Adventure & Sports Injuries

Frostbite is freezing of the skin and the tissue under it in extreme cold. The fingers are among the parts most at risk, along with the toes, nose and ears. Dr. Jindal sees frostbite in trekkers and mountaineers returning from high-altitude expeditions in the Himalaya, including Everest. A common story is that gloves were taken off for a few minutes, to take photographs, handle ropes or adjust equipment, or that the gloves worn were not warm enough or had become wet.

How serious is it?

• Frostnip: the fingers are cold, numb and pale, but recover fully once warmed. It is a warning sign.
• Superficial frostbite: the skin turns white or waxy. After warming it may swell and form blisters filled with clear fluid. It usually heals.
• Deep frostbite: the finger is hard, blue-grey or blackish, and blisters may be filled with blood. Deeper tissue is affected, and part of the finger may be lost.

First aid on the mountain

1. Get out of the wind and cold as soon as possible. Remove wet gloves and any rings.
2. Do not rub the fingers, and do not rub them with snow. This adds damage.
3. Do not rewarm the fingers if there is a chance they will freeze again before you reach safety. Thawing and refreezing does more harm than staying frozen. Keep them dry and protected until you are somewhere warm.
4. Once safe, rewarm the hands in warm, not hot, water (about 37 to 39 °C, comfortably warm to an unaffected hand) until the skin is soft and colour returns, usually 15 to 30 minutes. Rewarming is painful, and pain relief helps. Do not use a fire, stove or heater, because numb skin burns easily.
5. Do not burst blisters. Cover the hand loosely with a clean, dry dressing, with gauze between the fingers, and keep the hand raised.
6. Get medical help early. For severe frostbite, specialised hospitals can sometimes give medicines that improve blood flow to the fingers, but these work best when started within the first day or so. Tell the expedition doctor or team leader as soon as you notice symptoms.

Treatment after you return

Frostbite is treated patiently. Blisters and wounds are dressed, the hand is kept moving with therapy, and the fingers are watched closely. It often takes several weeks for the line between healthy and damaged tissue to become clear. Scans can sometimes help to show which tissue will survive. Surgery to remove any tissue that has died is usually delayed until this is clear, so that as much length as possible is saved.

Where part of a finger is lost, the hand can often be reconstructed later with skin cover (flaps and skin cover) or by restoring finger length. Some people have lasting cold sensitivity, numbness, stiffness or nail changes after frostbite, and hand therapy helps with these.

Tennis elbow is pain on the outer side of the elbow. It comes from overloading the tendon where the forearm muscles that lift the wrist and fingers attach to the bone. Despite the name, most people with tennis elbow do not play tennis. It is common in climbers, trekkers who lean on poles, racquet players, gym users, and people whose work involves repeated gripping, lifting or typing. It is most common between the ages of 35 and 55.

Symptoms

• pain on the outer side of the elbow, sometimes spreading down the forearm,
• pain when gripping, lifting a cup or kettle, shaking hands or turning a door handle,
• a weaker grip.

Treatment

Most people improve without surgery, although recovery can take several months.

• Relative rest: reduce, but do not stop, the activities that cause pain.
• A forearm strap worn just below the elbow can ease pain during activity.
• Exercises: a graded stretching and strengthening programme for the forearm is the main treatment.
• Equipment and technique: grip size, racquet or tool weight, and how poles and holds are gripped can all be adjusted.
• Pain relief: gels or tablets for short periods.
• Injections: in selected patients. A steroid injection can give short-term relief, but pain often returns, so it is used with care.

Surgery is considered only when pain continues despite a good trial of treatment, usually 6 to 12 months.

Pain on the outer side of the elbow is not always tennis elbow. A trapped nerve in the forearm (radial tunnel syndrome) or a problem in the neck can cause similar pain, which is why the elbow is examined carefully.

A hard cricket ball striking the end of a finger can cause a sprained or dislocated finger joint, a mallet finger (the tip droops and cannot straighten), a fracture, or a thumb ligament injury. Stop playing, remove rings, apply ice wrapped in a cloth, keep the hand raised, and get an X-ray if the finger looks crooked, cannot straighten or stays painful and swollen.

Read the full section on cricket ball injury, with what to do straight away and how each injury is treated, and the case study jammed finger after a cricket ball injury.

• Finger pulley injury: rock climbers can tear one of the bands (pulleys) that hold the finger tendons close to the bone, often with a pop at the base of the finger while hanging from a small hold. Most heal with rest, taping or a ring splint and a gradual return to climbing. Complete tears of several pulleys may need repair.
• Torn flexor tendon (jersey finger): a finger that is pulled straight while gripping hard can tear the tendon that bends the fingertip. If the tip cannot bend on its own, it needs to be seen within days, because early repair gives the best result.
• Falls on the outstretched hand: a fall on the trail or the rock can break the wrist or the scaphoid bone. See wrist fracture.
• Thumb ligament injury: a fall with a trekking pole or ski pole strapped to the hand can force the thumb outwards and tear its main ligament. See gamekeeper's thumb.
• Cuts, rope burns and crush injuries: clean wounds well, cover them, and watch for spreading redness, swelling or fever, which may mean infection. Deep cuts can damage tendons and nerves even when they look small.
• Overuse pain: repeated gripping can irritate the tendons at the wrist, for example in de Quervain's disease, or cause trigger finger.

• At altitude, layer your gloves: a thin liner glove, an insulated glove, and a windproof outer mitt for the coldest hours and summit days. Mitts keep fingers warmer than gloves.
• Never go bare-handed in extreme cold, even briefly. Use liner gloves for photographs and fine tasks.
• Carry a spare dry pair of gloves and change out of wet ones quickly.
• Keep wrist straps, watches and tight sleeves loose, so blood can reach the fingers.
• Eat, drink and rest well, and avoid smoking and alcohol on the mountain. Follow the expedition doctor's advice on oxygen at extreme altitude.
• Watch each other's hands and faces for white or waxy patches, and turn back early if numbness does not settle.
• In sport, wear well-fitting gloves for batting and keeping wicket, warm up before climbing, and build up training gradually.

See a hand surgeon promptly if:

• your fingers stayed white, hard, blue-grey or blistered after cold exposure,
• a finger looks crooked, cannot straighten or bend on its own, or stays swollen,
• your wrist is painful and swollen after a fall,
• your thumb feels loose or weak when you pinch,
• elbow or hand pain has not settled after a few weeks of rest and simple measures,
• a wound is red, swollen and getting more painful.

Book a consultation, or send a photograph of the injury on WhatsApp before you travel.