Cold intolerance after hand injury: Mechanisms, measurement challenges, and implications for clinical management

Cold intolerance of the hand is characterized by an exaggerated or painful response to cold exposure in an injured or affected extremity. It is a common and often disabling consequence of hand trauma and occurs across a wide range of injuries, including fractures, nerve injuries, and vascular insults. Patients frequently describe pain, numbness, stiffness, color change, and reduced dexterity when exposed to cold environments. The prevalence of cold intolerance following significant hand injury is high. Several studies report that up to 80-90% of patients develop cold-related symptoms after significant hand trauma. Symptoms begin early after injury and may persist for years or even lifelong in some individuals. The underlying mechanisms are likely multifactorial and include both vascular dysregulation and peripheral nerve injury, resulting in abnormal vasoreactivity and altered sensory signaling. Several assessment tools have been developed, including patient-reported questionnaires such as the Cold Intolerance Symptom Severity (CISS) score and objective cold-stress testing. Although these tools allow symptoms to be quantified, patient-reported symptom severity does not consistently correlate with objective vascular measurements. Clinically, cold intolerance can substantially affect hand function, work tolerance, and quality of life. Management remains largely symptomatic and includes cold avoidance, protective strategies, rehabilitation, and selected pharmacologic or procedural interventions. Emerging treatments such as digital botulinum toxin injections have shown early promise in small case series. This review summarizes the current understanding of the mechanisms, measurement challenges, and clinical management of cold intolerance after hand injury, with the aim of improving recognition and counseling in everyday hand surgery practice.