orthopaedics and trauma

1. Functional Outcomes and
Physical Impairment Rating
Tools in Orthopedic Trauma
David Hubbard, MD
West Virginia University
Morgantown, WV

2. Definition of Terms
• Disability
• Permanent impairment
• Handicap

3. Definitions
• Disability
– assessed by non medical means
– represents an alteration of an individual’s
capacity to meet personal, social, or
occupational demands or to meet
statutory or regulatory requirements.

4. Definitions
• Permanent Impairment
– any anatomic loss or functional
abnormality persisting after maximum
medical improvement has been achieved.

5. Definitions
• Handicap
– disadvantages that limit fulfillment of the
an individual’s usual role.

6. Your Role as Physician
• Identify objective findings
• Sole responsibility of the physician to
determine permanent impairment
• Most impairment is caused by
musculoskeletal injuries

7. Role as Physician
• Care not finished when fractures healed and
rehabilitation finished
• Must participate in the impairment
evaluation process
• Many state/federal laws limit how a
physician assigns ratings

8. Third-Party Payers
• Often request impairment evaluations
– Use this information to determine settlement of
claims
• Examples: state workman’s compensation
boards, private insurance companies, Social
Security and Veterans Administration
– Each has their own rules and regulations

9. Third- Party Payers
• Will ask specific questions about permanent
impairment
• Physicians usually send letters directly to
these payers to provide updates

10. Work Restrictions
• Another role of the physician is to estimate
how much and what level of work or
activity a patient can safely tolerate
• The physician assigns impairment and work
restrictions but it is the third-party payers’
and the patient’s responsibility to find the
appropriate job

11. Work Restrictions
• Most commonly used guidelines are those of
the Social Security Administration:
• Consist of differing levels of physical activity
– Very heavy
– Heavy
– Medium
– Light
– Sedentary

12. Work Restrictions
• Very heavy work is that which involves lifting
objects weighing more than 100 lb at a time, with
frequent lifting or carrying of objects weighing 50
lb or more
• Heavy work involves the lifting of no more than
100 lb at a time, with frequent lifting or carrying
of objects weighing up to 50 lb.
• Medium work involves the lifting of no more than
50 lb at a time, with frequent lifting or carrying of
objects weighing up to 25 lb

13. Work Restrictions
• Light work involves lifting no more than 25 lb at a
time, with frequent lifting or carrying of objects
weighing up to 10 lb.
• Sedentary work involves the lifting of no more
than 10 lb at a time and occasional lifting or
carrying of small items.

14. Work Restrictions
• Work restrictions should be placed at a
level that does not compromise healing or
cause too much discomfort during the
recovery phase of injury
• Once maximum medical improvement has
been reached if patient is unable to return to
previous job then permanent restrictions
should be set.

15. Modern Impairment Scales
• Most widely used:
• AMA’s Guide to the Evaluation of
Permanent Impairment
• AAOS’s Manual for Orthopedic Surgeons
in Evaluating Permanent Physical
Impairment

16. AMA’s Guide
• “Whole man” concept
• Each part of body assigned a percentage of
its contribution to the whole
• Loss of function of an extremity is
expressed as percentage of the value of the
whole extremity, then the impairment of the
whole man is calculated from this.

17. AMA’s Guide
• Lower extremity is 40% of whole man
• Upper extremity is 60%
• Other than amputation the ratings are based
solely on the residual range of motion and
does not consider factors like pain, limb
shortening, or weakness

18. AAOS’ Manual
• This considers loss of motion like the
AMA’s guide but also takes into account
pain separately
• Four grades of pain: Mild to severe

19. AAOS’s Manual
• Mild pain (Grade I) – does not contribute to
impairment
• Moderate pain (Grade II) – might require
treatment and does contribute to a minor degree to
impairment
• Severe pain (Grade III) – pathological changes
and clinical findings indicate that pain is
contributing significantly to impairment
• Very severe pain (Grade IV) – physical
impairment is nearly complete secondary to pain

20. Temporary Impairment
• Temporary total disability
• Temporary partial disability

21. Temporary Total Disability
• Starts at time of injury
• Lasts until patient achieves a reasonable
degree of mobility and independence, can
perform ADL’s reasonably
• Patient must be off narcotics
• Must be evaluated by physician periodically
to document/update progress

22. Temporary Partial Disability
• Starts at the end of temporary total
disability
• Lasts until patient back to normal function
or a permanent impairment is assigned
• May return to work with restrictions
• Must be reevaluated by physician

23. Fractures and Associated
Impairments
• Increased impairment may be assigned
based on the following:
1) Handiness (dominant vs nondominant
upper extremity injury)
2) Nonunion
3) Limb length discrepancy
4) Malunion

24. Fractures and Associated
Impairments
5) Infection
6) intra articular involvement
7) Associated neurological injury
8) Preexisting osteoarthritis
9) Spine fractures

25. Functional Outcomes
• Traditional orthopedic evaluations in the
past have focused on impairment measures
• These include findings like range of motion,
muscle strength, and radiographic healing
• These findings have the advantage of being
easy to measure

26. Functional Outcomes
• Disadvantage is that they do not consider
the patient’s opinion of the success or
failure of treatment

27. Functional Outcomes
• The focus of outcomes assessment has now
shifted to patient-based subjective
assessments of outcome
• A combination of impairment and patient-
based assessment is probably the ideal
measure of outcome
• Patient satisfactions is very important!

28. Functional Outcomes
• Up until recently the focus of most
orthopedic literature has been based on
clinical outcomes
• Ultimate outcome however, should be a
combination of clinical, functional, health-
related outcomes, and satisfaction with care.

29. Functional Outcomes
• Clinical outcomes are what we are used to
(range of motion, union, etc.)
• Functional outcomes are total patient
outcome, not just the injured part. Include:
– mental health
– social function
– role function,
– physical function
– ADL’s

30. Functional Outcomes
• Health-related functions are the patient’s
perception of how they are functioning
based on their overall health.

31. Clinical Outcomes in Trauma
• The trauma registry is the main source of
collected data at most institutions.
• The American College of Surgeons
Committee on Trauma has made
recommendations on what data should be
collected and evaluated

32. Clinical Outcomes in Trauma
• One of the key components is measure of
ISS (Injury Severity Score)
– Not a good measure for most orthopedic
injuries
• OTA has developed their own software to
track orthopedic injuries more completely
• Extensive resources required for appropriate
data collection

33. Clinical Outcomes in Trauma
• Unrealistic to collect functional outcome
data on all trauma patients
• Multicenter studies are the wave of the
future for outcomes research

34. Health-Related Quality-of-Life
Instruments in Common Use for
Musculoskeletal Problems
• Medical Outcomes Study Short Form 36
(SF-36)
• Sickness Impact Profile (SIP)
• Western Ontario and McMaster University
Osteoarthritis Index (WOMAC)
• Nottingham Health Profile

35. Quality-of-Life Instruments (cont)
• Quality of Well-Being Scale (QWB)
• Musculoskeletal Functional Assessment
(MFA)
• AAOS Instruments

36. Summary
• Our goal should be to fairly identify our
patient’s impairments, assist in disability
evaluation, and begin assessing patient’s
outcomes based on their perceptions as well
as our objective findings

37. Thank You
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