Introduction
Background
Frostbite is a cold-related injury characterized by freezing of tissue. Most cases are encountered in soldiers, in those who work outdoors in the cold, in homeless people, in athletes engaging in sports with seasons extending into the cold months of the year, and among winter outdoor enthusiasts such as Nordic skiers.1 Mountain frostbite is a variation observed among mountain climbers and others exposed to extremely cold temperatures at high altitude. It combines tissue freezing with hypoxia and general body dehydration. Near-immediate frostbite was also recently reported in a man who spilled liquid oxygen on both hands while working.2
The image below shows frostbite on a hand.
Frostbite of the hand.
Pathophysiology
Cold exposure leads to ice crystal formation, cellular dehydration, protein denaturation, inhibition of DNA synthesis, abnormal cell wall permeability with resultant osmotic changes, damage to capillaries, and pH changes. Rewarming causes cell swelling, erythrocyte and platelet aggregation, endothelial cell damage, thrombosis, tissue edema, increased compartment space pressure, bleb formation, localized ischemia, and tissue death.
Underlying responses to these injuries include generation of oxygen free radicals, production of prostaglandins and thromboxane A2, release of proteolytic enzymes, and generalized inflammation. Tissue injury is greatest when cooling is slow, cold exposure is prolonged, rate of rewarming is slow, and, especially, when tissue is partially thawed and refreezes.
Frequency
United States
No standardized reporting system exists; thus, true frequency of frostbite in the United States and abroad is unknown. Frostbite is uncommon in most of North America, except for northern states, Alaska, and Canada.
International
In Finland, a nation-wide study of hospital admissions for frostbite from 1986-1995 yielded an incidence of 2.5 cases per 100,000 inhabitants.3
Mortality/Morbidity
- Frostbite is a disease of morbidity, not mortality. However, when combined with hypothermia or wound-related sepsis, death is possible.
- Long-term sequelae include paresthesias and sensory deficits, hyperhidrosis or anhidrosis, cracking skin and loss of nails, abnormal color changes indicative of vasospasm, cold sensitivity, joint stiffness, tremor, premature closure of epiphyses in children, osteoporosis, intrinsic muscle atrophy, and phantom pain of amputated extremities.
Race
During the Korean War, frostbite was more common among black soldiers than whites. Similarly, a US Army study of all cases of cold weather injuries, including frostbite, from 1980-1999 demonstrated that African American men and women were 4 times and 2.2 times, respectively, as likely to sustain cold weather injuries as their white counterparts.4 An increased risk among those of African descent was noted by the British during the Falklands Islands War in 1982,5 and in a more recent British Army study that showed that soldiers of African descent had a 30 times greater chance of developing a peripheral cold injury than whites6 . Arabs appear to be similarly predisposed, as are individuals from warmer climates, such as Pacific Islanders.
Sex
Most frostbite victims are male.7 This disparity may result from increased outdoor activity among males as opposed to genetic predisposition. However, it has also been noted that women are at greater risk of developing hypothermia than men. There may therefore be gender variations in susceptibility to cold-related injuries that have not been fully elucidated.
Age
In one case study, the mean patient age was 41 years.8
Clinical
History
- Symptoms affecting frostbitten body parts include the following:
- Coldness and firmness
- Stinging, burning, numbness
- Clumsiness
- Pain, throbbing, burning, or electric current-like sensations on rewarming
Physical
- Location
- While hands and feet are affected most frequently, shins, cheeks, nose, ears, and corneas may be involved, as shown in the images below.
Frostbite of the foot. Photo courtesy of Kevin P. Kilgore, MD, Department of Emergency Medicine, Regions Hospital.
Frostbite of the ear. Photo courtesy of Kevin P. Kilgore, MD, Department of Emergency Medicine, Regions Hospital.
- As in thermal burns, frostbite injuries may be classified by degree.
- First-degree injuries involve the epidermis, while fourth-degree injuries involve the epidermis, dermis, subcutaneous tissue, and deeper structures
- Degree of injury
- First-degree injury - Erythema, edema, waxy appearance, hard white plaques, and sensory deficit
- Second-degree injury - Erythema, edema, and formation of blisters filled with clear or milky fluid and which are high in thromboxane (These blisters form within 24 hours of injury.)
- Third-degree injury - Presence of blood-filled blisters, which progress to a black eschar over a matter of weeks
- Fourth-degree injury - Full-thickness damage affecting muscles, tendons, and bone, with resultant tissue loss
- Other signs
- Excessive sweating
- Joint pain
- Pallor or blue discoloration
- Hyperemia
- Skin necrosis
- Gangrene
Causes
- Predisposing factors and populations at greatest risk for frostbite include the following:
- Individuals stranded in cold weather
- Soldiers, cold weather rescuers, and laborers working in a cold environment
- Winter and high-altitude athletes
- Extremes of age
- Homelessness
- Altered mental status (eg, head trauma, ethanol or illicit drug abuse, psychiatric illness)
- Exposure to water or dampness
- Immobilization
- Use of nicotine or other vasoconstrictive drugs
- Previous cold injury
- Use of inadequate or constrictive clothing
- Persons exposed to chronic hand or arm vibration
- Individuals whose hands tend to become white in the cold
- Underlying illness
- Malnutrition
- Infection
- Peripheral vascular disease
- Atherosclerosis
- Arthritis
- Diabetes
- Thyroid disease
- Stroke
More on Frostbite |
 Overview: Frostbite |
| Differential Diagnoses & Workup: Frostbite |
| Treatment & Medication: Frostbite |
| Follow-up: Frostbite |
| Multimedia: Frostbite |
| References |
| Next Page » |
References
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Further Reading
Keywords
frostbite, frostbite symptoms, frostbite treatment, frostbite causes, cold exposure, cold weather injuries, frostbitten, frostnip, cold-related injury, mountain frostbite, hyperemia, gangrene, skin necrosis, hypoxia, dehydration
