant Entire lower third of leg or more 92 Not healed 91 y 96 cm Full compliance, stockings + elevation
Inflammation Induration No. of active ulcers Active ulcer duration Active ulcer diameter Compression therapy
Diffuse, but limited in area and old (brown) None Mild cellulitis, limited to marginal area around ulcer None Focal, circummalleolar 0 1 None G3 mo None G2 cm Not used or patient Intermittent use of stockings not compliant
Diffuse over most of gaiter distribution (lower third) or recent pigmentation (purple) Moderate cellulitis, involves most of gaiter (lower third) Medial or lateral, less than lower third of leg 2 93 mo, G1 y 2-6 cm Wears elastic stocking most days
Ricci MA, Emmerich J, Callas PW, et al. Evaluating chronic venous disease with a new venous severity scoring system. J Vasc Surg 2003;38:909-15. Used with permission. https://openaccess. leidenuniv.nl/bitstream/1887/1578/1/303_071.pdf. Last accessed June 11, 2013. (For complete description, see reference Rutherford RB, Padberg FT, Comerota AJ, Kistner RL, Meissner MH, Moneta GL. Venous severity scoring [an adjunct to venous outcome assessment]. J Vasc Surg 2000;31:1307-12).
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LITERATURE REVIEW
Table 7.
FONTAINE CLASSIFICATION FOR PAD Stage I
Stage II
Stage III
Stage IV
Asymptomatic Of note: Fontaine Stage I does, in fact, describe patients who are for the most part asymptomatic. Careful history may actually reveal subtle and nonspecific symptoms such as paresthesias. Physical examination may reveal cold extremities and other signs of ‘‘subclinical’’ peripheral artery disease. More examples include bruits over blood vessels and lack of normal pulses. Intermittent claudication This stage takes into account the fact that patients usually have a very constant distance at which they have pain: Stage IIaVIntermittent claudication after 9200 m of pain-free walking. Stage IIbVIntermittent claudication after G200 m of walking Rest pain Rest pain is especially troubling for patients during the night. The reason for this is 2-fold: First, the legs are usually raised up on to a bed at night, thus diminishing the positive effect gravity may have had during the day when the legs were dependent. Second, during the night, the lack of sensory stimuli allows patients to focus on their legs. Ischemic ulcers or gangrene (which may be dry or humid).
Adapted with permission from Weinberg I. Fontaine Classification. http://www.angiologist.com/arterial-disease/fontaine-classification.
is useful for research purposes, and the Rutherford classification (Table 8) is commonly used in the clinical setting.
SUMMARY This article presented the most common classification system for all wounds in general, and specifically for skin tears, PrUs,
diabetic foot ulcers, venous ulcers, and arterial ulcers in order to improve awareness for clinicians treating chronic wounds. Understanding wound classification by depth of tissue destruction of various wound types is important for developing treatment plans and clear communication among medical professionals caring for individuals with wounds.
&
Table 8.
RUTHERFORD CLASSIFICATION FOR PAD Stage 0 Stage 1 Stage 2
Stage Stage Stage Stage
3 4 5 6
Asymptomatic Mild claudication Moderate claudication The distance that delineates mild, moderate, and severe claudication is not specified in the Rutherford classification, but is mentioned in the Fontaine classification as 200 m. Severe claudication Rest pain Ischemic ulceration not exceeding ulcer of the digits of the foot Severe ischemic ulcers or frank gangrene
Adapted with permission from Weiner I. Rutherford Classification. http://www.angiologist. com/arterial-disease/rutherford-classification.
REFERENCES 1. Payne RL, Martin ML. Defining and classifying skin tears: need for a common language. Ostomy Wound Manage 1993;39(5):16-26. 2. LeBlanc K, Baranoski S. Skin tears: state of the science: consensus statements for the prevention, prediction, assessment, and treatment of skin tears. Adv Skin Wound Care 2011; 24(9)(Suppl 1):2-15. 3. LeBlanc K, Baranoski S, Holloway S, Langemo D. Validation of a new classification system for skin tears. Adv Skin Wound Care 2013;26:263-5. 4. Wagner FW. The dysvascular foot: a system for diagnosis and treatment. Foot Ankle 1981; 2(2):64-122. 5. Armstrong DG, Lavery LA, Harkless LB. Validation of a diabetic wound classification system. Diabetes Care 1998;21(5):855-8.
CALL FOR PAPERS Advances in
SKIN& ® WOUND CARE
Advances in Skin & Wound Care is soliciting manuscripts on a variety of topics, including original investigations, clinical concepts, and literature reviews. Consult the journal’s Web site, www.woundcarejournal.com, for the Author Guidelines.
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