Elsevier

Hand Clinics

Volume 25, Issue 4, November 2009, Pages 481-496
Hand Clinics

Cold Injury

https://doi.org/10.1016/j.hcl.2009.06.004Get rights and content

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Historical impact of cold

Man is a warm-blooded organism best suited to a tropical environment with temperatures around 81°F (27°C).1 Our sense of adventure and entitlement has led us to live in climates not ideally suited to our existence. Although we have some ability to adapt to colder climes, most of our survival is due to behavioral changes in response to the weather conditions. When we impair our ability to prepare adequately for freezing temperatures, we place ourselves at risk for cold injuries.

Throughout

Epidemiology/Predisposition

Many factors increase the risk of cold injury. The majority of civilian frostbite injuries are associated with mental impairment related to mental illness (10%–100%),11, 12 alcohol consumption (35%–53%),11, 13, 14, 15 or drug use (4%).14, 16 Alcohol and sedative drugs decrease the awareness of cold and impair the judgment necessary to seek shelter.17 Alcohol also inhibits shivering and causes cutaneous vasodilatation,18 precipitating frostbite at warmer temperatures (−8°F [−22°C] vs −20°F

Spectrum of injury

Frostbite is the most common local cold injury, although not all cold exposure results in tissue freezing.28 There is a continuum that ranges from minimal skin chilling to frank tissue crystallization from exposure to subfreezing temperatures.29, 30 There are two key factors that categorize these injuries, the rate of cooling and the ultimate presence or absence of ice crystals in the tissues (Box 1). A patient may have a combination of these injuries in different body parts following a cold

Pathophysiology

The body's thermostat for temperature regulation is the hypothalamus with sensors located in the skin and core.33 This system allows us to maintain tight control of our temperature, varying from 101.3°F (38.5°C) in the liver, 100.4°F (38°C) in the rectum, 98.6°F (37°C) under the tongue, and 89.6°F (32°C) in the skin at room temperature.8 At rest and under most conditions, the body can produce more heat than it needs. When in a positive heat balance, the skin temperature of the digits is higher

Clinical manifestations

Frostbite symptoms are predictable and can indicate the severity of the injury. Initially, the patient may describe a feeling of numbness in the affected hands, often accompanied by clumsiness and a lack of fine control. This numbness is replaced by a throbbing sensation on rewarming that may last for days or even weeks. Residual tingling sensations may develop, with occasional electric shock-type sensations, as nerve function returns.20

The extent of the frostbite injury is determined by

Historical

Larrey recommended friction massage of the frostbitten part with snow, and noted the similarities between the appearance of reperfused frostbite and burns. He recognized that warming the affected area next to a campfire initially improved the color of the frozen limb, but realized the edema (and sometimes a superimposed burn) that resulted was detrimental, and that the cycle of freeze-thaw-freeze was devastating.20 Although rubbing snow on a frostbitten part would eventually be discredited, the

Thrombolytics

The standard treatment of severe frostbite is directed at melting the extracellular ice crystals without causing thermal injury, returning blood flow to the affected area, and modifying the inflammatory response. The authors believe a major determinant of outcome is the microvascular thrombosis that occurs after rewarming.20, 29, 30, 44, 50 The combination of rapid rewarming, oral ibuprofen, and topical aloe vera treatment attempt to decrease this process,27, 44 but have only been modestly

Bone Scan

99mTc pertechnetate scintigraphy can be used to evaluate perfusion of bone and soft tissues. These studies reveal flow in three phases: early blood, early bone, and late bone. The lack of flow in the late (bone) phase is a poor prognostic sign of tissue healing with extremity frostbite. The predictive accuracy of the scans varies with time post injury.87, 88, 89, 90 Several reports have found good correlation with final surgical outcomes,89, 90 similar to early animal models.91 The diagnostic

Definitive surgical management

Urgent surgical intervention for local cold injuries is unusual, but necessary on occasion for soft tissue infections not controlled by antibiotics.50 The authors use a guillotine amputation as the primary procedure, followed by secondary closure when the infection is controlled. Despite the potential for significant edema formation following rewarming, compartment syndrome is rare, occurring in less than 1% of our patients.26

The traditional surgical adage for frostbite, “frostbite in January,

Surgical caveats

As with most debilitating conditions, frostbite of the hands should be treated by a multidisciplinary team, including a burn surgeon, a hand surgeon, a physical medicine and rehabilitation specialist, and an occupational-hand therapist. The functional rehabilitation of the frostbitten hands can be optimized using this team approach. If amputations are required, discussions regarding the level of amputation among the team are appropriate to provide the patient with the best outcome. The

Prognosis and sequelae

Frostbitten tissues seldom recover completely.50 Long-term symptoms include cold sensitivity (75%), sensory loss (68%), hyperhidrosis (75%), and chronic pain (67%).100 Patients with tissue loss almost uniformly report an electric shock-type of pain.44 Osteoarthritis develops in approximately half of the hands with frostbite involvement,21, 31 38% report joint problems, and heterotopic calcification can occur.20 Benign skin color changes are common (56%).100 There is a single report of a

Summary

The cold has been a lethal adversary throughout history. Our ability to live beyond our tropical thermal comfort zone is due to planning and protection against the elements. Any impairment in our mental capacity, judgment, or risk taking behavior can put us at odds with our environment. The most frequent factors related to frostbite injury are alcohol and drugs, mental illness, and lack of available shelter.

Frostbite results in direct and indirect mechanisms of tissue injury. The direct process

Acknowledgments

Stephen V. Fisher, MD (Physical Medicine and Rehabilitation Specialist), Loree K. Kalliainen, MD (Plastic and Hand Surgeon), Frederick W. Endorf, MD (Burn, Trauma and Critical Care), and the Department of Plastic and Hand Surgery at Regions Hospital (St. Paul, MN, USA).

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    Disclosure: None of the authors has a financial interest in any of the products, devices, or drugs mentioned in the article.

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