Fourth-degree frostbite complicated by necrotizing fasciitis in an indigenous Mexican patient: bilateral below-knee amputation and ethical challenges in tissue salvage a case report

Frostbite, a debilitating injury caused by freezing temperatures, disproportionately affects marginalized populations, yet data from non-circumpolar regions remain critically underrepresented. We present the first documented case in Mexico of severe frostbite requiring bilateral below-knee amputation in a 26-year-old Indigenous man discovered unconscious with alcohol intoxication in subfreezing conditions. Clinical assessment revealed fourth-degree frostbite manifesting as dry necrosis, absent distal pulses, and purulent vesicles. Computed tomography angiography demonstrated popliteal artery occlusion and subfascial gas, confirming concurrent necrotizing fasciitis. Emergency bilateral amputation with fasciocutaneous flap reconstruction resulted in an uncomplicated recovery, enabling discharge on postoperative day 6 for multidisciplinary rehabilitation. This case underscores the ethical complexity of prioritizing limb salvage versus infection mitigation in resource-limited settings and advocates for context-specific, dynamic frostbite management guidelines. Furthermore, frostbite emerges as a sentinel of systemic inequity, reflecting social determinants such as inadequate access to cold-weather protection, alcohol misuse, and healthcare disparities. Culturally tailored prevention strategies—including multilingual community education and equitable healthcare infrastructure—are imperative. As climate change intensifies extreme weather events, frostbite management must evolve beyond acute interventions to address structural vulnerabilities, integrating public health and policy reforms.