Based on these clinical results and on the results of bone scans (previously validated), a new classification of frostbite severity at day 0 is proposed. Four degrees of severity are defined: first degree, leading to recovery; second degree, leading to soft tissue amputation; third degree, leading to bone amputation, and fourth degree, leading to large amputation with systemic effects.

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Because of its peculiar geographic location beneath Mont-Blanc, the Chamonix Hospital plays an important role in the management of mountaineering- and skiing-related traumatic injuries. The authors, thanks to the study of 5200 mountain rescue medical reports, set out to explain the different aspects of this activity: epidemiology, specific equipment, care in the field, reception and primary survey, dispatching, common therapeutic attitudes, progress, and results. In the dangerous environment of the high mountains, emphasis is put on the physicians' experience, allowing an early evacuation in the best conditions to the hospital. Diagnosis at the scene of the accident is very basic, and the initial treatment is based on immobilization, analgesia, and sedating. In the case of resuscitation, only the vital maneuvers are performed; these actions are carried on during the short flight and improved in the crash rooms. Finally, different specific pathologies are mentioned, including cold- or heat-related injuries, exhaustion, lightning strikes, and mountain sickness.

We performed a retrospective study of the results of two-phase technetium-99m hydroxymethylene diphosphonate bone scans in 88 patients with severe frostbite of the extremities. All patients were evaluated within 48 h after rewarming and all underwent a first bone scan (BS1) within 5 days after rewarming (median, day 2) (group 1). An excellent correlation was found between absence of tracer uptake in the phalanges and later amputation; this correlation was especially strong during the bone phase of the scans (specificity = 0.99, sensitivity = 0.96, positive predictive value = 0.92). Normal or high uptake in the phalanges was a reliable indicator of ultimate healing (negative predictive value = 0.99). The sensitivity of the examination was enhanced by performing a second scan (BS2) more than 5 days (median, day 8) after rewarming (group 2, n = 36). A comparative analysis of BS1 and BS2 demonstrated that some of the lesions continued to evolve between day 2 and day 8. This suggests that the lesions could still be modified during this period. On the basis of the findings it is recommended that bone scan be performed close to day 2 in all patients who present with lesions extending proximally to include the entirety of one or more phalanges. In the case of severe sepsis, the results of the first bone scan, BS1, can serve as an indication for emergency amputation. BS2 should be performed close to day 8 only if there is an area of low or absent uptake on BS1. It is concluded that scintigraphy is an excellent means of evaluating patients with severe frostbite of the extremities: as early as day 2 after the injury it can indicate whether amputation is necessary, and between days 2 and 8 it provides valuable information on the efficacy of treatment.

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