Deep Tissue Pressure Injury

What Is a Deep Tissue Pressure Injury?

A deep tissue pressure injury (DTPI) is defined by the National Pressure Injury Advisory Panel (NPIAP) as intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, or purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes.

Unlike other pressure injuries that start at the skin surface and progress downward, deep tissue injuries originate in the deeper tissues—muscle and fat—adjacent to the bone. The damage occurs from the inside out, meaning significant destruction may already exist before any visible signs appear on the skin.

This "inside-out" injury pattern makes DTIs uniquely dangerous because the skin may appear relatively intact while extensive tissue destruction has already occurred beneath the surface.

Visual Description and Appearance

Recognizing a deep tissue pressure injury early is critical for both medical treatment and establishing when the injury occurred:

Classic Purple or Maroon Discoloration

The hallmark sign of a DTPI is a distinctive purple or maroon area of discoloration over a bony prominence. This color results from damaged blood vessels and bleeding into the tissue beneath the skin. The area typically:

• Does not blanch (turn white) when pressed
• May feel firm, mushy, boggy, warmer, or cooler than surrounding tissue
• May be painful, though some patients cannot feel the area due to nerve damage
• Is located over a bony prominence (sacrum, heels, hips, elbows)

Blood-Filled Blister

In some cases, a DTPI may present as a blood-filled blister (hemorrhagic bulla). This dark, fluid-filled blister indicates significant tissue damage beneath the skin surface and should be treated as a serious injury requiring immediate intervention.

Evolution of Appearance

Over days to weeks, a DTPI typically evolves in one of several ways:

• Resolution: Some injuries may resolve without skin breakdown if the underlying damage was limited
• Progression: Many DTIs rapidly evolve to reveal extensive tissue destruction, becoming Stage 3 or Stage 4 injuries
• Eschar formation: The area may become covered with thin eschar (dead tissue), becoming unstageable

Rapid Deterioration Risks

One of the most alarming characteristics of deep tissue injuries is how quickly they can deteriorate, often despite aggressive intervention:

Unpredictable Evolution

Unlike staged pressure injuries where progression typically follows a predictable pattern, DTIs can evolve unpredictably. A wound that appears minor one day may open to reveal extensive necrosis within 24-48 hours. This rapid evolution often surprises even experienced clinicians.

Hidden Damage Already Present

Because the injury occurs deep in the tissue before becoming visible, the damage seen on the surface represents only a fraction of the total destruction. When the skin finally breaks down, it often reveals:

• Extensive dead tissue (necrosis) in muscle and fat layers
• Undermining extending far beyond the visible wound edges
• Tunneling into surrounding tissues
• Potential exposure of bone, tendon, or joint capsule

May Not Respond to Treatment

Even with immediate and aggressive treatment once a DTPI is identified, the injury may continue to progress. This is because the tissue damage has already occurred—the visible wound is simply the delayed manifestation of destruction that happened days earlier. This "unavoidable progression" defense is sometimes raised by facilities, but it does not excuse the failure to prevent the initial injury.

Detection Challenges

Deep tissue pressure injuries present significant detection challenges that can delay identification and treatment:

Patients with Darker Skin Tones

The purple or maroon discoloration that characterizes DTIs can be extremely difficult to detect in patients with darker skin pigmentation. Research has shown that pressure injuries are often detected at later stages in Black and Hispanic patients compared to white patients. For patients with darker skin, healthcare providers should:

• Compare skin color to surrounding areas and the opposite side of the body
• Assess for temperature changes (warmer or cooler than surrounding skin)
• Evaluate for texture differences (firm, boggy, or edematous areas)
• Ask about pain or discomfort even in areas that appear normal
• Use bright, natural lighting during skin assessments

Delayed Visible Signs

Because DTIs form at the bone-muscle interface and progress outward to the skin, visible signs may not appear until 24-72 hours after the causative pressure event. This delay means that:

• The injury may have occurred during a previous shift or earlier admission
• Documentation may not capture when the pressure actually occurred
• The responsible party may not be immediately apparent

Misidentification

DTIs are sometimes misidentified as bruises, hematomas, or Stage 1 pressure injuries. This misclassification can lead to inappropriate treatment protocols and failure to recognize the serious nature of the injury. Accurate identification requires training and experience that may be lacking in some care settings.

Common Locations

Deep tissue pressure injuries most commonly develop over bony prominences where tissue is compressed between bone and an external surface:

• Sacrum/Coccyx: Most common location, occurring in patients who remain supine (on their back) for extended periods
• Heels: Extremely vulnerable due to minimal tissue between bone and skin surface
• Ischial tuberosities: In patients who sit for prolonged periods without repositioning
• Greater trochanters (hips): When patients lie on their sides without adequate pressure redistribution
• Spinous processes (spine): In very thin patients lying supine

Legal Implications

The unique characteristics of deep tissue pressure injuries have important legal implications:

Evidence of Prior Pressure

Because DTIs result from sustained pressure that occurred before the visible signs appeared, the presence of a DTPI is strong evidence that proper pressure injury prevention protocols were not followed. The injury documents a failure that may have occurred 24-72 hours before the wound was visible.

Facility Defense Considerations

Facilities sometimes argue that DTIs are "unavoidable" because they can progress despite treatment. However, this argument ignores the critical question: could the original pressure event have been prevented? The focus should be on whether adequate prevention measures were in place before the injury occurred.

Documentation Red Flags

When investigating a DTPI case, important documentation to review includes:

• Turning and repositioning schedules in the days before discovery
• Pressure-redistributing surface orders and implementation
• Risk assessment scores and when they were last updated
• Skin assessment documentation for the affected area
• Nursing staffing levels during relevant time periods
• Any events requiring extended immobility (surgery, procedures)

Severity and Damages

DTIs that progress to Stage 3 or Stage 4 wounds can result in:

• Months to years of wound care treatment
• Multiple surgeries including debridement and skin grafting
• Life-threatening infections and sepsis
• Permanent scarring and disfigurement
• Chronic pain and reduced quality of life
• Death in severe cases, particularly in elderly or medically fragile patients

Warning Signs to Watch For

Family members should be alert to these potential signs of a developing or existing deep tissue pressure injury:

• Purple, maroon, or unusually dark areas of skin over bony areas
• Dark blood-filled blisters over pressure points
• Areas that feel different in temperature than surrounding skin
• Complaints of pain or tenderness over bony prominences
• Skin that feels unusually firm or mushy compared to other areas
• Rapid changes in wound appearance over short time periods
• Staff seeming surprised by how quickly a wound appeared or worsened

Documenting Deep Tissue Injuries

If you discover your loved one has a deep tissue pressure injury, document the following:

1. Photograph the area with dates and a ruler or coin for size reference if possible
2. Note the date and time you first observed the injury
3. Ask when staff first documented the injury and request copies of those records
4. Obtain turning and repositioning logs for the days before and after discovery
5. Request information about any events requiring prolonged immobility (surgery, procedures, imaging)
6. Track the evolution of the wound with photos at each visit, noting any changes
7. Document all treatments ordered and whether they were implemented

When to Seek Legal Help

You should consult a bedsore attorney if your loved one has developed a deep tissue pressure injury in a care facility and:

• The injury developed after admission to the facility
• The wound rapidly progressed to a Stage 3 or Stage 4 injury
• There are concerns about inadequate turning or repositioning
• Your loved one has developed multiple pressure injuries
• The facility failed to use appropriate pressure-relieving surfaces
• You were not promptly informed about the injury
• The wound became infected or led to other serious complications
• You have questions about the adequacy of care provided

At Traction Law Group, we understand the unique aspects of deep tissue pressure injury cases. We investigate how these injuries developed, when the causative pressure event occurred, and whether the facility failed in its duty to prevent harm. There is no fee unless we win your case.