Upper Limb. The following case studies relate to injuries to the Upper Limb.

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1 Upper Limb The following case studies relate to injuries to the Upper Limb. More detailed information regarding the assessment of injuries to the upper limb may be found at Chapter 2 of the MAA s Permanent Impairment Guidelines and Chapter 3.1 of the AMA4 Guidelines. The Motor Accidents Authority of NSW makes no warranties or representation about the accuracy or completeness of the information contained in these Case Studies. It should be noted that the information contained herein is not provided as a substitute for legal advice.

2 Upper Limb Case study # Brief Description Primary Body System Secondary Body System UL1 Fractured radius and wrist injury Upper Limb Lower Limb UL2 Shoulders with pre-existing condition Upper Limb UL3 Shoulder injury ROM Upper Limb Spine UL4 Wrist fracture Upper Limb Spine UL5 Joint crepitation Upper Limb Spine UL6 Neuropathy and CRPS Upper Limb Spine UL7 Wrist injury Upper Limb UL8 Shoulder arthroplasty Upper Limb UL9 Finger impairment Upper Limb UL10 Peripheral nerve assessment Upper Limb UL11 Clavicle fracture Upper Limb UL12 Contralateral shoulder Upper Limb Spine UL13 Comminuted wrist fracture Upper Limb UL14 Sensory loss in finger Upper Limb Spine UL15 Right shoulder tendonopathy Upper Limb Spine UL16 Left humerus fracture/left shoulder Upper Limb Lower Limb UL17 Fractured fingers/lumbar radiculopathy Upper Limb Spine UL18 Right shoulder and elbow Upper Limb UL19 Contralateral Joint Upper Limb UL20 Request for x-rays to be taken Upper Limb UL21 Contralateral Joint Upper Limb Spine UL22 Inconsistent ROM Upper Limb Lower Limb UL23 Sternoclavicular joint dislocation Upper Limb Spine UL24 Carpal Tunnel Syndrome and Fractured Wrist Upper Limb UL25 Fractured Clavicle Upper Limb Lower Limb UL26 Fractured Hand Upper Limb

3 Injuries: Right intra-articular radial styloid fracture Wrist ligament tear Both knees crepitus The claimant was a 33-year-old motor cyclist whose bike was struck by a car. He was thrown over the vehicle and landed heavily on the road. He had immediate pain in his knees, right hip, chest, left thigh, left elbow, right wrist and neck. He was unable to stand and was taken by ambulance to hospital. An M.R.I scan revealed a right intra-articular radial styloid fracture (forearm) and a full thickness tear of the dorsal transverse part of the scapho-lunate ligament (in the wrist). Other orthopaedic injuries included a fracture of the head of the radius on the left side, right rib fracture, traumatic anterior pain to both knees, and multiple abrasions to the right side of body. The claimant underwent right wrist arthroscopy seven days after the accident. This surgery involved repair of the right scapho-lunate ligament and internal fixation of the right radial styloid fracture using K-wires. The plaster cast remained in place for eight weeks, and was then replaced by a removable splint. Two months following the right wrist surgery, the claimant had the K-wires removed from his wrist. He was reviewed by a Specialist for the ongoing left elbow pain, but did not proceed with surgical treatment. The dispute was referred to MAS two years after the accident. At the time of assessment, x-rays of the right wrist, left wrist, left elbow and MRI scan of right wrist were available. Clinical examination The claimant complained of symptoms including intermittent sharp pain in the right wrist, especially if he moved the wrist suddenly, attempted to lift heavy weights and after prolonged periods of computer work. Intermittent left elbow pain and soreness in both knees exists, as well as an inability to squat during martial arts and this restricts his ability to engage in this sport. Left Elbow: No joint effusion was noted. The following movements were recorded. ROM UEI AMA 4 Reference Flexion 130 1% Figure 32 p 40 Extension 10 1% Figure 32 p 40 Pronation 80 0% Figure 35 p 41 Supination 80 0% Figure 35 p 41 Sum of UEI 2%

