Photo Quiz

Foot Lesions in a Rehabilitation Facility Resident


Am Fam Physician. 2021 May 1;103(9):559-560.

A 69-year-old patient was referred to the wound care clinic from a rehabilitation facility for evaluation of gluteal skin ulcers. The patient had no fever or chills. The medical history included atrial fibrillation (without anticoagulation), uncontrolled type 2 diabetes mellitus, peripheral neuropathy, and stage 3 chronic kidney disease.

On physical examination, the patient had erosive dermatitis in moist gluteal areas. Further examination revealed nontender, discolored lesions on the plantar surface of the right foot (Figure 1).




Based on the patient's history and physical examination findings, which one of the following is the most likely diagnosis?

  • A. Arterial embolization.

  • B. Calciphylaxis.

  • C. Deep tissue injury.

  • D. Morel-Lavallée lesions.

  • E. Morphea.


The answer is C: deep tissue injury. Deep tissue injury presents as a localized area of dark purple or maroon intact skin or blood-filled blisters. It is caused by underlying soft tissue damage from pressure and/or a shearing force, and a likely combination of ischemic and reperfusion injury.1,2 Deep tissue injuries make up approximately 9% of all pressure injuries and are often poorly recognized by health care professionals.3 The lesions form rapidly, with 24 to 72 hours between soft tissue damage and onset of discoloration.4 Even with optimal treatment, the affected areas may progress to stage 3 and 4 pressure injury. Immediate off-loading, restoration of perfusion, improved patient nutrition, and diligent topical care are essential. The presence of both moisture-associated dermatitis and deep tissue injury

Address correspondence to Igor Melnychuk, MD, at Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.


show all references

1. European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, Pan Pacific Pressure Injury Alliance. Prevention and treatment of pressure ulcers/injuries: clinical practice guideline. 2019. Accessed March 24, 2021.

2. Parks DA, Granger DN. Ischemia-reperfusion injury: a radical view. Hepatology. 1988;8(3):680–682.

3. VanGilder C, MacFarlane GD, Harrison P, et al. The demographics of suspected deep tissue injury in the United States: an analysis of the International Pressure Ulcer Prevalence Survey 2006–2009. Adv Skin Wound Care. 2010;23(6):254–261.

4. Black JM, Brindle CT, Honaker JS. Differential diagnosis of suspected deep tissue injury. Int Wound J. 2016;13(4):531–539.

5. Ferderber M, Pruett K. Knee bruising and swelling in a teenager. Am Fam Physician. 2020;102(1):49–50. Accessed February 3, 2021.

This series is coordinated by John E. Delzell Jr., MD, MSPH, associate medical editor.

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