Destruction of phalangeal epiphyses by frostbite.

Abstract

The pathogenesis, prevention, and treatment of frostbite injury to the hands of adults has been extensively studied (5, 7, 10, 11). The large number of military personnel sustaining this type of injury during the Korean War afforded several authors the opportunity to study intensively the roentgenographic bone changes found in these patients (5, 10). The sequelae of frostbite injury in children has received considerably less attention. Severe frostbite damage of the hands of children causes significant destruction of the phalangeal epiphyses with resultant shortening and deformity of the fingers. Since first reported in 1930 by Löhr (8), only 18 cases have been presented. The rarity of this form of injury is evidenced by the fact that of 7 papers published, 6 are single case reports (1, 4, 6, 8, 9, 12). The solitary large series of 13 patients revealed an interval of injury to radiographic evaluation of up to fifty years (2). Only 3 of the patients described in the literature sustained their injury in the United States (1, 9, 12). The purpose of reporting this case is to call attention to the characteristic roentgenographic appearance of this condition. Case Report A 9-year-old girl was referred for evaluation of shortening of the fingers of both hands. Six years previously the patient had been playing in the snow, without gloves, for about thirty minutes on a very cold day. When she came in she was suffering from severe pain in the hands, and the child's mother noted that all of the girl's fingers appeared “crystallized.” Subsequently, many of the digits turned black, and the fingernails separated. The left little finger remained black for four months, and it was thought that it might have to be amputated. Over the years, however, she has recovered good use of the hands, but does note that her fingers become cold quite easily during the winter months. Physical examination revealed symmetrically shortened, stubby fingers with noticeable incurving of the little fingers. There was good range of motion of all digital joints. The fingernails were normal. A roentgenogram of both hands (Fig. 1) revealed total absence of the distal phalangeal epiphyses. The middle phalangeal epiphyses were also absent with the exception of the third finger of the right hand. All of the proximal phalangeal epiphyses were normal. The distal metaphyses of the middle phalanges were quite irregular, particularly on the third and fourth fingers on the right and both fifth fingers. Radial clinodactyly of the distal phalanges of these fingers was also noted. Discussion The roentgenographic appearance of this case is nearly identical to those previously reported with the exception that more phalangeal epiphyses were destroyed in this patient. The severe soft-tissue injury as an initial consequence of the exposure evoked the greatest concern in all reported patients.