Frostbite Injuries Treated in the Helsinki Area from 1995
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-
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 1995.5They 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.6In 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.8–10Few
reports have been published on frostbite in the civilian pop-
ulation, though such injuries are fairly common in northern
countries.5,11The 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
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.
Quality of life, Death, Reconstructive
J Trauma. 2004;57:1315–1320.
xposure to cold results in a variety of injuries, from
local, superficial chilblains and frost nips, to immersion
injuries from cold or warm water,1to more severe, and
The pathophysiology of frostbite is thought to have two
distinct mechanisms: direct cellular damage at the time of
exposure to the cold12and post-thaw arterial vasoconstric-
tion, leading to disordered vascular flow patterns and damage
to the microcirculation. The outcome is vascular thrombosis
and dermal necrosis.13,14Recent 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.16Although
current research has exposed some essential factors in the
progress of frostbite injury17and thus provided more options
for medical treatment, the primary treatment is still princi-
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
tissue viability.18,19Laser-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.21Characteristic 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,
Address for reprints: Virve Koljonen, Department of Plastic Surgery,
and Töölö Hospital, P.O. Box 266, FIN 00029 HUS, Helsinki, Finland;
The Journal of TRAUMA?Injury, Infection, and Critical Care
Volume 57 • Number 6
served in adult patients who had sustained severe frostbite in
Amputations and other consequences of frostbite may
impair the patient’s working ability. Information on the
health-related quality of life (QOL) is, therefore, needed to
assess the outcome of treatment from the patient’s point of
view. Amputations can be life-saving procedures, especially
in severe frostbite injuries, but they may reduce the patient’s
ability to cope with normal everyday routines and thus di-
minish his or her QOL.23Unfortunately, very little is known
about the QOL of frostbite patients after recovery.
The purpose of this study was to investigate risk factors
for frostbite and the outcome of frostbite patients admitted to
hospital. We also wanted to establish how patients hospital-
ized for frostbite injury experience their quality of life and
how well they adjust to everyday life after injury and subse-
PATIENTS AND METHODS
The surgical database was reviewed for patients treated
for frostbite in Töölö hospital from 1995 to 2002. Forty-three
patients were found. The clinical data, and accident and
treatment characteristics of these patients were collected. The
Finnish Meteorological Institute provided the temperature for
the day of the frostbite. Two consecutive temperatures were
selected close to the accident time, and the mean temperature
was calculated from these figures.
A statistical analysis was performed using NCSS 2000
software to find prognostic factors for patient survival. Mul-
tivariate analysis was conducted for age, gender, temperature,
exposure time, consumption of tobacco or alcohol, or an
underlying vascular disease with an unfavorable course of
disease. Unfavorable course of disease was classified accord-
ing to outcome, the need for amputation or other surgical
procedure being considered as a poor outcome. Furthermore,
operations were categorized as minor (amputation of distal
phalanx of the extremities) or major (larger amputations or
reconstruction of the defect with full-thickness skin grafts or
flaps, either local or microvascular). Comparisons were made
using the Mann-Whitney U test and Fisher’s exact test. Sig-
nificance was defined as p ? 0.05.
Quality of Life
A RAND-36-Item Health Survey 1.0 questionnaire was
mailed to patients, and their responses were then statistically
analyzed. Questionnaire with items covering several aspects of
life, physical, mental as well as social, are commonly used to
assess QOL. The health-related QOL questionnaire we used has
been established under two names: The MOS 36-Item Short-
Form Health Survey (MOS SF-36) and The RAND-36 Item
Health Survey. RAND-36 has a Finnish version, with questions
relevant to Finnish society.
The two above questionnaire are similar, as both explore
well-being and function in eight dimensions. RAND-36 can
be used to provide insight into the consequences of chronic
disease. It contains questions on eight aspects of life: general
health, physical functioning, emotional well-being, social
functioning, energy, bodily pain, role functioning/physical,
and role functioning/emotional.
