What is a Freezing Cold Injury in the Armed Forces?

Freezing cold injuries and non-freezing cold injuries can occur in military personnel due to exposure to extreme cold and wet conditions. These injuries typically affect the extremities, and are a result of either the actual freezing of body tissues or prolonged exposure to cold without freezing.

Here, JMW explores the nature of these injuries within the armed forces, highlighting the causes and risk factors, and the importance of effective prevention, treatment and recovery strategies.

Understanding Freezing Cold Injuries

Freezing cold injuries occur when the skin and other tissues freeze due to exposure to temperatures below freezing point. This primarily affects the body's extremities, such as the fingers, toes, ears and nose, where blood circulation is more exposed in cold conditions. The severity of these injuries can range from mild frostnip, which does not cause permanent damage, to severe frostbite, where ice crystals form within cells, leading to tissue death and possible amputation.

In contrast, non-freezing cold injuries, often referred to as trench foot or immersion foot, result from prolonged exposure to wet and cold environments, but without the temperatures dropping below freezing. These injuries damage capillaries and nerves, leading to long-term problems with pain, swelling and sensitivity to cold.

Both types of injuries share common risk factors including wet conditions, inadequate protective clothing, and direct cold exposure. However, the mechanisms of the different injuries, and the long-term effects on the body and its ability to regulate temperature, differ significantly. Understanding these differences is key for military personnel and medical teams to effectively prevent, diagnose and treat these conditions, ensuring those affected can recover and return to duty or transition to civilian life with minimal long-term health impacts.

Prevalence in the Armed Forces

Military personnel are particularly susceptible to freezing and non-freezing cold injuries due to the nature of their training and operational environments. Exercises and missions often take place in diverse and extreme climates, ranging from arctic conditions to wet, temperate settings where cold exposure is a constant threat. The combination of prolonged outdoor activity, limited access to shelter, and the necessity to remain stationary for extended periods increases the risk of such injuries.

The prevalence of these injuries within the armed forces highlights the importance of understanding environmental risks and implementing effective preventive measures. Training exercises designed to simulate real-life combat scenarios can expose military personnel to conditions ripe for the development of cold injuries, especially when the body's ability to maintain a healthy core temperature is compromised by wet uniforms, heavy equipment, and inadequate personal protection against the cold.

Moreover, operational deployments in cold regions necessitate prolonged exposure to harsh conditions, further elevating the risk. The impact of cold injuries affects the immediate health and operational effectiveness of military personnel, and can also have long-term consequences on their physical wellbeing and ability to perform in the field.

Risk Factors for Cold Injuries

Identifying and understanding the risk factors for cold injuries are crucial steps in protecting military personnel from the potential harm caused by extreme cold and wet conditions. While environmental factors play a significant role, individual susceptibility also influences the likelihood of developing these injuries. The primary risk factors include:

1. Wet conditions: moisture significantly increases heat loss from the body, making wet conditions one of the most critical risk factors for both freezing and non-freezing cold injuries. Wet skin or clothing can reduce body temperature much faster than cold air alone, exacerbating the risk of injury.
2. Cold exposure: direct exposure to cold air, water or surfaces leads to rapid heat loss. The risk is particularly high in environments where temperatures are near or below freezing, but even above-freezing temperatures can be dangerous if other risk factors are present.
3. Wind chill: wind increases the rate of heat loss from the skin, making the air feel colder than it actually is. This effect, known as wind chill, can significantly increase the risk of cold injuries by accelerating the drop in body temperature.
4. Inadequate clothing and gear: proper insulation and protection are vital to prevent heat loss. Military personnel without adequate cold-weather gear are at a higher risk, as their bodies are more exposed to the elements.
5. Individual health and physiology: factors such as fatigue, dehydration, previous cold injuries, and certain health conditions can impair the body's ability to regulate temperature and circulation, increasing vulnerability to cold injuries.
6. Lack of movement: physical activity generates heat and promotes blood circulation. Prolonged inactivity, especially in cold conditions, can lead to decreased body temperature and increased risk of injury.

Symptoms and Effects of Freezing Cold Injuries

The symptoms and long-term effects of freezing cold injuries and non-freezing cold injuries can vary significantly, impacting military personnel's health and ability to perform. Early recognition and treatment are crucial to minimise damage and facilitate recovery.

For Freezing Cold Injuries

• Early symptoms: can include numbness, a prickling sensation and pale skin, followed by a hardening of the skin. As the injury progresses, the affected area may become white or grey and feel firm or waxy.
• Long-term effects: can include persistent pain, sensitivity to cold, and in severe cases, gangrene, which may necessitate amputation. Frostbite can also lead to long-term changes in skin colour, nail growth, and increased risk of infection.