4 Right Wrist The alignment of the right wrist was anatomically normal. There was slight dorsal tenderness of the right wrist but no swelling. Finger movements were full and grip strength was slightly reduced. There was normal sensation and reflexes in the upper limbs. The following movements were recorded: ROM UEI AMA 4 Reference Flexion 30 5% Figure 26 p 36 Extension 40 4% Figure 26 p 36 Radial Deviation 5 3% Figure 29 p 38 Ulnar Deviation 25 1% Figure 29 p 38 Sum of UEI 13% Right Knee No joint effusion (swelling). Circumference of his right thigh was 53cm (measured 10cm above the patella). Slight tenderness related to the lower pole of the patella. Slight discomfort on gentle patellar compression. Crepitus during mid-range of flexion, with a range of motion from The cruciate and collateral ligaments were stable and rotatory tests were negative. Left Knee No joint effusion. Slight tenderness related to the under surface of the patella and slight pain on gentle patellar compression. Circumference of his left thigh was 53cm (measured 10cm above the patella). Slight crepitus during mid range of flexion, with a range of motion from The knee joint was stable. Impairment Evaluation Right Wrist A reduction in the range of motion of the wrist resulted in 13% Upper Extremity Impairment. Table 3, p20 of AMA4 is used to convert Upper Extremity to Whole Person Impairment. 13% Upper Extremity Impairment equates to 8% WPI. Elbow A reduction in the range of motion of the elbow resulted in 2% Upper Extremity Impairment. Table 3, p20 of AMA4 is used to convert Upper Extremity to Whole Person Impairment. 2 % Upper Extremity Impairment equates to 1% WPI. Left knee: A concussive injury to his left knee was sustained that has resulted in traumatic anterior knee pain. Continuing anterior knee pain and crepitation was noted on clinical examination. Full range of movement in his left knee was noted and therefore the left knee attracts 0% - Table 41 (AMA4, p 78). However a finding of 2% WPI is appropriate on the basis of a history of direct trauma, a complaint of patellofemoral pain and crepitation on physical examination Footnote, Table 62 (AMA4, page 83).

5 Right knee: A similar injury to the left knee was sustained to his right knee. Full range of movement, anterior knee pain and crepitus was noted on physical examination and evidence exists of direct trauma to the knee. 0% WPI is attributed on the basis of full knee range of movement. 2% is attributed Footnote, Table 62 (AMA4, page 83). Whole Person Impairment The Combined Values Chart (AMA4, p 322) is used to combine the impairment values, 8%, 2%, 2% and 1% results in 13% WPI.

6 This matter was subject to review by a Medical Review Panel. These are the Review Panel s findings. Claimant s Date of Birth: 7 April 1951 Date of Motor Accident: 2 June 2005 Injuries: Right and Left Upper Extremities aggravation of degeneration of both gleno-humeral joints/injury.

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9 Injuries: Shoulder Injury Cervical spine soft tissue injury The claimant was a 44 year old front seat passenger, involved in a high-speed rear end collision approximately 3 years prior to the MAS assessment. The claimant had to be cut from the vehicle that had spun into a wall after the initial collision. He was admitted to hospital with pain in the neck. He complained of pain in the left shoulder and left elbow where they struck the interior of the vehicle. He was discharged after being hospitalised overnight. The claimant attended his GP and also underwent both chiropractic treatment and physiotherapy. He made little progress and was subsequently referred to an Orthopaedic Surgeon, specifically for review of his left shoulder. Cortisone injections in the left shoulder did not help and surgery was recommended. The claimant underwent subacrominal bursectomy for rotator cuff impingement. The surgery revealed that there was no tear in the rotator cuff. After the surgery he experienced pain over the left acromio-clavicular joint (where collar bone articulates with the acromion; a prominence on the shoulder blade) requiring further cortisone injections. He was also referred to a Spinal Orthopaedic Surgeon as a result of continuing back and neck pain with symptoms radiating to his left arm and left leg. An MRI demonstrated a broad-based disc bulge at the C6/7 level of his cervical spine, with postero-lateral protrusion to the right side without evidence of nerve root compression. It also showed a small left postero-lateral disc protrusion at lumbosacral level, also without evidence of nerve root compression. Clinical Examination At the time of assessment x-rays of the left shoulder, cervical spine and lumbar spine and the MRI scans (described above) were available. The x-rays showed no evidence of fracture at the shoulder, the shoulder joints were normal and there was no evidence of calcification within the rotator cuff. The cervical and lumbar spine x- ray showed the disc heights to be normal and there was no vertebral body fracture. Impairment Evaluation Neck At assessment the claimant complained of constant neck pain with headaches occurring every few days. Clinical examination revealed a stuck neck posture with restricted neck movement in extension and sideways tilting. The WPI was assessed as being DRE Cervicothoracic category 2 (that is, 5% WPI)