Amputees report significantly more problems with mov-
ing, social isolation, pain, and disturbed sleep than do control
groups.24Most studies on amputees concern patients who
have undergone amputation because of vascular disease; little
is known about the QOL of frostbite patients after their
Forty-three patients with frostbite were admitted to
Töölö Hospital during 1995 - 2002. Clinical data on one
patient were unavailable, and the patient was excluded from
the study. The final series thus consisted of 42 patients. The
patients’ characteristics are presented in Table 2. The distri-
bution of injuries by month is listed in Figure 1.
Table 1 Predisposing Factors in Military and Civilian
Inability to protect oneself against
Unbalanced marital status
Lack of regular residence
Vehicular trauma or failure
Clothing too light for conditions
Marine ski-march leather
Table 2 Patient Characteristics
Duration of hospital stay
Time between accident and 1st
Outpatient clinic visits
42.5 (range 13–79) yr
9 (range 1–32) days
41 (range 1–323) days
3 (range 1–12)
The Journal of TRAUMA?Injury, Infection, and Critical Care
A total of 92 frostbite injuries were recorded. Character-
istically most of the injuries occurred at night. The patients
typically suffered injuries in multiple anatomic regions, the
average number of injuries being 2.2 per patient. The loca-
tions of injuries are illustrated in Figure 2.
The mean exposure time was 2.5 hour (from 10 minutes
to 9 hour). There was no significant difference in exposure
times between patients under the influence of alcohol or
drugs and patients with mental disorders (2.3 hour) as com-
pared with mean exposure time. At lower temperatures, ?10
C° or colder, the exposure times seem to be slightly shorter,
2.3 hour. The mean exposure time in patients treated surgi-
cally was 2.4 hour as compared with 2.3 hour in patients
treated conservatively. None of these differences were statis-
tically significant. A total of 11 patients suffered frostbite
injury when the temperature was above ?10 C°; the exposure
time was then 2.5 hour.
The length of hospital stay ranged from 1 to 32 days
(mean 9 days). After discharge, 31 patients later attended the
outpatient clinic. The mean number of outpatient clinic visits
was three, ranging from one to 12 visits. No patients died of
their frostbite injuries though 12 (29%) died during the fol-
low-up time; the mean interval was 2.7 yr. Five of those
patients, who died during the follow-up period were treated
conservatively. The remaining seven had operations; five
patients had partial finger amputations, one patient partial toe
amputation and one leg amputation.
The mean interval between injury and primary operation
was 40 days (range 1 to 323 days). Twenty-one patients
(50%) had no operation; four (10%) underwent a minor
operation, and 17 (40%) had a major operation. All except
one of the 11 patients (90%) who sustained frostbite injuries
at temperatures above ?10°C were treated surgically. In this
group, most of the injuries affected the upper extremities. The
remaining 31 patients were injured at temperatures below
?10°C, and 12 (39%) of these were treated surgically.
Nine patients (20%) needed secondary reconstructive
procedures. These were six full-thickness skin grafts, one
venous flap transfer, one microvascular scapular flap transfer,
and one toe-to-thumb transplantation. The latter operation
was in a patient who had both thumbs amputated.
Statistically, temperature (p ? 0.01) and age (p ? 0.05)
were prognostic factors for an unfavorable course of disease.
Exposure time, consumption of tobacco or alcohol, or under-
lying vascular disease were not found to have an effect on the
outcome of frostbite injury. The older the patient the greater
the likelihood of an operation.
The study design is presented in the Figure 3. Thirty
RAND-36 questionnaire were mailed, and 14 (47%) were
returned completed. Sixteen could not be delivered because
the address of the recipient was unknown. Ten (71%) of the
respondents were satisfied or totally satisfied with their phys-
ical performance; 5 (36%) reported their emotional well-
being as very poor and 9 (64%) as excellent. Half of the
respondents experienced no limitations to their social func-
tioning. In addition, half of the respondents still had chronic
pain and 2 (15%) reported having intolerable pain daily.
