Case Study - A seasonal diagnosis

The severe winter weather recently has brought an unexpected case to the surgery of Dr Kathryn Fleming.

One toe had necrotic tissue but otherwise the tissues were viable
One toe had necrotic tissue but otherwise the tissues were viable

Mr M, an active 54-year-old, attended the surgery one morning during the exceptionally cold and snowy period last month.

He is a postman well known to everyone in our country village as he walks through every development and street delivering letters of good cheer.

He had noticed his feet were colder after the first few days of the snow. Despite his heavy boots and the purchase of thermal socks, his feet continued to become sore and finally walking had become quite unbearable.

A colleague at the surgery had prescribed nifedipine by telephone.

'Doctor, I think I've got chilblains' he said as he sat down and took off his socks.

Ulcerated toes
He showed me the ulcerated tips of the toes on both feet, which were consistent with second degree frostbite.

One toe had some necrotic tissue but otherwise the tissues were viable.

The last time I had seen frostbite was when I was the medical officer on an expedition to Mount Everest in 1993.

I had never expected to see it in the less savage climate of Northern Ireland.

Examination revealed no underlying conditions. His peripheral pulses were strong. There were no signs of arthritis but a history suggestive of Raynaud's disease which had not particularly troubled him in the past.

Frostbite is the freezing of the tissue with microvascular occlusion and subsequent tissue anoxia.

Some of the damage may result from the reperfusion during rewarming. The main complication in an otherwise healthy individual is secondary wound infection and treatment is aimed at optimising tissue healing.

Balancing work and rest
For Mr M, while providing cover with antibiotics and skin dressings was straightforward, the advice to rest and elevate the damaged feet was a huge blow.

The three weeks prior to Christmas were his busiest time, when he achieved maximal overtime and the resulting bonuses.

As always, in practice the dilemma of optimal care has to be balanced with real life.

I advised him he had a work-related illness and suggested that he take the time to talk to his employer's occupational health department.

He attended the treatment room for regular dressings. There was a bit of tissue loss over the third toe on the left foot but otherwise he made a full recovery.

He managed to take some time off but also got extra shifts in the office thus avoiding heavy weight bearing.

Prevention with thermal insoles, thermal socks and early vasodilators will be indicated in the future.

  • Dr Fleming is a GP in Northern Ireland.

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