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

Case Report

A 67-year-old man with an early stage of dementia and major peripheral neuropathy with difficulty walking presented to the outpatient wound clinic with a 1-week history of painful sacral and right gluteal indurated areas with erythema and heterogeneous pigmentation. A small area of macerated skin was also found on the lower sacrum and coccyx (Figure 1). The involved area was covered with a protective foam dressing, an air mattress was ordered for his home, and he was asked to remain on either side while in bed, where he spent most of his time at home.

Figure 1.

Deep tissue injury at presentation with pain and induration on the lower sacrum, coccyx, and right gluteal area.

During the next follow-up visit 1 week later, the symptoms remained the same with increased pain. The patient was then taken to the operating room for wound exploration. A 5-cm angular incision was made over the lower part of the sacrum and extended to the right gluteal area, which was indurated and painful on palpation. Subcutaneous fat necrosis was discovered extending down to the right gluteal fascia and a thin layer of the muscle itself. The skin flap was intact, and the necrotic tissue was excised down to healthy bleeding tissue. After achieving hemostasis using electrocautery and vessel ligation with 3-0 Vicryl sutures (Ethicon, Somerville, NJ), the wound was irrigated with normal saline and packed with a wet dressing made of gauze and quarter strength Dakin's solution. The dressing was changed daily for 7 days then NPWT was initiated at 125 mm Hg continuous fashion. The NPWT dressing was changed on Tuesdays and Fridays.

At 2 months postop the NPWT was stopped and daily dressing changes using wound gel was applied until complete healing was achieved 2 weeks later. Figure 3 shows the wound 2 weeks prior to complete healing.

Figure 2.

Stage IV sacral and right gluteal pressure wound 1 week after excision of fascia and subcutaneous fatty tissue. Suture shows ligated intraoperative bleeding vessel.

Figure 3.

Wound 2 months postoperatively.