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


Pressure ulcers develop as a result of ischemic insult to the soft tissue when compressed between the bony tuberosity and the patient's chair or bed. If permanent capillary occlusion occurs, then tissue necrosis will follow. Subcutaneous fatty tissue is avascular and the first to die upon excessive pressure. The skin is very resilient to ischemia due to support from the rich vasculature of the subdermal plexus and is the last to succumb to excessive pressure. This can explain how DTI may only present with erythema and induration, which represent the calcified necrotic fatty and muscular tissue surrounded by inflamed tissue, like the authors found in this case after exploring the injured area intraoperatively. The term DTI is used loosely by clinicians; thus, it may create staging confusion that may result in legal implications. This issue is due to the lack of strong evidence-based science to confirm early diagnosis and predict the clinical outcomes of DTI. In the authors' experience, DTIs may heal without sequelae, or they may evolve into stage IV pressure ulcers.

They can develop from the bottom up, from the top down, or remain in the middle, as seen in this case.

This unusual clinical presentation of DTI with only pain, induration, and discoloration should serve as a reminder of the possibility of this diagnosis. This patient did not present with the typical features of DTI, including bruised purple discoloration described by the NPUAP.[5]

While the skin was mostly intact during surgical exploration, the subcutaneous tissue, fascia, and part of the muscle were necrotic. A surgical exploration was prompted by the increased pain exacerbated by pressure at the involved area. Furthermore, the lumpy, indurated area had raised the suspicion for subcutaneous fat and muscle necrosis, and it warranted exploration to confirm the diagnosis and to determine the extent of necrosis needing debridement to hasten the healing process.

Early diagnosis of DTI is critical to prevent the development of pressure ulcers and to prevent their worsening. In fact, infrared thermography could serve as an efficient tool for early detection of DTI lesions.[7] Further clinical investigations are needed to help clinicians understand the pathophysiology of DTI, better evaluate the extent of injury, and predict its clinical outcome. This will finally help establish a clear definition of DTI.