10 as there was dysmetria (asymmetric loss of range of motion) but no evidence of objective radiculopathy to warrant a higher DRE category. Left shoulder The Assessor was satisfied that there had been a discrete injury to the left shoulder. The contour of the shoulder was normal with some minor posterior shoulder muscle wasting but no loss of strength. Range of movement measures are recorded below. Sensation was normal. There was no joint instability or crepitation. Range of motion readings equated to the following impairments: Plane of Movement Degrees UEI Reference AMA 4 Flexion 180º 0% Figure 38, p. 43 Extension 30º 1% Figure 38, p. 43 Abduction 160 º 1% Figure 41, p. 44 Adduction 30º 1% Figure 41, p. 44 Internal rotation 50º 2% Figure 44, p. 45 External rotation 70º 0% Figure 44, p. 45 Sum of UEI 5% WPI 3% Table 3, p. 20 Whole Person Impairment The WPI of the cervical spine and shoulder are combined (AMA4, Combined Values Chart, pp ). The cervicothoracic spine impairment of 5% combines with 3% from the left shoulder to give 8% WPI.

11 This matter was subject to review by a Medical Review Panel. These are the Review Panel s findings. Claimant s Date of Birth: 24 April 1970 Date of Motor Accident: 18 April 2004 Injuries: Left Arm - Fractured radial styloid Cervical Spine musculoligamentous injury Clinical Findings The claimant s posture was normal. A 7cm vertical scar was present over the mid thoracic region and a 5cm horizontal scar was present over the right lumbar paraspinal region. These scars were from the implantation of the spinal cord stimulator. At the cervical spine there was mildly and symmetrically reduced range of movement without muscle spasm or guarding. Mild tenderness was present over the left trapezius. No hyperalgesia or allodynia was present in the left upper extremity. The skin temperature was normal in the left upper extremity. There were no abnormalities of the nails. Mild reduction in muscle bulk was present in the left hand. Circumferences of the upper extremities were: above elbow left and right 39cm; below elbow left and right 28cm. Muscle power was normal in the upper extremities and no neurological deficit was detected. Ranges of movement in the upper extremities were as follows: Left and right shoulder - abduction 170, adduction 50, flexion 170, extension 50, external rotation 80, internal rotation 80, Left elbow - extension 0, flexion 140, supination 40, pronation 80 Right elbow - extension 0, flexion 140, supination 80, pronation 90 Left wrist - extension 30, flexion 20, radial deviation 20, ulnar deviation 20 Right wrist - extension 60, flexion 60, radial deviation 30, ulnar deviation 30 In the lumbosacral spine there was mildly and symmetrically reduced range of movement without muscle spasm or guarding. Ranges of movements of the knees were as follows: Right knee extension 0 and flexion 135 Left knee extension 0 and flexion 135 No instability was present at either knee. Crepitus was present at both knees. Circumferences of the lower extremities were: above knee left and right 52cm; below knee left and right 43cm.

12 The claimant s gait was normal and there was no muscle weakness in the lower extremities. Imaging was noted as follows: X-ray cervical spine, 18 May 2004, no abnormality Bone scan, 13 July 2004, not suggestive of complex regional pain syndrome but consistent with synovitis MRI left wrist, 25 November 2004, no definite abnormality Panel Decision Cervical spine musculo-ligamentous injury There are complaints and symptoms only with reference to the cervicothoracic and therefore DRE Cervicothoracic Category I (0% WPI) is the appropriate evaluation. There are no symptoms or signs, that are currently present, that justify assessment of DRE II in this spinal region. Left arm fractured radial styloid The fracture united but subsequently symptoms developed that were consistent with complex regional pain syndrome. Stiffness of the left wrist developed in association with severe pain. Treatment, particularly the spinal cord stimulator, has been effective and the clinical reports suggest that the claimant s impairment has improved substantially as a result. However, there is residual restriction in movement at the left wrist that is assessable as being associated with permanent impairment. The panel considered the treatment that had been provided. The spinal cord stimulator is treatment that will be used in the long term. The panel agreed that, if the spinal cord stimulator was not present, the claimant would revert to a more fully impaired state as set out in section 1.28, page 5 MAA Guidelines, and therefore the whole person impairment that is present should be increased by 3% WPI. This finding is based on the marked improvement experienced by the claimant after the trial of spinal cord stimulation and again after the permanent implantation of the device. There is abnormal motion at the left wrist (and elbow as supination and pronation are classified as elbow movements). The movements are: left elbow - extension 0, flexion 140, supination 40, pronation 80 ; left wrist - extension 30, flexion 20, radial deviation 20, ulnar deviation 20. Using Figure 35, page 41 AMA4 Guides, the abnormal supination is equivalent to 2% upper extremity impairment. Using Figure 26, page 36 AMA4 Guides, the abnormal extension and flexion at the wrist are equivalent to 5% and 7% upper extremity impairment respectively. Using Figure 29, page 38 AMA4 Guides, the abnormal radial and ulnar deviation at the wrist are equivalent to 0% and 2% upper extremity impairment respectively. These impairment values are added to give 16% upper extremity impairment which converts to 10% whole person impairment using Table 3, page 20 AMA4 Guides. As explained above, this impairment percentage is increased to 13% WPI for the effects of treatment.

