How should I manage a deep tissue injury on the heel now that the scab has fallen off?

Management of Deep Tissue Injury on Heel After Scab Loss

Immediately implement aggressive pressure offloading with a non-removable device (such as a posterior splint or heel suspension boot) to completely eliminate pressure on the heel, as this is the single most critical intervention to prevent wound progression and promote healing of heel deep tissue injuries.

Critical First Steps

The exposed wound after scab loss indicates the injury is evolving and at high risk for rapid deterioration. Deep tissue injuries on the heel are particularly dangerous because they originate in deep muscle layers near bone and can progress rapidly despite superficial appearance 1, 2.

Immediate Offloading (Most Important)

• Use non-removable offloading to ensure continuous pressure relief, as removable devices depend on patient compliance which is often inadequate 3
• Consider a posterior splint specifically designed for heel offloading - this is readily available, familiar to practitioners, and less likely to be removed by the patient 4
• Alternatively, use heel suspension techniques that completely float the heel off any surface
• The heel's anatomical vulnerability (no muscle or fascia, minimal subcutaneous tissue) makes it extremely susceptible to pressure damage 5

Key pitfall to avoid: Removable offloading boots are commonly used but frequently removed by patients, leading to continued pressure exposure and wound progression 2.

Wound Assessment and Local Care

Examine the wound for:

• Depth and tissue involvement - DTIs often appear more superficial than they actually are 6, 7
• Purple/maroon discoloration at wound edges suggesting ongoing deep tissue damage 1, 8
• Signs of infection - erythema, warmth, purulent drainage, odor
• Vascular status - check pedal pulses, capillary refill, skin temperature

For local wound management:

• Keep the wound moist with appropriate dressings
• Avoid aggressive debridement initially unless clear necrotic tissue is present, as the full extent of injury may not yet be apparent 6
• Monitor closely for progression - DTIs characteristically deteriorate rapidly despite appropriate care 1

Support Surface Considerations

If the patient is bedbound or has limited mobility:

• Strongly consider air-fluidized therapy (AFT) bed over standard low-air-loss surfaces
• Recent evidence shows AFT beds prevent wound progression (median change 0.0 cm²) compared to significant progression on low-air-loss beds (median increase 6.8 cm²) 2
• AFT beds also promoted better healing (median reduction -7.4 cm²) versus continued enlargement on low-air-loss beds 2

Additional Risk Factor Management

Address these critical factors that increase heel pressure ulcer severity:

• Diabetes status - if diabetic, ensure glucose control and assess for neuropathy 3, 5
• Vascular perfusion - poor tissue perfusion dramatically impairs healing 5
• Nutritional status - optimize protein intake and correct anemia if present 9
• Respiratory disease - associated with higher pressure ulcer incidence 9

Monitoring and Follow-up

• Assess the wound daily for the first week - DTIs can evolve rapidly 1
• Watch for development of eschar or further purple discoloration indicating progression
• If the wound progresses despite offloading, consider more aggressive interventions or specialist wound care consultation
• Do not be reassured by stable appearance - DTIs are notorious for sudden deterioration 6, 1

Common Pitfalls

1. Underestimating injury severity - the visible wound may represent only a fraction of the actual tissue damage 6, 7
2. Using removable offloading devices - patients frequently remove these, negating their benefit
3. Inadequate pressure relief - partial offloading is insufficient; the heel must be completely suspended 4, 5
4. Delayed recognition of progression - monitor closely as these injuries can deteriorate within days 1, 2

The heel location makes this injury particularly challenging, with reported incidence rates of 13-16% in orthopedic populations and often requiring longer hospital stays 9. Aggressive offloading from the outset is your best strategy to prevent the wound from progressing to a full-thickness ulcer requiring months to heal.