About 5,600 victims of cold injury were evacuated from Korea during the winter of 1950-1951. Most of these patients were considered to have cases of frostbite rather than trench foot. A group of 100 of these patients, selected as a representative sample of the total number evacuated from Korea, were observed on average six days after the occurrence of their cold injury. Additional studies carried out four years later on these 100 patients form the basis for this report.

Material and Methods

Throughout this study, cold injury has been classified into four degrees of severity: first degree involves only hyperemia and edema; second degree, hyperemia with vesicle formation; third degree, necrosis of the skin and subcutaneous tissue; and fourth degree, complete necrosis and loss of tissue.

Of the 100 young men with cold injuries, 89 reported to medical installations where especially complete data, including a history, statement of symptoms, photographs of healed lesions, roentgenograms, circulatory measurements, and other physical findings were obtained.

Symptomatology

The six most common symptoms of these former patients were cold feet, pain, excessive sweating, numbness, abnormal color, and symptoms in joints. All symptoms, with the exception of excessive sweating, were much more severe during the winter months than during the summer months. The pain and cold feet experienced in cold weather were the most bitter complaints expressed by the patients with frostbite.

Clinical Observations

The report on clinical observations was restricted to those 50 patients examined and studied personally by the authors. All symptoms were more severe than organic physical findings would indicate, but to what degree these complaints may have a psychogenic basis could not be determined.

In third- and fourth-degree frostbite cases residual pathology could always be detected four years after the injury. The most common physical findings were tissue loss, scars, abnormal nails, hyperhidrosis, abnormal color, and stiff joints. Tissue loss did not occur in second-degree cold injury, but did occur in all fourth-degree cases. Third-degree injury was a tissue defect (rather than a loss of a part), a “punched-out” area resulting from sloughing of the overlying eschar and subsequent granulation of the lesion. Scars were absent in patients with ill-defined conditions of the feet and could not be detected in any patients with second-degree frostbite. Scars were usually present at the site of injury in cases of third-degree injury and always extensive in cases of fourth-degree cold injury.

One of the most characteristic physical findings was that of abnormal toenails. In more than two-thirds of the cases in which the injury was severe enough to involve full-skin thickness (third-degree of severity), the nails were markedly thickened, heavily ridged, contracted at the front margin, and the nail beds often had a cyanotic appearance. No abnormalities of the nails, however, were observed in cold injuries of less than third-degree severity.

The determination of hyperhidrosis or excessive sweating was qualitative. One question that could not be answered was whether the excessive sweating was a cause or effect of cold injury. Because a hyperhidrotic person is a likely candidate for cold injury, the hyperhidrosis may have been present before the frostbite occurred and a major factor in causing the frostbite.

The finding of abnormal color was different for Caucasian patients as compared to the Afro-American patient. Abnormal color was primarily an erythrocyanotic appearance in Caucasian patients and probably associated with peripheral circulatory disturbance. In Afro-American patients abnormal color was caused by skin depigmentation which occurred in all patients with third- or fourth-degree frostbite.

Damage to the joints was more frequent and more extensive in patients with more severe cold injury. In fourth-degree frostbite some of the stiffness of the joints could be attributed to heavy, contracted scar tissue surrounding the joint rather than pathology within the joint itself. In patients with pathological findings in the joints of previously frostbitten extremities, there was no evidence of arthritic changes or changes in the joints elsewhere in the body.

Roentgenographic Studies

None of the patients showed late occurrence of osteoporosis four years after cold injury. Trabecular changes as noted in a few of the four-year films consisted of coarsening of the trabeculae as seen in patients with changed statics. In those cases where a complete follow-up was possible for soldiers with partially mutilated terminal phalanges, it appeared that a loss of overlying soft tissue and exposure to air caused the mutilation. There was no convincing evidence that cold injury itself had caused mutilation of bone without loss of the overlying soft tissue. Of particular interest were the punched-out defects of the surfaces of the joints of toes and fingers. An exact comparison between the degree of frostbite and the occurrence of lesions of the joint was not possible.

Comment

In cases of first- and second-degree injury, there were almost no physical findings present in patients with cold injury after four years. However, when cold injury is full-skin thickness (third- or fourth degree of severity), certain findings become evident and relatively constant:

Summary

Symptoms after frostbite, in order of frequency, are excessive sweating, pain, cold feet, numbness, abnormal color, and symptoms in the joints. Characteristic physical findings are tissue loss and scarring, abnormal nails, discoloration and depigmentation, hyperhidrosis, and joint abnormalities. Roentgenographic changes include early transient osteoporosis, mutilation of terminal phalanges, cyst-like defects of the bone near the joint surfaces of fingers and toes, early transient periosteal new bone formation, and growth disturbance in patients with open epiphyses.

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If you have questions or special needs concerning
this independent study, please contact:

John Whatley, PhD
Birmingham EERC
Medical Forum Building, Suite 500
950 22nd Street North
Birmingham, AL  35203-5300

e-mail: john.whatley@lrn.va.gov

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Reviewed/Updated: February 21, 2002