An Unusual Presentation of Deep Tissue Injury, Do We Really Understand It?

A Case Report and Literature Review

Walid Mari, MD; Sara Younes, MD; Richard Simman, MD, FACS, FACCWS


Wounds. 2017;29(5):E32-E35. 

In This Article

Abstract and Introduction


Deep tissue injury (DTI) is an injury to the soft tissue under the skin due to pressure and is usually over boney prominence. This injury is commonly seen in bedridden patients in hospitals and nursing homes. Although many efforts were made to elucidate the precise mechanism and clinical presentation, the pathogenesis and the final clinical outcome are yet to be determined. Although the current agreed upon presentation describes DTI as purple- or maroon-colored skin with ulceration, presented herein is an unusual case where DTI presented with only erythema and induration over the sacrum and right gluteal area.


Deep tissue injury (DTI) was described as early as 1873 when Sir James Paget defined purple areas of unbroken skin that sloughed and turned into cavities.[1] In 1942, Groth, a German scientist, applied an external pressure to create ulcers in an animal and described these ulcers that started in the muscles as malignant.[2] Taking Groth's study further, Darrell Shea was the first to introduce classification to pressure ulcers and added closed pressure ulcers into the staging system in 1975.[3,4]

The idea of another cause for pressure ulcers was debated by the National Pressure Ulcer Advisory Panel (NPUAP) in 2001.[2] These pressure ulcers emerged as maroon-purple colored tissue, and many of them tended to become stage IV ulcers.[2]

The term "deep tissue injury" was chosen because the most likely cause of these pressure ulcers was a great level of pressure at the bone-soft tissue crossing point. At first, DTI was defined as a pressure-related injury to subcutaneous tissues under intact skin that initially have the appearance of a deep bruise and may herald the development of a Stage III-IV pressure ulcer, even with optimal treatment.[3] According to the NPUAP, DTI is unbroken skin with nonblanchable purple or maroon discoloration that may be preceded by pain. This area of skin could be different in texture (mushy, boggy, firm) as compared with neighboring skin area, and the . maroon or purple color is hard to recognize in dark skin.[5] This type of ulcer is severe and hard to diagnose. Indeed, if such type of ulceration reaches an advanced level, it becomes hard to treat and the prognosis is unprivileged. Thus, focusing on skin cannot reflect the extent of the total damage induced by the pressure.[6] Deep tissue injury is commonly seen in bedridden patients in nursing homes and hospitals. Although many attempts have been made to explain the exact mechanism and clinical presentation, the pathophysiology and the final clinical outcomes have yet to be determined.

The authors have seen many patients with DTI in their practice. The presentations and outcomes may vary from healing without tissue necrosis and sequelae to complete tissue necrosis evolving into stage IV pressure wounds needing surgical debridement. Although the currently agreed upon presentation describes DTI as purple- or maroon-colored skin with ulceration, herein the authors present a case where DTI presented with only erythema, induration, and pain over the sacrum and right gluteal areas. A DTI diagnosis was made on the clinical examination, which was later confirmed intraoperatively.