Comment compartment syndrome the TcPo2 approached 0 mmHg in the injured limb and improved dramatically after fasciotomies were performed. In three patients the compartment pressure has been measured at the same time as the TcPo2 and abnormalities have been recorded in both readings. It has been shown in anatomical studies that the blood supply to the skin over the anterior compartment of the lower leg is by septal and intracompartmental vessels (1). These are presumably susceptible to compression in the presence of raised intracompartmental pressures resulting in reduced cutaneous blood supply. I would like to suggest that the measurement of TcPo2 is likely to be of more use in the assessment of the injured limb than distal pulse oximetry. KAREN E DALY FRCS Registrar in Orthopaedics South West Thames Training Programme
Reference I Carraquiry C, Aparecida Costa M, Vasconez LO. An anatomic study of the septocutaneous vessels of the leg. Plast Reconstr Surg 1985;76:354-61. I read with interest the above paper by David (Annals, September 1991, vol 73, p283). We have found pulse oximetry especially useful during the manipulation of supracondylar fractures of the humerus (1), which are commonly associated with vascular compromise. David's conclusion seems to emphasise oximetric detection of pulsatile flow, but this per se may not be evidence of adequate perfusion-Lawson et al. (2) have shown that oximeters may detect pulsatile flow at levels as low as 4% resting limb flow. More useful would be a combination of pulsatile flow and 95% (or control limb) saturation by oximeter as used successfully by Graham et al. (3) whilst monitoring replanted digits. It is unfortunate that David did not continue oximetric monitoring into the postoperative period where its role in the early detection of compartment syndrome could have been investigated too. S A RAY MA FRCS Registrar in General Surgery Royal Hampshire County Hospital Winchester
References I Ray SA, Ivory JP, Beavis JP. Use of pulse oximetry during manipulation of supracondylar fractures of the humerus. Injury 1991;22: 103. 2 Lawson D, Norley I, Korbon G, Loeb R, Ellis J. Blood flow limits and pulse oximeter signal detection. Anesthesiology 1987;67: 599-603. 3 Graham B, Paulus DA, Caffee HH. Pulse oximetry for vascular monitoring in upper extremity replantation surgery. J Hand Surg 1986;11A: 687-92.
A controlled trial of short-term versus standard axillary drainage after axiliary clearance and iridium implant treatment of early breast cancer We were interested to read the study by Inwang et al. looking at short term drainage of the axilla after axillary clearance (Annals, September 1991, vol 73, p326). In concluding the authors state that early drain removal was not associated with any increase in wound complications. It is
75
unclear what the statistical analysis shows (P < 0.1), but clearly there is a difference between the 49% with seroma in the shortterm group and 28% in the standard group. One of the stated aims of the proposed change of policy was the shortening of hospital stay and thus cost. While this is a laudable aim, it must surely not be the overriding consideration. Other factors must be taken into account. The cost of the excess 24 or so wound aspirations in the short-term drainage group was not assessed. Similarly, no mention was made of the pain or emotional impact of the seromas. To the patient, a seroma may represent a cancerous lump at the site of an operation for proven breast cancer. This may obviously cause considerable distress. Finally we question whether the authors' radiotherapy colleagues should manage the local surgical postoperative complications. M W SCRIVEN BSc FRCS Registrar N A BURGESS FRCS Registrar M SOWTER BSc MB BS Senior House Officer M H LEWIS MD FRCS Consultant
East Glamorgan General Hospital Church Village, Mid Glamorgan
Assessment of burn injury in the accident and emergency department: a review of 100 referrals to a regional burns unit The paper by Laing et al. (Annals, September 1991, vol 73, p329) shows that burn surface area assessment can be inaccurate and inconsistent, when compared with their own assessment. Unfortunately, their own assessment, as the standard by which others are judged, may not be unerring. Other studies have shown that an observer charts a burn accurately, but error occurs when estimating the percentage burn from the chart (1,2). Inaccuracy seems to be reduced, but not absent, even for those with experience of burns. After developing a computerised burn assessment system, I was able to verify assessments of charted bums, by 24 surgeons of various grades, against a computerised assessment. Although estimating from a chart only, and with no time restriction, average percentage errors still varied between 19% and 44%. Even those experienced with burns were inaccurate despite having adequate time to assess the burn area and with no patient to manage. Inaccurate assessment leads to inaccurate treatment, which at best means that accurate audit is impossible and, at worst, resuscitation may be dangerously inappropriate. A computerised assessment is standardised, more accurate, consistently reproducible and eliminates estimation of the burn area from a chart. A database could also be used to record detailed information about a burn injury (3). A computer forces the user into a structured, formalised and rigorous assessment of a patient (4). It minimises variation and inaccuracy between doctors, even in a specialised unit, and should inevitably lead to an improvement in care. D A MOSQUERA BSc FRCS East Birmingham Hospital, Bordesley Green East, Birmingham