Frostbite injuries treated in hospital are rare among the
civilian population. Töölö hospital is a tertiary hospital, part
of the Helsinki University Central Hospital complex. The
leading trauma center in southern Finland, it serves one
million inhabitants, which is one-fifth of the population of
Finland. We calculated an annual incidence of 0.05 per 100
000 inhabitants for hospital-treated frostbite injuries. This is
50 times more infrequent than the incidence reported by
Juopperi and coworkers.5However, they included all Finnish
patients with frostbite as a primary or secondary diagnosis in
their study, whereas we included only those patients who
required hospital attention and surgical treatment in southern
We found that male gender and anti-social behavior
increase the risk of frostbite in general. The female:male ratio
Fig. 1. Monthly distribution of frostbite injuries. On the left side
number of patients and on the right side temperatures in degrees
Fig. 2. Location of injuries according to the anatomic region. Of
the 21 upper extremity injuries there were 18 affecting both extrem-
ities. In the lower extremities 8 injuries, of which both sided 6. Only
one facial. 10 affecting both upper and lower extremities and 2
facial and upper extremity injuries
Frostbite and Quality of Life
Volume 57 • Number 6
was 1:6. There is, however, no physiologic male-female
difference in the potential for frostbite.25Previous studies
have found that the severity of frostbite correlates with anti-
social behavior.11,26In our study, over 60% of the patients
were acutely under the influence of alcohol at the time of
injury. Chronic alcohol consumption was apparent in the
records of 15 patients (35%). Moreover, six of these patients
lacked a permanent residence/address, and 14 (35%) had a
record of mental disorders. Our findings, higher incidence in
men, antisocial-behavior, and acute or chronic consumption
of alcohol, are consistent with those of previous studies.
The current study shows that age (p ? 0.05) and tem-
perature (p ? 0.01) were statistically significant prognostic
factors indicating the severity of injury and thus leading to a
more demanding operation. Colder temperature actually re-
duced the likelihood of surgical treatment. Ninety-one per-
cent of the patients who suffered frostbite at temperatures
above ?10°C were treated operatively, although there was no
major difference in exposure times (2.5 and 2.3 hour, respec-
tively). It is intriguing that most of these injuries were bilat-
eral, only three out of 11 having affected one extremity; the
remaining eight were bilateral and five of them were upper
extremity injuries. This inverse correlation between warmer
temperatures and operations is attributed to the preponder-
ance of digital injuries due to inadequate clothing. The upper
extremities, the fingers in particular, are more susceptible to
cold exposure, as the vascular structures are smaller and
narrower and the tissue coverage is thinner in the upper than
in the lower extremities.
Previously, exposure time has been shown to correlate
with severity of frostbite injury; such was not, however, the
case in our study. We found no difference in exposure times
between intoxicated and sober patients. Further, we noted no
difference in exposure times between surgically and conser-
vatively treated patients.
Patients typically presented with multiple injuries, the
average being 2.2 per patient. The majority of the injuries
were located in the upper extremities (59), followed by the
lower extremities (30) and the head and neck region (3). Ten
of the patients had both upper and lower extremity injuries.
Eighty-six percent of the upper extremity injuries and 75% of
the lower extremity injuries were bilateral. Predisposing fac-
tors differ in rural and urban environments. In the urban
environment, a prominent predisposing factor for frostbite is
reported to be inadequate or inappropriate clothing,5the se-
lection of clothes frequently being dictated by the occasion
rather than the weather conditions. The multi-location of
injuries also seems to be related to inadequate clothing. In
Finland, practically every house or apartment has sufficient
heating in winter, the inside temperature usually being in the
range 20–24°C. Modern living with its well functioning pub-
lic transport and warm indoors permits city dwellers to dress
Fig. 3. Study design. Number of patients included in the study.