13 Body Part or System AMA Guides/ MAA Guidelines References (chapter/ page/table) 1. Cervical Spine Chapter 3, page 103 (AMA4) 2. Left arm Chapter 3, multiple figures on pages 36 to 41 (AMA4) Section 1.28 page 5 of the MAA Guidelines Stabilised (YES/NO) Current %WPI* %WPI* from pre-existing OR subsequent causes Yes Yes Yes %WPI* due to motor accident 10 3 * %WPI = percentage whole person impairment Determination Regarding the Degree of Whole Person Impairment of the Injured Person as a Result of the Injuries Caused by the Motor Accident The total percentage whole person permanent impairment for assessed injuries caused by the motor accident is 13%. Therefore the total whole person impairment is greater than 10%.

14 Injuries: Right shoulder/elbow joint crepitation Cervical spine soft tissue injury A male, now aged 18, was assessed almost four years after the motor vehicle accident. He was getting off a bus when the door of the bus closed at the level of his right shoulder dragging him along for several metres with his arm still caught in the door. He was taken to the local hospital. He reported pain in the right side of his neck and the top of his right shoulder radiating to his right arm. X-rays were taken but showed no observable abnormality. Physiotherapy was recommended, which he attended once. Examination after the accident initially indicated that the claimant had sustained a mild brachial plexus injury to the right upper extremity, although it was later noted that all branches of the brachial plexus were intact and there was no obvious anomaly affecting the elbow or shoulder joint. Swimming was recommended, as was normal use of the arm. Full recovery was expected. Clinical Examination At the time of MAS assessment, the claimant reported localised pain over the tip of his right shoulder and the right side of his neck as well as discomfort over the inner aspect of his right forearm at, and distal to, the medial epicondyle with some intermittent pins and needles in his third and fourth fingers. Examination confirmed poor muscle tone. His cervical spine was examined and no guarding or dysmetria was evident. There was no neurological deficit originating from the cervical spine. Examination of his arm showed normal range of motion for all joints and no wasting around his shoulder. There was slight alteration of contour of his right acromioclavicular (AC) joint and there was mild joint crepitation in abduction/adduction and flexion that reproduced the localised shoulder pain. Examination of the elbow found tenderness over the right lateral epicondyle and even slight palpation reproduced pain in the ulnar distribution, with paraesthesia involving the fourth and fifth fingers. There was no muscle wasting, or sensory or motor loss in the forearm. Impairment Evaluation Cervical Spine The cervical spine injury was assessed as DRE 1 (0% WPI) as per the MAA and AMA4 Guides, as the claimant had no significant clinical findings, no muscular guarding, and no documented neurologic impairment. Right Shoulder/Elbow The right shoulder injury was assessed using Tables 18 (page 58) and 19 (page 59)