Reference I Carraquiry C, Aparecida Costa M, Vasconez LO. An anatomic study of the septocutaneous vessels of the leg. Plast Reconstr Surg 1985;76:354-61. I read with interest the above paper by David (Annals, September 1991, vol 73, p283). We have found pulse oximetry especially useful during the manipulation of supracondylar fractures of the humerus (1), which are commonly associated with vascular compromise. David's conclusion seems to emphasise oximetric detection of pulsatile flow, but this per se may not be evidence of adequate perfusion-Lawson et al. (2) have shown that oximeters may detect pulsatile flow at levels as low as 4% resting limb flow. More useful would be a combination of pulsatile flow and 95% (or control limb) saturation by oximeter as used successfully by Graham et al. (3) whilst monitoring replanted digits. It is unfortunate that David did not continue oximetric monitoring into the postoperative period where its role in the early detection of compartment syndrome could have been investigated too. S A RAY MA FRCS Registrar in General Surgery Royal Hampshire County Hospital Winchester
References I Ray SA, Ivory JP, Beavis JP. Use of pulse oximetry during manipulation of supracondylar fractures of the humerus. Injury 1991;22: 103. 2 Lawson D, Norley I, Korbon G, Loeb R, Ellis J. Blood flow limits and pulse oximeter signal detection. Anesthesiology 1987;67: 599-603. 3 Graham B, Paulus DA, Caffee HH. Pulse oximetry for vascular monitoring in upper extremity replantation surgery. J Hand Surg 1986;11A: 687-92.
A controlled trial of short-term versus standard axillary drainage after axiliary clearance and iridium implant treatment of early breast cancer We were interested to read the study by Inwang et al. looking at short term drainage of the axilla after axillary clearance (Annals, September 1991, vol 73, p326). In concluding the authors state that early drain removal was not associated with any increase in wound complications. It is
75
unclear what the statistical analysis shows (P < 0.1), but clearly there is a difference between the 49% with seroma in the shortterm group and 28% in the standard group. One of the stated aims of the proposed change of policy was the shortening of hospital stay and thus cost. While this is a laudable aim, it must surely not be the overriding consideration. Other factors must be taken into account. The cost of the excess 24 or so wound aspirations in the short-term drainage group was not assessed. Similarly, no mention was made of the pain or emotional impact of the seromas. To the patient, a seroma may represent a cancerous lump at the site of an operation for proven breast cancer. This may obviously cause considerable distress. Finally we question whether the authors' radiotherapy colleagues should manage the local surgical postoperative complications. M W SCRIVEN BSc FRCS Registrar N A BURGESS FRCS Registrar M SOWTER BSc MB BS Senior House Officer M H LEWIS MD FRCS Consultant
East Glamorgan General Hospital Church Village, Mid Glamorgan
Assessment of burn injury in the accident and emergency department: a review of 100 referrals to a regional burns unit The paper by Laing et al. (Annals, September 1991, vol 73, p329) shows that burn surface area assessment can be inaccurate and inconsistent, when compared with their own assessment. Unfortunately, their own assessment, as the standard by which others are judged, may not be unerring. Other studies have shown that an observer charts a burn accurately, but error occurs when estimating the percentage burn from the chart (1,2). Inaccuracy seems to be reduced, but not absent, even for those with experience of burns. After developing a computerised burn assessment system, I was able to verify assessments of charted bums, by 24 surgeons of various grades, against a computerised assessment. Although estimating from a chart only, and with no time restriction, average percentage errors still varied between 19% and 44%. Even those experienced with burns were inaccurate despite having adequate time to assess the burn area and with no patient to manage. Inaccurate assessment leads to inaccurate treatment, which at best means that accurate audit is impossible and, at worst, resuscitation may be dangerously inappropriate. A computerised assessment is standardised, more accurate, consistently reproducible and eliminates estimation of the burn area from a chart. A database could also be used to record detailed information about a burn injury (3). A computer forces the user into a structured, formalised and rigorous assessment of a patient (4). It minimises variation and inaccuracy between doctors, even in a specialised unit, and should inevitably lead to an improvement in care. D A MOSQUERA BSc FRCS East Birmingham Hospital, Bordesley Green East, Birmingham
