Assessment, classification, staging and intervention

Abstract

The approach to the diabetic foot consists of four simple steps: assessment, classification, staging and intervention. A simple assessment of the diabetic foot is described so that it is possible to classify and stage the foot, looking for eight clinical features, namely skin breakdown, infection, necrosis, ischaemia, neuropathy, deformity, callus and oedema. The diabetic foot can be classified into two groups: (1) the neuropathic foot with palpable pulses and (2) the ischaemic foot without pulses and a varying degree of neuropathy. The neuropathic foot may be further divided into two clinical scenarios: (1) foot with neuropathic ulceration (2) Charcot foot, which may be secondarily complicated by ulceration. The ischaemic foot may be divided into three clinical scenarios: (1) neuroischaemic foot characterised by both ischaemia and neuropathy and complicated by ulcer, (2) critically ischaemic foot, (3) acutely ischaemic foot. Each of these five main clinical scenarios (two neuropathic and three ischaemic) are characterised by having specific stages in their natural history. These stages have been described in a Simple Staging System. The stages are (1) Normal foot, (2) High risk foot, (3) Ulcerated foot, (4) Threatened foot, (5) Necrotic foot, (6) Unsalvageable foot. Intervention should achieve: wound control, microbiological control, vascular control, mechanical control, metabolic control and educational control.