A man with swollen, numb fingers

A man in his 40s presented to the burns and plastic surgery clinic with numbness, swelling, and limited flexion of both hands. While climbing Mount Everest 10 days previously he had removed his gloves for about 10 minutes at an altitude of 8000 metres. Over the next hour he experienced gradual numbness and limited flexion of both hands. Because queues to descend the mountain were long, rewarming with circulating warmed water was performed at the medical camp eight hours later. No blisters or haemorrhagic blisters appeared on the hands after rewarming. Cyanosis was present from the fingertips to the proximal metacarpal-phalangeal joint in all fingers. About four days after the cold injury, the patient was admitted to the emergency department with swollen, blue-grey hands (fig 1, left). He had no pre-existing conditions and was not taking any drugs. He had been a smoker for the past 20 years, averaging 10 cigarettes a day.