15 of the AMA4 Guides for impairment from joint crepitation. In accordance with clause 2.17 of the MAA Guidelines, these Tables should rarely be used and Assessors must take care to avoid duplication of impairments. The Assessor was satisfied that the shoulder injury was causally related to the subject accident and that there was no duplication as there was no impairment from range of motion. In other words, the assessment of the shoulder injury was based on the joint crepitation assessment only. The AC joint attracts 25% Upper Extremity Impairment (UEI) on Table 18 (page 58) of AMA4. This figure must then be modified by Table 19: Impairment from Joint Crepitation (page 59). The procedure section (page 58) directs that the relative value of the joint expressed as an UEI (i.e. 25%) be multiplied by the crepitation severity. In this case, the Assessor determined that the crepitation was mild as there was inconstant crepitation during active range of motion. Mild crepitation attracts a 10% joint impairment crepitation rating. Thus, 25% UEI was multiplied by 10% (for crepitation) resulting in 2.5% UEI which was then rounded up to 3% UEI. The Assessor has graded the sensory deficit for pain using Table 11, Determining Impairment of the Upper Extremity Due to Pain or Sensory Deficit Resulting from Peripheral Nerve Disorders (page 48). The procedure section (11b) of this Table outlines the methodology an Assessor must follow in order to assign an impairment rating for a peripheral nerve injury. This Table is modified by sections 2.11 and 2.12 of the MAA Guidelines, which say when applying Tables 11a and Table 12a the maximum values for each grade should be used. The Assessor determined the sensory loss as Grade 2, Decreased sensibility with or without abnormal sensation or pain, which is forgotten during activity. This equates to 25% sensory deficit. Following the methodology, the Assessor then went to Table 15 Maximum Upper Extremity Impairments Due to Unilateral Sensory or Motor Deficits or Combined Deficits of the Major Peripheral Nerves (page 54). The appropriate nerve is selected from the Table (in this case ulnar above mid-forearm ). Since the claimant has a sensory loss only, this Table assigns a maximum rating of 7% UEI for sensory deficit or pain. As per the methodology stated in Table 11b, the severity of the sensory deficit is multiplied by the maximum impairment value for the sensory loss. Therefore, 25% sensory loss is multiplied by 7% = 1.75% UEI. This is rounded up to 2% UEI. The UEI impairments are rounded to the nearest whole number and then combined with other UEI impairments using the Combination Tables (page 322). Whole Person Impairment

16 The total UEI was, therefore, assessed at 5% (3% UEI for the right shoulder combined with 2% UEI for the right elbow using the combination tables). 5% UEI converts to 3% WPI (Table 3, page 20). Conclusion The MAS Assessor determined that the claimant sustained a traction injury to the right arm while attempting to free his arm from the bus door. That injury had substantially resolved and ongoing symptomatology relating to the AC joint crepitation and residual paraesthesia below the elbow and in the hand was possibly due to neurapraxia (temporary failure of conduction of signals by a nerve without the loss of axonal continuity) at the elbow occurring when the arm was wrenched from the door. The Assessor determined that, although further slow improvement was possible, the injuries sustained in the motor vehicle accident were stable and WPI was found to be 3%, that is, not greater than 10%.

17 This matter was subject to review by a Medical Review Panel. These are the Review Panel s findings. Claimant s Date of Birth: 24 November 1961 Date of Motor Accident: 8 September 2004 Injuries: Neck soft tissue injury Right arm neuropathic pain Panel Findings

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20 Injuries: Right wrist arthroscopy The claimant, a 37 year old male, was riding his pushbike on a road near his home and was struck on the wrist by a passing truck s side gate. He was thrown from his bike on to the footpath. He attended the local hospital emergency rooms complaining of pain in his right wrist. X-ray examination of the wrist revealed no obvious abnormalities, however, his wrist was put in a cast for four weeks. Once the plaster was removed he reported ongoing problems with the wrist. Further tests and local cortisone injections were organised. These did not provide lasting relief and he underwent a right wrist arthroscopy and excision of the Pisiform bone (a pea-like bone in the little finger side of the wrist). Clinical examination The claimant complained of difficulty gripping or holding with his right hand, a tight grip resulting in pain shooting from the wrist into the forearm. Pain inhibited the use of the wrist and he was aware of reduced movement capability in the wrist. Active range of motion of both left and right shoulders was normal. Girth measurements of the upper arm were comparable. The right forearm girth was 2cm less than the left, however, this is consistent with left-hand dominance. Sensory testing showed normal perception of light touch. Reflexes were normal for biceps, triceps and supinator jerks. Muscle power was normal in the shoulders and elbows with normal muscle bulk. Power of the right wrist was diminished due largely to pain. There was no wasting in the muscles of the hand. Wrist ROM ROM UEI Reference Flexion 45 3% Figure 26 Extension 45 4% Figure 26 Radial Deviation 10 2% Figure 29 Ulnar Deviation 20 2% Figure 29 Sum of UEI 11% Finger movements were normal and there was no crepitus in the wrist. Impairment evaluation Upper extremity impairment due to the loss of range of wrist movement is 11% UEI. The resection arthroplasty of the pisiform bone is not specifically dealt with in AMA4. The MAA Guidelines at clause 1.26 allows a Medical Assessor to assess impairment by analogy if there is an objective clinical finding of a condition that indicates the

