Frostbite Injuries Treated in the Helsinki Area from 1995 to 2002 Virve Koljonen, MD, Katarina Andersson, RN, Kirsi Mikkonen, RN, and Jyrki Vuola, MD, PhD Background: Exposure to cold re- sults in frostbite, superficial or deeper tis- sue damage. In severe frostbites, amputa- tions are life-saving but diminish quality of life (QOL). Methods: Retrospective study was performed. RAND 36- questionnaire was administered to assess QOL. Our aim was to investigate risk factors and adjustment to everyday life of hospital- ized patients. Results: 92 frostbites in 42 patients were recorded. One third of the patients were chronic alcoholics. Age and temper- ature were statistically significant factors for unfavorable outcome. 20% of patients required secondary reconstructive proce- dures. One-third reported their emotional well-being very poor. Half had limitations in social life. Conclusions: Hospitalized cases of frostbite are rare. Anti-social behavior in- creases the risk in general, and patients present with complicated problems simi- lar to those encountered in burns victims. We recommend that frostbite patients re- quiring hospital attendance are treated in specialized units, where sufficient exper- tise for acute as well as reconstructive sur- gery is available. Keywords: Frostbite, Prognosis, Quality of life, Death, Reconstructive surgery. J Trauma. 2004;57:1315–1320. E xposure to cold results in a variety of injuries, from local, superficial chilblains and frost nips, to immersion injuries from cold or warm water, 1 to more severe, and sometimes lethal, injuries causing systemic hypothermia. 2–4 The incidence of frostbite in the civil population has not, however, been extensively studied. In Finland, Juopperi and coworkers reported the annual incidence of frostbite, with frostbite as a principal or secondary diagnosis, as 2.5 per 100 000 inhabitants between 1986 and 1995. 5 They noted an increase in the daily incidence in the most urban parts of Finland during this period. Another study from Finland gives an incidence of 1.8 per 1000 in conscripts. 6 In extreme weather conditions, such as in Antarctica, the reported inci- dence has been as high as 65.6 per 1000 annually among members of the British Antarctic Survey. 7 During the last centuries, research into frostbite has fo- cused almost entirely on injuries received in warfare. 8 –10 Few reports have been published on frostbite in the civilian pop- ulation, though such injuries are fairly common in northern countries. 5,11 The risk factors for among urban civilians ap- pear to differ from those identified in military personnel, rank and exercise being leading risk factors in the military, but alcohol and drug abuse and mental disorders among civilians (Table 1). The pathophysiology of frostbite is thought to have two distinct mechanisms: direct cellular damage at the time of exposure to the cold 12 and post-thaw arterial vasoconstric- tion, leading to disordered vascular flow patterns and damage to the microcirculation. The outcome is vascular thrombosis and dermal necrosis. 13,14 Recent studies have also revealed similarities to the inflammatory processes seen in burns. 15 These processes are thought to be the underlying mechanisms for progressive ischemic necrosis, and therefore anti-inflam- matory drugs have been used in the treatment of frostbite. Progressive ischemic necrosis is secondary to excessive thromboxane A2 production, which upsets the normal bal- ance between prostacyclin (prostaglandin I2) and thrombox- ane. One of the factors leading to necrosis could be a decrease in the prostaglandin I2:thromboxane A2 ratio. 16 Although current research has exposed some essential factors in the progress of frostbite injury 17 and thus provided more options for medical treatment, the primary treatment is still princi- pally surgical. Classical surgical management involves delayed debride- ment 1 to 3 months following the initial event, after the demar- cation line has evolved between necrotic and viable tissue. Sev- eral methods have been studied to define the demarcation line earlier. In an experimental study, Junila and coworkers used radionuclide scintigraphy and thermography to assess changes in tissue viability. 18,19 Laser-Doppler, microwave thermography, nuclear magnetic resonance (31P spectroscopy), and bone scin- tigraphy (technetium-99) have also been used to evaluate for- mation of the demarcation line, but none of these methods has proved superior to the old, well-tried “wait-and-see” approach. 20 Frostbite may have severe sequelae in the affected area, e.g., hypersensitivity to cold, numbness, and reduced sensitivity of touch. 21 Characteristic radiographic abnormalities and evidence of degenerative arthritis in the interphalangeal joints were ob- Submitted for publication February 9, 2004. Accepted for publication August 25, 2004. Copyright © 2004 by Lippincott Williams & Wilkins, Inc. From the Department of Plastic Surgery, Helsinki University Hospital, Helsinki, Finland. Address for reprints: Virve Koljonen, Department of Plastic Surgery, and Töölö Hospital, P.O. Box 266, FIN 00029 HUS, Helsinki, Finland; email: virve.koljonen@hus.fi. DOI: 10.1097/01.TA.0000151258.06910.83 The Journal of TRAUMA  Injury, Infection, and Critical Care Volume 57 • Number 6 1315