Practical Review of the Current Management of Frostbite Injuries

Taborah Z Zaramo, Japjit K Green, Jeffrey E Janis, Taborah Z Zaramo, Japjit K Green, Jeffrey E Janis

Abstract

Frostbite is an injury that occurs when the skin and tissues are exposed to temperatures below their freezing point. This type of injury can lead to various complications such as functional loss, chronic pain, and psychological trauma. As such, understanding frostbite management is crucial for optimal patient care. A scoping review was conducted in February 2022 using PubMed, EMBASE, referenced articles and snowballing to identify relevant published articled using the terms "frostbite" and "management" and "surgery. Articles related to pathophysiology, classifications, radiography, complications, and medical and surgical management were included to formulate recommendations for practical management. Two hundred fifty-one articles were identified and 54 met inclusion criteria. Rapid rewarming in warm water (40-42 °C) remains the standard of care. Thrombolytic therapy has been shown in numerous studies to improve tissue salvage. Radiographic imaging has become crucial in the evaluation and management in frostbite injury. Current literature recommends delayed surgery with soft tissue debridement and bone scan-guided amputations. Surgical intervention including debridement, selective blister drainage, fasciotomies, surgical salvage, skin grafts' and flaps are often necessary in these patients towards optimizing form and function. The true prevalence and incidence of frostbite injury is unknown. A centralized national database will improve our understanding of the diagnostic and management modalities used in frostbite care. Plastic surgeons have a critical role in the management of frostbite care and must work with an interdisciplinary team to identify the best treatment route for optimal patient care.

Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.

Figures

Fig. 1.
Fig. 1.
PRISMA Flow Diagram. PRISMA flow diagram detailing the number of database searches, abstracts screened and full texts articles retrieved to arrive at 54 articles.
Fig. 2.
Fig. 2.
Frostbite injury pathophysiology adapted from Knapik et al and Murphy et al. Schematic diagram of frostbite injury, which ensues when tissue is exposed to temperatures below –0.53°C, followed by the successive formation of extracellular ice crystals, microvascular damage, inflammation, and eventually cellular death. Abbreviations: ROS, reactive oxygen species.
Fig. 3.
Fig. 3.
Frostbite management algorithm. Key management of frostbite injury begins with proper field management, and rapid rewarming. Following rewarming, identification of tissue ischemia with diagnostic angiography or bone scans is often necessary. If tPA is administered, patients require monitoring of CBC/platelets/fibrinogen and PTT to avoid hemorrhagic events. Abbreviations: CBC, complete blood count; PTT, partial thromboplasmin time.
Fig. 4.
Fig. 4.
Algorithm for surgical salvage adopted from Su et al. Patients with decreased or absent Tec-99m uptake on bone scans should be considered for surgical salvage by assessing affected area and quantifying tissue loss. Injuries that are prognosticated to promote significant impairment of function requires early debridement and surgical salvage within 10 days (before dry eschar forms) using vascularized tissue. Abbreviations: PIP, proximal interphalangeal joint.