21 presence of impairment. The rationale for the methodology should be included in the report. The Assessor referred to Table 27 (AMA4, p 61) where resection arthroplasty of the entire proximal row of four carpal bones attracts 12% UEI. He determined that resection of the pisiform bone is, by analogy, loss of a quarter of the proximal carpal row and therefore allocated 3% UEI. AMA4 (p 62) states that in the presence of decreased motion, motion impairments are derived separately and combined with arthroplasty impairments using the Combined Values Chart. The values for the wrist ROM (11%) and the resection arthroplasty (3%) are combined to give the overall impairment evaluation of 14% UEI. Upper Extremity Impairment is then converted to whole person impairment (Table 3, AMA4, p 20) 14% UEI equals 8% WPI. Total whole person impairment = 8%.

22 This matter was subject to review by a Medical Review Panel. These are the Review Panel s findings. Claimant s Date of Birth: 1 January 1942 Date of Motor Accident: 2 February 2005 Injuries: Left shoulder rotator cuff tear Clinical Findings The panel agreed with the assessment of upper extremity impairment resulting from the restricted range of shoulder movement as determined by the following findings: Function Movement AMA Guides, 4th Edition Flexion 70 Chapter 3, figure 38, Page 43 Extension 30 Chapter 3, figure 38, Page 43 Abduction 70 Chapter 3, figure 41, Page 44 Adduction 30 Chapter 3, figure 41, Page 44 External rotation 20 Chapter 3, figure 44, Page 45 Internal Rotation 50 Chapter 3, figure 44, Page 45 Upper extremity impairment 7% 1% 5% 1% 1% 2% The impairment values for loss of each shoulder motion are added to determine the impairment of the upper extremity. Total upper extremity impairment = 17%. The panel noted the report from the claimant s treating orthopaedic surgeon, which indicated that the surgical procedure had included excision of the outer end of the clavicle. The panel agreed that this constituted a resection arthroplasty of the distal clavicle which according to AMA 4 Table 27, page 61 results in 10% upper extremity impairment. The panel noted that in the paragraph on Arthroplasty on page 62 of the American Medical Association s Guides to the Evaluation of Permanent Impairment Fourth Edition (AMA 4 Guides) the following information is provided: in the presence of decreased motion, motion impairments are derived separately and combined with arthroplasty impairments using the Combined Values Chart. Based on the instruction in the AMA 4 Guides it was therefore the panel s opinion that the impairment resulting from the resection arthroplasty of the distal clavicle should be combined with the impairment rating for loss of range of movement of the left shoulder.

23 In arriving at this conclusion the panel gave careful consideration to the relevance of Item 2.17 of the MAA Guidelines, page 12 which states that the section Impairment due to Other Disorders of the Upper Extremity should be rarely used in the context of motor vehicle injuries. The Assessor must take care to avoid duplication of impairments. The panel was satisfied however that the information in the paragraph on Arthroplasty in the AMA 4 Guides was quite clear and that Item 2.17 of the MAA Guidelines did not alter the obligation of an Assessor to conform to the instructions provided. The panel was of the opinion that the impairment value attributed to a distal clavicle resection arthroplasty by the AMA 4 Guides was relatively high, but not withstanding this, agreed that the rating provided by the AMA 4 Guides should be accepted. The combined upper extremity impairment for the loss of range of movement of the left shoulder (17%) and resection arthroplasty of the left distal clavicle (10%) is 25% upper extremity impairment (AMA 4 Guides Combined Values Chart, page 322), which equates to 15% whole person impairment (AMA 4 Guides, Table 3 page 20). Panel Decision The whole person permanent impairment of the injuries caused by the accident was calculated as follows: Body Part or System 1. Left upper extremity AMA Guides/ MAA Guidelines References (chapter/ page/table) Fig 38, 41, and 44 Pages 43, 44 and 45 MAA: Pgs 9 to 12 Stabilised (YES/NO) * %WPI = percentage whole person impairment Current %WPI* %WPI* from pre-existing OR subsequent causes %WPI* due to motor accident Yes 15% Nil 15% Determination Regarding the Degree of Whole Person Impairment of the Injured Person as a Result of the Injuries Caused by the Motor Accident The total percentage whole person permanent impairment for assessed injuries caused by the motor accident is 15%. Therefore the total whole person impairment is greater than 10%.

