Stage IV Pressure Injury Classification and Management

Definition and Staging Criteria

• Stage IV pressure injury is defined by full-thickness tissue loss with exposed or directly palpable bone, tendon, muscle, or ligament, representing the most severe category of stageable pressure injuries, where deep anatomical structures become visible through the wound 1, 2, 3
• The American College of Physicians recommends distinguishing full-thickness ulcers based on the deepest tissue layer involved, with Stage IV characterized by full-thickness tissue loss with exposed bone, muscle, ligament, or tendon 1

Clinical Features and Complications

• Stage IV pressure injuries frequently involve additional complications beyond simple tissue exposure, including undermining and tunneling 1
• The Infectious Diseases Society of America notes that osteomyelitis risk is significantly elevated when bone is exposed, with prevalence ranging from 17% to 58% in patients with Stage IV injuries 2, 4
• Anatomical barriers are breached in Stage IV injuries, increasing risk of contiguous spread of infection 3

Management and Treatment

• Surgical debridement and flap coverage are indicated for nonhealing Stage IV pressure injuries to achieve rapid closure, reduce pain, decrease infection risk, and improve quality of life, as recommended by the Clinical Infectious Diseases society 5, 6