Indian Journal of Nuclear Medicine
Home | About IJNM | Search | Current Issue | Past Issues | Instructions | Ahead of Print | Online submissionLogin 
Indian Journal of Nuclear Medicine
  Editorial Board | Subscribe | Advertise | Contact
Users Online: 35 Print this page  Email this page Small font size Default font size Increase font size


 
 Table of Contents     
INTERESTING IMAGES
Year : 2017  |  Volume : 32  |  Issue : 4  |  Page : 367-368  

Bone scan in evaluation of bone viability in severe frostbite of the hand


Department of Radiology, Mayo Clinic College of Medicine, Rochester, MN, USA

Date of Web Publication12-Oct-2017

Correspondence Address:
Ishan Garg
Department of Radiology, 200 First Street SW, Rochester, MN 55905
USA
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijnm.IJNM_53_17

Rights and Permissions
   Abstract 


A 39-year-old male presented to the emergency department (ED) with frostbite to the fingers of both hands. In the ED, he received warm baths, acetylsalicylic acid, clopidogrel, and heparin. A three-phase bone scintigraphy with technetium-99m-methylene diphosphonate revealed absent radiotracer uptake in distal phalanges of both hands. The patient received acetylsalicylic acid, clopidogrel and wound care for the next 5 days and made an excellent recovery with satisfactory wound healing in both hands. Early rapid rewarming and reperfusion can improve the prognosis significantly and therefore bone scan done within first 1–2 days may give spurious results.

Keywords: Bone scan, cold thermal injury, frostbite, hand


How to cite this article:
Garg I, Baladron Zanetti MJ, Kendi AT. Bone scan in evaluation of bone viability in severe frostbite of the hand. Indian J Nucl Med 2017;32:367-8

How to cite this URL:
Garg I, Baladron Zanetti MJ, Kendi AT. Bone scan in evaluation of bone viability in severe frostbite of the hand. Indian J Nucl Med [serial online] 2017 [cited 2021 Apr 15];32:367-8. Available from: https://www.ijnm.in/text.asp?2017/32/4/367/216554



A visually impaired 39-year-old male was brought to the emergency department (ED) with frostbite to the fingers of both hands. The patient was found in a disoriented state outside his house in frigid temperatures after being out there for at least one and a half to possibly 4 h. The patient had a known history of poorly controlled type 1 diabetes, end-stage renal disease, congestive heart failure, hypertension, and polysubstance abuse. In the ED, within the first 24 h after the frostbite, the patient received warm water baths, acetylsalicylic acid, and clopidogrel. Perfusion into the fingers was preserved in both the hands but with delayed capillary refill time. Gray to light purple discoloration, particularly in the distal phalanges of both hands and marked blistering on the right hand beginning at about the level of the proximal phalanx were noted [Figure 1]. The examination of his forearms and wrists was unremarkable.
Figure 1: Day 0 (a-f) swollen fingers with skin erythema, blue-gray discoloration of distal phalanges and large blisters (a and b - left hand, c and d - right hand). Technetium-99m-methylene diphosphonate three-phase bone scan revealed absent radiotracer uptake in the second to fifth distal phalanges of the right hand on blood pool (e) and delayed phase planar images (f). Day 14 (g - right hand) showing wound healing with re-epithelization of dorsal aspect of fingers

Click here to view


A three-phase bone scintigraphy with technetium-99m-methylene diphosphonate (99m Tc MDP) was done immediately following the rewarming of the hands. It revealed absent radiotracer uptake in all the distal phalanges of the right hand and second to fourth distal phalanges of the left hand [Figure 1]. In view of multiple comorbidities, the patient was not started on an aggressive treatment with tissue plasminogen activator (tPA). The patient received heparin for 48 h. After that, he was continued on acetylsalicylic acid, clopidogrel and wound care for the next 5 days. He made an excellent recovery with improved motor function and satisfactory wound healing in both hands [Figure 1].