24 Injuries: Fracture of metacarpal head Fractured clavicle The claimant was a 38-year-old male motorbike rider involved in an accident approximately 2½ years before the MAS assessment. He was taken unconscious to hospital with multiple orthopaedic injuries including a displaced fracture of the mid-shaft right clavicle, fractures of the right 7th, 8th and 9th ribs, fracture of the right 2nd metacarpal head and various soft tissue injuries. The right arm was fitted with a volar splint for the hand fracture and a sling for the right shoulder. He was noted to have worn the right shoulder sling for approximately two months and the volar splint on the right forearm for approximately 4 weeks. Clinical Examination X-rays of the chest confirmed a displaced, comminuted mid-shaft fracture of the right clavicle with evidence of bony callus formation. There was also evidence on x-ray of healed fractures of the 7 th, 8 th and 9 th ribs on the right side. There were no x-rays or x-ray reports available of the right hand. Clinical examination of the right shoulder revealed palpable step at the mid-shaft of the right clavicle, but with no related pain or tenderness and there was full range of movement in abduction (180º), adduction (50º), flexion (180º), extension (50º), internal rotation (90º) and external rotation (90º). It was noted that there was no impingement and no evidence of instability. Examination of the right elbow revealed normal movements in flexion (140º), extension (0º), pronation (80º) and supination (80º). Right wrist movements were normal flexion (60º), extension (60º), radial deviation (20º) and ulnar deviation (30º). Assessment of the right hand revealed restriction of flexion of the index (2nd) finger from neutral extension to 70º, with no obvious collateral or volar plate laxity in the metacarpophalangeal (MCP) joint. PIP (proximal interphalangeal) joint movement was from full extension to 90º and DIP (distal phalangeal) joint movement from full extension to 50º. There was no evidence of rotatory deformity of the right hand. There was normal power, sensation and reflexes in the upper limbs. Impairment Assessment Right Shoulder To assess the injury to the right shoulder the Assessor used chapter 3.1j (AMA4, pp 41-45). Clinical findings indicated a full range of motion for each plane of movement for the

25 right and left shoulders. Using Figures 38, 41 and 44 the Assessor awarded 0% WPI. The claimant experienced no direct trauma or injury to the right elbow or wrist, so the MAS Assessor did not assign a WPI rating. Right Index Finger 2nd Metacarpal Joint Assessing the right hand fracture of the 2nd metacarpal head, the Assessor used Figures 19, 21 & 23 (AMA4, and pages 32-34). Each finger joint impairment is determined separately then combined to give the total impairment for abnormal motion. The appropriate worksheet (AMA4, p 16) provides step-by-step instructions for this process. DIP (Distal Interphalangeal Joint) The assessment of the movement in this joint (the finger joint closest to the end of the finger) was conducted using Figure 19 (AMA4, p 32). The Assessor found full extension, thus impairment due to loss of extension was 0%. Assessment of impairment due to loss of flexion revealed 50º of flexion in this joint, giving rise to 10% (finger impairment). Adding the DIP joint impairments (0% + 10%) results in a total of 10% finger impairment. PIP (Proximal Interphalangeal) In assessing this joint movement (using AMA4, Figure 21, p33) indicated extension to 0, and 90º, of flexion. This gives rise to impairment due to loss of extension of 0% and impairment due to loss of flexion of 6%. Adding the PIP joint impairments (0% + 6%) gives a total of 6% finger impairment. MCP (Metacarpophalangeal) The assessment of this joint s movement (using AMA4, Figure 23, p24) shows extension to 0, and flexion to 70º. This equates to impairment due to loss of extension of 5% and impairment due to loss of flexion of 11%. Adding the MCP joint impairments (5% + 11%) gives a total of 16% finger impairment. Using the Combination Chart (AMA4, p322), the total right index finger impairment is calculated by combining finger impairments of 16% + 10% + 6% = 29% finger impairment. Index Finger Impairment is converted to a percentage hand impairment using AMA4, Table 1, page 18. Ensuring the correct column for Index finger is used, this converts 29% finger impairment to 6% hand impairment.

