Frostbite

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 22 Nov 2024

Last updated: 02 Dec 2024

Frostbite severity is determined by the depth of the freezing and subsequent injury. Grading scales are sometimes used to guide therapy.

Diagnosis is clinical, but technetium-99m or magnetic resonance scanning can give an early indication of prognosis.

The mainstay of treatment is rapid initial rewarming of the injured tissue.

Being a thermal injury, wound management is similar to the management of burns and involves debridement of white blisters (in hospital), regular aloe vera application, and regular hydrotherapy. Early therapy with a nonsteroidal anti-inflammatory drug is advised.

Iloprost and thrombolytic therapy have been shown to be of benefit in severe frostbite where there is a risk of amputation, particularly if given within 24 hours of injury.

It usually takes 1 to 3 months to determine the viability of the surrounding injured tissue and surgery should normally be delayed.

Risk factors for amputation include severe injury grades, late presentation, lower extremity involvement, and wound infection.

Definition

Frostbite is an injury produced by tissue freezing following exposure to cold. Frostbite requires temperatures of 32°F (0°C) or colder to occur.

History and exam

Key diagnostic factors

cold or numbness of affected extremity
pain during rewarming
purplish skin discoloration
white or yellowish, waxy skin discoloration
superficial skin vesiculation
deep purple blisters
tissue necrosis and mummification (dry gangrene)

Full details

Other diagnostic factors

erythema
joint dislocation
fractures

Full details

Risk factors

cold exposure
previous frostbite
vascular insufficiency
high altitude
hypoxia
alcohol
tobacco
dehydration
extremity trauma
constrictive clothing or equipment

Full details

Diagnostic tests

1st tests to order

clinical diagnosis

Full details

Tests to consider

technetium-99m pertechnetate scintigraphy
magnetic resonance angiography of affected extremity
plain radiography

Full details

Emerging tests

thermography and duplex imaging

Treatment algorithm

ACUTE

all patients

Contributors

Authors

Elizabeth A. Kaufman, MD, CAQ-SM

Attending Physician

Department of Orthopedics, Sports Medicine

Scripps Clinic

Attending Physician

Rady Children’s Hospital San Diego

Department of Orthopedics, Sports Medicine

San Diego

Disclosures

EAK declares that she has no competing interests.

Christopher Imray, PhD, FRCS, FRCP, FRGS

Consultant Vascular and Renal Transplant Surgeon

University Hospital Coventry and Warwickshire NHS Trust

Professor Coventry University, Warwick Medical School, Exeter University

Coventry

Disclosures

CI has been asked to provide expert testimony on frostbite. He has delivered lectures, and produced educational material on frostbite.

Acknowledgements

Professor Christopher Imray and Dr Elizabeth A. Kaufman would like to gratefully acknowledge Professor Paul S. Auerbach and Dr Claire Turchi, previous contributors to this topic. PSA and CT declare that they have no competing interests.

Peer reviewers

Luanne Freer, MD, FACEP, FAWM

Medical Director

Yellowstone National Park

Founder/Director

Everest Base Camp Medical Clinic

Nepal

Disclosures

LF declares that she has no competing interests.

Grant S. Lipman, MD

Clinical Assistant Professor of Surgery and Emergency Medicine

Associate Director Wilderness Medicine Fellowship

Assistant Research Director

Stanford University School of Medicine

Palo Alto

Disclosures

GSL declares that he has no competing interests.

Peter Hackett, MD

Director

Institute for Altitude Medicine

Telluride

Disclosures

PH declares that he has no competing interests.

Differentials
- Cutaneous burns
- Frostnip
- Raynaud phenomenon
More Differentials
Guidelines
- 2024 American Heart Association and AmericanRed Cross Guidelines for First Aid
- Clinical practice guidelines for the prevention and treatment of frostbite: 2024 update
More Guidelines
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Frostbite

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic tests

1st tests to order

Tests to consider

Emerging tests

Treatment algorithm

all patients

Contributors

Authors

Elizabeth A. Kaufman, MD, CAQ-SM

Disclosures

Christopher Imray, PhD, FRCS, FRCP, FRGS

Disclosures

Acknowledgements

Peer reviewers

Luanne Freer, MD, FACEP, FAWM

Disclosures

Grant S. Lipman, MD

Disclosures

Peter Hackett, MD

Disclosures

Differentials

Guidelines

Log in or subscribe to access all of BMJ Best Practice

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