References

    1. Heil K, Thomas R, Robertson G, et al. . Freezing and non-freezing cold weather injuries: a systematic review. Br Med Bull. 2016;117:79–93.
    1. Murphy JV, Banwell PE, Roberts AH, et al. . Frostbite: pathogenesis and treatment. J Trauma. 2000;48:171–178.
    1. Carceller A, Javierre C, Ríos M, et al. . Amputation risk factors in severely frostbitten patients. Int J Environ Res Public Health. 2019;16:E1351.
    1. Nguyen TQ, Song DH. Pathophysiologic difference between frostbite and burn injury and implications for therapy. J Surg Res. 2012;174:247–249.
    1. Schellenberg M, Cheng V, Inaba K, et al. . Frostbite injuries: independent predictors of outcomes. Turk J Surg. 2020;36:218–223.
    1. Lindford A, Valtonen J, Hult M, et al. . The evolution of the Helsinki frostbite management protocol. Burns. 2017;43:1455–1463.
    1. Hutchison RL. Frostbite of the hand. J Hand Surg Am. 2014;39:1863–1868.
    1. Handford C, Thomas O, Imray CHE. Frostbite. Emerg Med Clin North Am. 2017;35:281–299.
    1. McIntosh SE, Freer L, Grissom CK, et al. . Wilderness medical society clinical practice guidelines for the prevention and treatment of frostbite: 2019 Update. Wilderness Environ Med. 2019;30(4S):S19–S32.
    1. Regli IB, Strapazzon G, Falla M, et al. . Long-term sequelae of frostbite—a scoping review. Int J Environ Res Public Health. 2021;18:9655.
    1. Biem J, Koehncke N, Classen D, et al. . Out of the cold: management of hypothermia and frostbite. CMAJ. 2003;168:305–311.
    1. Rintamäki H. Predisposing factors and prevention of frostbite. Int J Circumpolar Health. 2000;59:114–121.
    1. Cauchy E, Chetaille E, Marchand V, et al. . Retrospective study of 70 cases of severe frostbite lesions: a proposed new classification scheme. Wilderness Environ Med. 2001;12:248–255.
    1. Millet JD, Brown RK, Levi B, et al. . Frostbite: spectrum of imaging findings and guidelines for management. Radiographics. 2016;36:2154–2169.
    1. Gonzaga T, Jenabzadeh K, Anderson CP, et al. . Use of intra-arterial thrombolytic therapy for acute treatment of frostbite in 62 patients with review of thrombolytic therapy in frostbite. J Burn Care Res. 2016;37:e323–e334.
    1. Lorentzen AK, Davis C, Penninga L. Interventions for frostbite injuries. Cochrane Injuries Group, ed. Cochrane Database Syst Rev. 2020;12(12):CD012980.
    1. Cauchy E, Davis CB, Pasquier M, et al. . A new proposal for management of severe frostbite in the austere environment. Wilderness Environ Med. 2016;27:92–99.
    1. Heggers JP, Robson MC, Manavalen K, et al. . Experimental and clinical observations on frostbite. Ann Emerg Med. 1987;16:1056–1062.
    1. Golant A, Nord RM, Paksima N, et al. . Cold exposure injuries to the extremities. J Am Acad Orthop Surg. 2008;16:704–715.
    1. Imray C, Grieve A, Dhillon S; Caudwell Xtreme Everest Research Group. Cold damage to the extremities: frostbite and non-freezing cold injuries. Postgrad Med J. 2009;85:481–488.
    1. Lee J, Higgins MCSS. What interventional radiologists need to know about managing severe frostbite: a meta-analysis of thrombolytic therapy. AJR Am J Roentgenol. 2020;214:930–937.
    1. Joshi K, Goyary D, Mazumder B, et al. . Frostbite: current status and advancements in therapeutics. J Therm Biol. 2020;93:102716.
    1. Bruen KJ, Ballard JR, Morris SE, et al. . Reduction of the incidence of amputation in frostbite injury with thrombolytic therapy. Arch Surg. 2007;142:546–51; discussion 551.
    1. Paine RE, Turner EN, Kloda D, et al. . Protocoled thrombolytic therapy for frostbite improves phalangeal salvage rates. Burns Trauma. 2020;8:tkaa008.
    1. Kraft C, Millet JD, Agarwal S, et al. . SPECT/CT in the evaluation of frostbite. J Burn Care Res. 2017;38:e227–e234.
    1. Jones LM, Coffey RA, Natwa MP, et al. . The use of intravenous tPA for the treatment of severe frostbite. Burns. 2017;43:1088–1096.
    1. Poole A, Gauthier J, MacLennan M. Management of severe frostbite with iloprost, alteplase and heparin: a Yukon case series. CMAJ Open. 2021;9:E585–E591.