The Journal of TRAUMA?Injury, Infection, and Critical Care
in light clothing. They no longer need to dress according to
the outside temperature, which causes a false sense of the
outdoor reality. In some of our patients, at least, these factors
appear to have contributed to their injury.
The average length of hospital stay was 9 days (range 1
to 32 days). The mean time between injury and primary
operation was 40 days, median 31 days (range 1 to 323 days.)
The 323-day delay was caused by the failure of one patient to
keep his outpatient clinic appointments due to his alcoholism.
After 11 months he reappeared with very well-demarcated
limbs. One leg was amputated, whereafter he once again
vanished from our surveillance. Most of the patients were
operated on after a period of home treatment (Fig. 4). Half of
the patients22underwent a primary operation and nine (21%)
had reconstructive procedures at a later stage (Fig. 5).
The monthly distribution of frostbite injuries showed that
almost half (48%) occurred in the shortest and coldest month,
February. The second largest accumulation of injuries (26%)
was recorded in December. Since Christmas falls in December,
this is traditionally considered as the family month. Feelings
of loneliness and alienation mount during family holidays, lead-
ing to even more anti-social behavior. Anecdotally, in Finland,
January is considered as “Dropless month,” because several
organizations encourage people to go without alcohol.
RAND-36 questionnaire was mailed to 30 patients. Forty-
seven percent of those patients returned the RAND-36 question-
naire. Such a low response rate is not uncommon in question-
naire surveys.27Sixteen questionnaire did not reach the recipient
because the address was unknown. Most of the patients were
satisfied or totally satisfied with their present physical perfor-
mance. One-third reported that their emotional well-being was
poor and two-thirds that it was excellent. Half of the respondents
experienced no limitations to their social functioning. These
excellent results for patients who have recovered from frostbite
are merely a sampling bias; they do not represent the majority of
frostbite patients. Only one third of the initial 42 patients admit-
ted to hospital due to frostbite answered the quality of life
questionnaires. It is assumed that the patients who responded are
not those who suffered from social or mental problems. There-
fore these results should be regarded as indicative only. On the
other hand, half of the respondents still had chronic pain and
15% reported having intolerable pain daily, so much so that it
interfered with their sleep.
The high death rate, almost 30%, during our follow-up
time is striking. No patients died of frostbite directly, all those
who died during the follow-up being alcoholic. Alcoholism is
a chronic disease that gradually undermines people’s capacity
to take care of themselves. Sustaining a frostbite injury may
be an indication of this disease reaching its endpoint.
In conclusion, we found that cases of frostbite requiring
hospitalization are very rare even in countries where winter
lasts almost half of the year. Fortunately, most frostbite in-
juries are mild chilblains and frost nips which, like their burn
counterparts, superficial grade I burns, are treated conserva-
tively without complications in outpatient clinics or at home.
In urban settings, most frostbite injuries seem to be multi-
locational, the majority in the upper extremities. The best and
easiest way to avoid this type of frostbite is probably to wear
adequate and appropriate clothing.
Anti-social behavior and older age are major risk factors
leading to severe outcome of frostbite injuries. Twenty percent
of our patients needed reconstructive procedures, including mi-
crovascular operations such as venous or scapular flap transfer
and toe-to-thumb transplantation. Physical injuries are com-
pounded by the mental problems suffered by patients and the
difficulties many experience with their social life. Progressive
alcoholism leads to an inability to take care of oneself, and our
study revealed that frostbite might be an indication of terminal
alcoholism. Similar problems are encountered in burn victims.
Severe frostbite injury requires multidisciplinary expertise in
as well as dealing with the social problems typical with these
patients. Therefore we recommend that frostbite injuries requir-
ing hospital attendance should be treated in specialized burn
units, where ample know-how of acute as well as reconstructive
surgery is available.
We thank Mr. Timo Pessi for his assistance with the statistical work
and Ms. Helena Pohjanoksa from the Finnish Meteorological Institute for
providing the temperature data.
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