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Pressure Injury Toolkit For Spinal Cord Injury and Spina Bifida

Beyond the wound - Bringing best practice to the bedside


Possible causes and contributing factors:

Poor sitting posture

Sitting with posterior pelvic tilt and shearing forces from sliding forward in the wheelchair can contribute to a sacral PI. In addition to the wheelchair seat and backrest, this posture can also shift the pelvis forward  on the shower commode seat or toilet seat resulting in the sacrum bottoming out on the inside rim of the seat.

Sliding down the bed

Sitting reclined in bed increases shear at the sacrum. Do not elevate head of bed past 30o for more than 20 mins.

Trauma during transfers

Trauma to the sacrum can occur during transfers as a result of one poor transfer or repeated poor technique.
For example:

  • If  the sacrum hits the wheel of a manual wheelchair
  • If the sacrum lands heavily on the firm part of a cushion
  • Poor slide board technique
  • Transfers that are made between two surfaces of different heights or with limited space e.g. car transfers.



  • Wheelchair seating
  • Other seating support surface such as car seat and commode seat
  • Friction from commode seat during self care activities
  • If the person has a prominent coccyx, consider the mattress if they lie in supine.
  • Thick or harsh trouser material , clothing seams, pockets, button or creases
  • Hoist technique and sling if PI is on the natal cleft

Based on information from the Spinal Seating Professional Development Program
RD14.1: Likely Causes of Pressure Injuries