    1. Twomey JA, Peltier GL, Zera RT. An open-label study to evaluate the safety and efficacy of tissue plasminogen activator in treatment of severe frostbite. J Trauma. 2005;59:1350–1354; discussion 1354.
    1. Ibrahim AE, Goverman J, Sarhane KA, et al. . The emerging role of tissue plasminogen activator in the management of severe frostbite. J Burn Care Res. 2015;36:e62–e66.
    1. Cauchy E, Cheguillaume B, Chetaille E. A controlled trial of a prostacyclin and rt-PA in the treatment of severe frostbite. N Engl J Med. 2011;364:189–190.
    1. Tavri S, Ganguli S, Bryan RG, Jr, et al. . Catheter-directed intraarterial thrombolysis as part of a multidisciplinary management protocol of frostbite injury. J Vasc Interv Radiol. 2016;27:1228–1235.
    1. Wagner C, Pannucci CJ. Thrombolytic therapy in the acute management of frostbite injuries. Air Med J. 2011;30:39–44.
    1. Lacey AM, Rogers C, Endorf FW, et al. . An institutional protocol for the treatment of severe frostbite injury—a 6-year retrospective analysis. J Burn Care Res. 2021;42:817–820.
    1. Shenaq DS, Gottlieb LJ. Cold injuries. Hand Clin. 2017;33:257–267.
    1. Brandão RA, St John JM, Langan TM, et al. . Acute compartment syndrome of the foot due to frostbite: literature review and case report. J Foot Ankle Surg. 2018;57:382–387.
    1. Mohr WJ, Jenabzadeh K, Ahrenholz DH. Cold injury. Hand Clin. 2009;25:481–496.
    1. Leonard LG, Daane SP, Sellers DS, et al. . Salvage of avascular bone from frostbite with free tissue transfer. Ann Plast Surg. 2001;46:431–433.
    1. Classen DA. Free flap coverage of bilateral frostbite of the feet. Plast Reconstr Surg. 2000;106:1316–1320.
    1. Su CW, Lohman R, Gottlieb LJ. Frostbite of the upper extremity. Hand Clin. 2000;16:235–247.
    1. Greenwald D, Cooper B, Gottlieb L. An algorithm for early aggressive treatment of frostbite with limb salvage directed by triple-phase scanning. Plast Reconstr Surg. 1998;102:1069–1074.
    1. Fisher OL, Benson RA, Venus MR, et al. . Pedicled abdominal flaps for enhanced digital salvage after severe frostbite injury. Wilderness Environ Med. 2019;30:59–62.
    1. O’Connell JJ, Petrella DA, Regan RF. Hypothermia – Frostbite. 9. Available at . Retrieved October 3, 2022.
    1. Manganaro MS, Millet JD, Brown RK, et al. . The utility of bone scintigraphy with SPECT/CT in the evaluation and management of frostbite injuries. Br J Radiol. 2019;92(1092):20180545.
    1. Fodor M, Bota O, Fodor L. Simultaneous extended ALT flaps for foot salvage after severe frostbite. J Burn Care Res. 2016;37:e383–e386.
    1. Woo EK, Lee JW, Hur GY, et al. . Proposed treatment protocol for frostbite: a retrospective analysis of 17 cases based on a 3-year single-institution experience. Arch Plast Surg. 2013;40:510–516.
    1. Kamei W, Yago H, Morioka K, et al. . Bilateral multiple fingertip reconstruction with free medialis pedis flaps for treating frostbitten fingertips: a case report. Int J Surg Wound Care. 2020;1:76-83.
    1. Foucher G, Nagel D. Pinch reconstruction by hand to hand finger transfer associated with hallux transfer after a severe frostbite injury. J Hand Surg Br. 1999;24:617–620.
    1. Borovikov A. Toe-to-hand transfers in the rehabilitation of frostbite injury. Ann Plast Surg. 1993;31:245–250.
    1. Das De S, Sebastin SJ. Soft tissue coverage of the digits and hand. Hand Clin. 2020;36:97–105.
    1. Rehim SA, Chung KC. Local flaps of the hand. Hand Clin. 2014;30:137–151.
    1. Simman R, Abbas FT. Foot wounds and the reconstructive ladder. Plast Reconstr Surg Glob Open. 2021;9:e3989.
    1. Khan MI, Tariq M, Rehman A, et al. . Efficacy of cervicothoracic sympathectomy versus conservative management in patients suffering from incapacitating Raynaud’s syndrome after frost bite. J Ayub Med Coll Abbottabad. 2008;20:21–24.
    1. Nygaard RM, Endorf FW. Frostbite in the United States: an examination of the national burn repository and National Trauma Data Bank. J Burn Care Res. 2018;39:780–785.
    1. Janis JE, Kwon RK, Attinger CE. The new reconstructive ladder: modifications to the traditional model. Plast Reconstr Surg. 2011;127:205S–212S.

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe