An experimental study of iatrogenically induced operating theatre burns.

An experimental study was undertaken to investigate the rate of decay of heat from standard orthopaedic mallets post-autoclaving. A temperature-specific burn analysis was performed using a laboratory animal model, and in combination with the results of the heat decay study, the identification of a 'critical zone' has been made. It is during this 'critical zone' that iatrogenic burns can occur. Two economically viable, practical solutions are offered. One is an autoclavable thermometer which can be included in the instrument tray. The second is a 'new design' orthopaedic mallet. The most reliable preventative measure, however, is constant vigilance. Iatrogenic burns can and do occur.