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Urban Frostbite: Strategies for Limb Salvage.

INTRODUCTION
Under ideal circumstances, severely frostbitten extremities are rapidly rewarmed and treated with thrombolytic therapy within 6-24 hours. In an "inner city," urban environment, most patients who suffer frostbite injuries present in a delayed fashion, sustain repeated injuries further complicated by psychological issues or intoxication, and are rarely ideal candidates for thrombolytic therapy within the prescribed timeframe. We describe our experience with the treatment of urban frostbite injuries.


METHODS
A retrospective review of patients with cold injuries sustained between November 2013 and March 2014 treated at a verified burn center in an urban setting was performed.


RESULTS
Fifty-three patients were treated (42 males, 11 females). Average patient age was 41.8 years (range 2 - 84 years). No patients met criteria for thrombolytic therapy due to multiple freeze-thaw cycles or presentation greater than 24 hours after rewarming. Deep frostbite was seen in ten patients. Of these patients, nine underwent debridement, resulting in partial limb amputations at levels guided by Tri-phasic technetium (Tc-99m) bone scans. Wound closure and limb-length salvage was then achieved by: free flap coverage (n=2), local flaps (n=8), split thickness skin grafting (n=22) and secondary intention healing (n=6).


CONCLUSION
While tPA has been successful in reducing the need for digital amputation following frostbite injuries, in our experience, this treatment modality is not applicable to the urban patient population who often present late and after cycles of re-injury. Therefore, our approach focused on salvaging limb length with durable coverage, as the injuries were unable to be reversed.