Are all pressure ulcers the result of deep tissue injury? A review of the literature.

Pressure ulcers are a common problem that significantly contributes to morbidity and mortality. To elucidate the confusion surrounding the origin of pressure ulcers, the question of whether pressure ulcers are caused exclusively by deep tissue injury is addressed. A review of the literature relevant to the pathophysiology and pathogenesis of pressure ulcers is presented and focuses on studies that examine the relationship between mechanical stresses and deep and superficial tissue injury. The studies suggest that deep tissue is more susceptible than superficial tissue to injury caused by externally applied pressure; clinically superficial skin injuries induced by pressure tend to be associated with deep tissue damage; and superficial injuries appear to be caused by factors other than pressure. Based on these observations, pressure ulcers are believed to be the result of deep tissue damage, implying that prevention and treatment of superficial lesions need not necessarily conform to pressure ulcer management that makes eliminating pressure the highest priority. Conversely, the treatment of pressure ulcers should account for the likelihood, even if not visually noted, that deep tissue is involved.