For Non-Freezing Cold Injuries

• Early symptoms: are characterised by a cold sensitivity, numbness and tingling, followed by swelling, redness and pain as the area warms up. Blisters and ulcers may also develop.
• Long-term effects: include chronic pain, sensitivity to cold, and an increased risk of developing infections. Some individuals may experience permanent nerve damage, leading to difficulties in temperature regulation and chronic discomfort.

Recognising and Responding to Symptoms

Military personnel and medical teams must be vigilant for these symptoms, especially during or after exposure to cold and wet conditions. Early intervention can prevent the progression of injuries and reduce the risk of long-term complications.

Medical Treatment and Military Treatment Protocols

Effective medical treatment for freezing and non-freezing cold injuries is critical to mitigate long-term damage and ensure the best possible outcome for affected military personnel. The approach to treatment varies depending on the type and severity of the injury, but follows a general protocol to restore normal body temperature and address immediate and long-term effects.

Initial Treatment

• Gradual rewarming: the first step in treating cold injuries is to gently warm the affected area. This should be done gradually to avoid thermal shock and further tissue damage. For freezing injuries, rewarming in a water bath at a controlled temperature is often recommended.
• Pain management: rewarming can be painful, requiring appropriate pain management. Analgesics are commonly administered to manage discomfort during the rewarming process.
• Dry and insulate: once rewarming is initiated, the affected area should be dried carefully and insulated to maintain warmth.

Medical Evaluation and Ongoing Care

• Frostbite evaluation: in cases of frostbite, further medical evaluation is necessary to assess the extent of tissue damage. This may include imaging tests to determine blood flow and tissue viability.
• Wound care: for both freezing and non-freezing injuries, proper wound care is essential to prevent infection and promote healing. This may involve cleaning, debridement, and dressing of blisters and ulcers.
• Physiotherapy: rehabilitation exercises and physiotherapy may be recommended to restore function and mobility, particularly if there is long-term damage or amputation.

Military Treatment Protocols

The armed forces have specific protocols for the treatment and management of cold injuries, reflecting the unique conditions and challenges military personnel face. These protocols emphasise:

• Rapid identification and response: quick action is vital. Military protocols stress the importance of early identification of symptoms and immediate initiation of treatment.
• Specialised training: military medical personnel receive specialised training in managing cold injuries, ensuring they can provide effective care in challenging environments.
• Preventive measures: beyond treatment, military protocols heavily focus on prevention, including education on risk factors, proper use of gear, and strategies to maintain warmth and dryness.

For military personnel who have suffered cold injuries, long-term management may be necessary to address chronic symptoms such as sensitivity to cold, pain and nerve damage.

Recovery and Management

Recovery from freezing and non-freezing cold injuries involves a tailored approach that addresses the immediate and long-term health needs of affected military personnel. Effective management is required to facilitate healing, prevent complications, and support a return to duty or adjustment to civilian life where necessary.

Immediate Post-Injury Care

• Continued medical monitoring: after initial treatment, continued monitoring is essential to assess recovery progress and identify any complications early. This includes regular check-ups with healthcare providers specialising in cold injury treatment.
• Pain management: managing pain and discomfort is a priority during the recovery phase. This may involve medication, as well as physical therapy to restore function and mobility.

Long-Term Health Management

• Physical rehabilitation: for those with lasting effects from their injuries, physical rehabilitation programmes are designed to strengthen affected areas, improve range of motion, and reduce discomfort.
• Adaptation to sensitivity: individuals experiencing long-term sensitivity to cold may require strategies to adapt their living and working environments. This can include special clothing, modifications to heating systems, and lifestyle adjustments to minimise exposure to cold.
• Psychological support: the psychological impact of sustaining a cold injury and dealing with its long-term effects can be significant. Access to mental health support and counselling is an important part of the recovery process, offering coping strategies and emotional support.

Prevention of Re-Injury

• Education: armed forces personnel who have experienced cold injuries are at an increased risk of re-injury. Educating them on personal risk factors and prevention strategies is critical to avoid future incidents.
• Modified duty: in some cases, modifications to duty assignments may be necessary to protect individuals from conditions that could exacerbate their condition or lead to re-injury.

Support and Compensation

• Support services: the armed forces provide support services to assist personnel in their recovery and rehabilitation, including access to medical specialists and resources for adapting to any long-term effects.
• Compensation and benefits: individuals who have sustained cold injuries during their military service may be eligible for compensation and benefits. These are designed to acknowledge their service and sacrifice, providing financial support and access to specialised care.