What is a Deep Tissue Injury?

Deep Tissue Injury ExampleA deep tissue injury is a unique form of pressure ulcer. The National Pressure Ulcer Advisory Panel defines a deep tissue injury as ““A pressure-related injury to subcutaneous tissues under intact skin. Initially, these lesions have the appearance of a deep bruise. These lesions may herald the subsequent development of a Stage III-IV pressure ulcer even with optimal treatment.”(NPAUP, 2005). Why is it important to have yet another stage for pressure ulcers? The answer lies in the fact that, even with proper treatment, deep tissue injuries can deteriorate quickly into your worst nightmare.

The Problem With Deep Tissue Injuries

The problem with deep tissue injuries is that they are not readily apparent. A patient who has fallen at home and lain on the floor for a day may be admitted to the hospital and have every inch of skin examined upon admission, and then develop the tell-tale area of purplish discoloration several days after admission. In many cases, hospitals and other care facilities are being blamed (and payment is being withheld) when patients end up with a gaping hole in their sacrum that takes several months (and several trips to the OR) to heal, if they don’t succumb to their injury.

How to Recognize a DTI

You should be alert to the development of deep tissue injuries. Here’s how NPUAP describes these ulcers:

  • localized area of maroon or purplish discoloration of intact skin OR a blood-filled blister that forms due to shear and/or pressure
  • prior to the identification of the discolored area, the skin may feel boggy, firm, mushy, painful, cooler or warmer than the surrounding skin
  • the wound may progress to a thin blister overlaying a dark wound bed, which may eventually be covered by eschar
  • additional tissue layers may become rapidly exposed even with optimal treatment

Notice the last words (italicized). These wounds may become extremely large and may form very large pockets that expose the bone, despite your best efforts and the use of every wound care adjunct we have in our arsenals. Also remember that these ulcers may be even more difficult to detect in dark-skinned individuals.

The point is not to scare you, but to make you very aware of the danger that these types of ulcers present. It is important to be on your guard and watch for the development of these ulcers. Early identification, proper and accurate documentation and aggressive treatment are extremely important should you come in contact with a patient with a DTI.


Ankrom, M., Bennett, R., Sprigle, S., Langemo, D., Black, J., Berlowicz, D., Lyder, C., and the National Pressure Ulcer Advisory Panel (2005). Pressure-related deep tissue injury under intact skin and the current pressure ulcer staging systems. Advances in Skin and Wound Care 18, (in press).

NPUAP Pressure Ulcer Stages/Categories. http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/

About the Author

About Laurie Swezey

Laurie Swezey, founder and president of WoundEducators.com, has been a Registered Nurse for more than a quarter century, with most of those years dedicated to wound treatment. Ms. Swezey is a Certified Wound Care Nurse and a Certified Wound Specialist.


  1. Anthony T. Tuccio, DPM says:

    Thank you. I have seen this several times in my wound healing practice. The DTI appeared so benign that I would pay little attention to the area in question. I would then be amazed at the depth of the subsequent lesion. Many times the only reason that you initially pay attention to the area is a cellulitis is present.

  2. Mike had major surgery 17 months ago. He had the Ivor Lewis procedure done. His stomach incision has occasionally developed a bread through wound about the size of a dime. Off and on it develops a blister that has a thin skin over it. It is painful to the touch, drains bloody liquid. Doctor put him on antibiotics which did not change anything. He now has an opening the looks like a beebee hit him. No one knows what to do with it. Could this be an like ulcer you talked about in the article? If so, how can we get a doctor to treat it as such?

  3. He did go 6 months with the incision totally closed, then blistered up again in same spot and has lasted about 6 weeks.

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