What is a Deep Tissue Injury?

Deep Tissue Injury Example

A 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 Deep Tissue Injury (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/


  1. 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. I have a resident that has developed DTI on L bunion, L outer Gr toe, L outer ankle, L outer foot near 5th toe, L outer 5th toe and L Achilles, this was after applying foam heel boot. Boot is always on except for dressing and hygiene. Should this be considered pressure. This is the resident stroke side.

    1. We have had several patients develop pressure injury from the heel protective boot! DeRoyal boot can be fastened too tightly and cause pressure especially in patients with ischemic disease. We stopped using them and are looking for an alternative.

  4. We have a patient that is thrombocytopenia . He was so sick that it’s hemodynamically unstable , (on septic shock )to turn for the first 8-12 hours shift. His arm , knees has purplish discoloration and bruises already. Because of multiple pressors his fingers and toes are cold and clamped and purplish dark colored too. When we are able to turn him, his butt cheek is mottled, is it consider DTI? Because it’s around the butt area but not the coccyx or sacrum.

    1. Deep tissue injury is a term proposed by NPAUP to describe a unique form of pressure ulcers. Since this is not a pressure ulcer, it is incorrect to call it a DTI.

  5. I would like to take the chance of saying thanks to you for that professional direction I have
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      1. Quick question that has been discussed: Do I need to report DTI as pressure wounds on my Weekly Acquired Pressure Wound report? If they are DTI and have not developed into stage III or IV?

  6. Bed bound patient with healing ischial pressure injuries. Granulation tissue present as well as epithelial tissue growth.
    Randomly develops hematoma within the wound bed that comes and goes within 2-3 weeks.
    Categorized as a sDTI however I’m not convinced.

  7. Can a DTI not be present one day but then the next ? Say first day skin just red category 1 then next day small DTI ?

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