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Cold Exposure Injuries to the Extremities

Dr. Golant is Resident, Hand Service, Department of Orthopaedic Surgery, NYU–Hospital for Joint Diseases, New York, NY. Dr. Nord is Resident, Hand Service, Department of Orthopaedic Surgery, NYU–Hospital for Joint Diseases. Dr. Paksima is Assistant Clinical Professor, Department of Orthopaedic Surgery, NYU School of Medicine, New York. Dr. Posner is Clinical Professor, Department of Orthopaedic Surgery, NYU School of Medicine.

None of the following authors or a member of their immediate families has received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Golant, Dr. Nord, Dr. Paksima, and Dr. Posner.

Reprint requests: Dr. Posner, Department of Orthopaedic Surgery, NYU–Hospital for Joint Diseases, 301 East 17th Street, New York, NY 10003.

Cold exposure injuries comprise nonfreezing injuries that include chilblain (aka pernio) and trench, or immersion, foot, as well as freezing injuries that affect core body tissues resulting in hypothermia of peripheral tissues, causing frostnip or frostbite. Frostbite, the most serious peripheral injury, results in tissue necrosis from direct cellular damage and indirect damage secondary to vasospasm and arterial thromboses. The risk of frostbite is influenced by host factors, particularly alcohol use and smoking, and environmental factors, including ambient temperature, duration of exposure, altitude, and wind speed. Rewarming for frostbite should not begin until definitive medical care can be provided to avoid repeated freeze-thaw cycles, as these cause additional tissue necrosis. Rewarming should be rapid and for an affected limb should be performed by submersion in warm water at 104° to 107.6°F (40° to 42°C) for 15 to 30 minutes. Débridement of necrotic tissues is generally delayed until there is a clear demarcation from viable tissues, a process that usually takes from 1 to 3 months from the time of initial exposure. Immediate escharotomy and/or fasciotomy is necessary when circulation is compromised. In addition to the acute injury, frostbite is associated with late sequelae that include altered vasomotor function, neuropathies, joint articular cartilage changes, and, in children, growth defects caused by epiphyseal plate damage.