Intended for healthcare professionals

Endgames Picture Quiz

Helsinki −20°C

BMJ 2011; 343 doi: (Published 20 December 2011) Cite this as: BMJ 2011;343:d8020
  1. Andrew J Lindford, consultant plastic surgeon,
  2. Jyrki Vuola, consultant plastic surgeon
  1. 1Helsinki Burn Centre, Department of Plastic Surgery, Helsinki University Hospital, Töölö Hospital, FIN 00029 HUS, Finland
  1. Correspondence to: A J Lindford andrew.lindford{at}

A 36 year old unemployed man with a history of depression and heavy alcohol consumption presented to the local accident and emergency department with injuries to both feet. The previous night he had been drinking heavily. He had attempted to return home but did not make it and had spent the entire night sleeping outside in a snow drift.

He was otherwise fit and well with no allergies, and the only drug that he took regularly was citalopram for his depression.

On arrival, he was systemically well with a normal core temperature. Bilateral foot injuries were noted (figure). The more severely affected right foot had a dusky ischaemic appearance, with a clear temperature change at the level of the ankle joint and absent distal pulses. The toes of the left foot were also dusky and cool, with blistering over their dorsal aspect. The distal pulses were weakly palpable in this foot. The patient had no other injuries and all other systems examinations were normal.


  • 1 On the basis of the history and examination findings, what is the likely diagnosis?

  • 2 What are the predisposing risk factors for this condition?

  • 3 What investigations might you consider to confirm your diagnosis?

  • 4 How is this condition treated?

  • 5 What is the role of surgery in this condition?


1 On the basis of the history and examination findings, what is the likely diagnosis?

Short answer

The likely diagnosis is frostbite. This occurs when the temperature of the skin drops to about −0.5°C and tissue freezes, resulting in the formation of intracellular ice crystals and microvascular occlusion.

Long answer

There are three types of peripheral cold injury (box 1).1 2 3 4

Box 1 The three types of peripheral cold injury

  • Frostnip: A mild, completely reversible, cold injury that is characterised by skin pallor and numbness

  • Tissue freezing injury: Commonly known as frostbite, this type of injury is defined as tissue damage caused by the tissue freezing below −0.5

  • Non-tissue …

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