Frostbite is defined as tissue injury resulting from prolonged exposure of tissue to temperature below its freezing point.[1] Frostbite injuries usually involve the hands and feet.[2] Many coexisting conditions present in this reported case can also predispose to frostbite such as illicit drug use and disease such as diabetes mellitus.[3] Clinically, frostbite injuries are divided into superficial ( first and second degrees) or deep (third and fourth degrees).[4],[5] First-degree frostbite presents with erythema and mild edema. Second degree presents with erythema, substantial edema and clear or milky fluid-filled blister. Third degree has hemorrhagic blisters with severe edema. Fourth degree can show blue-gray mottled appearance with eventual gangrene and extensive necrosis.[4],[5],[6]

Early radiological investigations with angiography can provide vital information on vessel patency, identify potential targets for thrombolysis, and monitor response to thrombolytics.[7] Rapid rewarming using warm baths, and early reperfusion with peripheral vasodilators, heparin, tPA are the mainstay of treatment. To minimize tissue damage, the treatment must be started within the first 24 h.[7] For further potential surgical management, it is crucial to assess the depth of injury, which can be difficult to determine clinically. Multiphase bone scintigraphy using Tc-99m MDP is an excellent tool to assess bone viability. It can be used to establish the depth of injury and to provide early prognostic evaluation including the bone perfusion and demarcation of viable from necrotic bone tissue.[7],[8],[9] The scan should be performed 2–4 days after the original injury. The early treatment can lead to marked improvement in the perfusion and therefore bone scan done too early can give a false level of demarcation between viable and necrotic tissue, as seen in this case.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Handford C, Buxton P, Russell K, Imray CE, McIntosh SE, Freer L, et al. Frostbite: A practical approach to hospital management. Extrem Physiol Med 2014;3:7.  Back to cited text no. 1
    
2.
Imray C, Grieve A, Dhillon S; Caudwell Xtreme Everest Research Group. Cold damage to the extremities: Frostbite and non-freezing cold injuries. Postgrad Med J 2009;85:481-8.  Back to cited text no. 2
    
3.
Ingram BJ, Raymond TJ. Recognition and treatment of freezing and nonfreezing cold injuries. Curr Sports Med Rep 2013;12:125-30.  Back to cited text no. 3
    
4.
Mohr WJ, Jenabzadeh K, Ahrenholz DH. Cold injury. Hand Clin 2009;25:481-96.  Back to cited text no. 4
    
5.
Hallam MJ, Cubison T, Dheansa B, Imray C. Managing frostbite. BMJ 2010;341:c5864.  Back to cited text no. 5
    
6.
McIntosh SE, Opacic M, Freer L, Grissom CK, Auerbach PS, Rodway GW, et al. Wilderness Medical Society practice guidelines for the prevention and treatment of frostbite: 2014 update. Wilderness Environ Med 2014;25 4 Suppl: S43-54.  Back to cited text no. 6
    
7.
Millet JD, Brown RK, Levi B, Kraft CT, Jacobson JA, Gross MD, et al. Frostbite: Spectrum of imaging findings and guidelines for management. Radiographics 2016;36:2154-69.  Back to cited text no. 7
    
8.
Cauchy E, Chetaille E, Marchand V, Marsigny B. Retrospective study of 70 cases of severe frostbite lesions: A proposed new classification scheme. Wilderness Environ Med 2001;12:248-55.  Back to cited text no. 8
    
9.
Roca I, Barber I, Fontecha CG, Soldado F. Evaluation of bone viability. Pediatr Radiol 2013;43:393-405.  Back to cited text no. 9
    


    Figures

  [Figure 1]



 

Top
  
 
  Search
 
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
    Abstract
    References
    Article Figures

 Article Access Statistics
    Viewed695    
    Printed8    
    Emailed0    
    PDF Downloaded106    
    Comments [Add]    

Recommend this journal