What is the appropriate terminology for full thickness sacral ulcers?

Appropriate Terminology for Full-Thickness Sacral Ulcers

Full-thickness sacral ulcers should be classified as Stage III or Stage IV pressure injuries, depending on whether bone, tendon, muscle, or ligament is exposed. 1

Staging Classification

The current staging system distinguishes full-thickness ulcers based on the deepest tissue layer involved:

Stage III Pressure Injury

• Full-thickness tissue loss exposing subcutaneous fat 1
• Bone, muscle, and tendon are not visible or directly palpable 1
• Slough or eschar may be present but does not obscure the depth of tissue loss 1
• The wound bed is visible and assessment of depth is possible 1

Stage IV Pressure Injury

• Full-thickness tissue loss with exposed bone, muscle, ligament, or tendon 1, 2
• Slough or eschar may be present on portions of the wound bed 1
• Often includes undermining and tunneling 1
• May involve osteomyelitis when bone is exposed and infected 1

Unstageable Pressure Injury

• Full-thickness tissue loss where the base is covered by slough or eschar 1
• The true depth and stage cannot be determined until the slough or eschar is removed 1
• Once debrided, these wounds are revealed to be either Stage III or Stage IV 1

Anatomic Location Terminology

When documenting sacral pressure injuries, specify:

• Sacral region as the anatomic site 1, 3
• The sacrum is the most common location for pressure ulcers (39% of all pressure injuries) 4
• Sacral ulcers have lower recurrence rates after surgical repair compared to ischial or trochanteric ulcers 1, 3

Clinical Documentation Requirements

Complete documentation should include 3:

• Stage (III or IV based on deepest tissue involvement)
• Wound dimensions (length, width, depth in centimeters)
• Presence of exposed structures (bone, tendon, muscle)
• Amount and type of necrotic tissue (slough vs. eschar)
• Exudate characteristics (amount, color, odor)
• Surrounding skin condition (maceration, erythema, induration)

Common Pitfalls to Avoid

• Do not stage a wound covered by eschar or slough—these must be classified as "unstageable" until debrided 1
• Do not downstage a healing wound—a Stage IV ulcer that is healing remains a Stage IV ulcer even as it fills with granulation tissue 5
• Do not confuse deep tissue injury with Stage III/IV—intact skin with deep bruising or discoloration represents suspected deep tissue injury, not a staged ulcer 5
• Do not use outdated terminology such as "decubitus ulcer" or "bedsore"—the preferred term is "pressure injury" or "pressure ulcer" 1, 3