Anomalous Presentation of Deep Tissue Injuries (DTI): A Case Series

Deep Tissue Injuries (DTI) are the manifestation of multiple layers of tissue insult and possible necrosis and are often secondary to chronic mechanical stress to an area of bony prominence. The prevalence of these injuries among the chronically ill and those in long-term care, coupled with the additional healthcare costs associated with treatment requires a strong understanding of their etiology and a highly sensitive identification algorithm. Though the NPUAP has released new guidelines with accurate descriptions of injury presentation, there are a significant number of patients that present atypically. Consequently, treatment plan and prognosis are difficult to predict based on physical presentation alone. This can lead to either delays in aggressive care or conversely, an overzealous treatment plan in hopes of addressing a pathology that may be self-limiting. We present three patient cases of DTI where the initial presentation was not as described by the current staging system. Furthermore, the initial presentation was not a diagnostic predictor of prognosis. We will discuss these differences and course of treatment for these cases and posit a more comprehensive diagnostic approach in hopes of more accurately identifying these injuries with a focus on prediction of disease trajectory.