26 The Assessor next converted hand impairment to upper extremity impairment using AMA4, Table 2, page 19 cconverts 6% hand impairment to 5% upper limb impairment. Whole Person Impairment The shoulder impairment was then combined with the hand impairment. That is, 0% shoulder UEI (upper extremity impairment) combined with 5% UEI for the hand = 5% UEI for the Right Upper Extremity. Converting the Upper Extremity Impairment using AMA4, Table 3, page 20 of 5% to Whole Person Impairment gives 3% WPI.

27 This matter was subject to review by a Medical Review Panel. These are the Review Panel s findings. Claimant s Date of Birth: 21 December 1992 Date of Motor Accident: 2 May 2004 Injuries: Left wrist and hand soft tissue and tendon injury Clinical Findings Panel Deliberations

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31 Injuries: Fractured Left Clavicle The claimant was a 48 year old female hit by a car at a light controlled pedestrian crossing. She sustained a fracture of the left clavicle and a head laceration. The claimant was taken by ambulance to hospital and her head laceration was sutured. The fracture to the clavicle failed to unite and bone grafting from the right hip and surgery to the clavicle to repair the fracture occurred. Examination The claimant reported constant left shoulder pain and restricted movement and some difficulty with certain aspects of self-care such as hair washing. Difficulties were also reported in relation to lifting heavy objects and participating in her pre-accident leisure activities. Restricted range of movement was present in the left shoulder. Active shoulder movements were measured three times using a goniometer for both the left and right shoulder. The results were consistent each time and are outlined below: Left Shoulder Degree Right Shoulder Degree Flexion 80 Flexion 180 Extension 20 Extension 50 Abduction 30 Abduction 180 Adduction 10 Adduction 50 Internal Rotation 10 Internal Rotation 90 External Rotation 20 External Rotation 90 Impairment to the shoulder is assessed based on abnormal motion of the joint. Upper Extremity Impairments are obtained by reading Figures 36, 39 & 41 on pages of AMA4. The Table below details the % UEI attributable to the shoulder range of movement measure recorded. Left Shoulder Degree UEI Reference Flexion 80 7% Figure 38 AMA 4 Extension 20 2% Figure 38 AMA 4 Abduction 30 7% Figure 41 AMA 4 Adduction 10 1% Figure 41 AMA 4 Internal Rotation 10 5% Figure 44 AMA 4 External Rotation 20 1% Figure 44 AMA 4 The upper extremity impairments (UEI) for the shoulder are then added together. Sum of UEI is 23% ( ). UEI must then be converted into WPI using Table 3, page 20 of AMA4. 23% UEI converts to 14% WPI. Final Whole Person Impairment is greater than 10%.

32 This matter was subject to review by a Medical Review Panel. These are the Review Panel s findings. Claimant s Date of Birth: 10 February 1924 Date of Motor Accident: 19 November 2004 Injuries: Thoracic spine soft tissue injury Lumbar spine soft tissue injury Left thumb soft tissue injury (laceration) Cervical spine soft tissue injury Right knee laceration and scarring Right shoulder soft tissue injury Chest soft tissue injury and fractures Coccyx fracture Clinical Findings With respect to the cervicothoracic spine soft tissue injury, it is noted that there was no muscle spasm, there was generalised restriction in range of motion in all directions with complaint of generalised neck pain but all movements were with care but not with guarding, and restrictions were equivalent. There was no tenderness over the neck or upper trapezius muscles, brachial plexus stretch was negative on each side and the neurovascular status of the upper limbs was intact. On the basis of this, although there were complaints of pain there were no objective clinical findings that would suffice the verification for any higher than a Cervicothoracic Spine DRE I category (0%WPI). With respect to the thoracic spine, examination confirms that there was generalised and equal restriction of movements and no dysmetria, but guarding was noted to be present. As such the clinical findings fall under the criteria for verification of Thoracolumbar category DRE II, which is 5%WPI. With respect to the lumbar spine, it was noted that there was symmetrical restriction and no dysmetria. There was no evidence of neurological abnormality in the lower extremities and as such the verification for DRE category for the lumbosacral spine is DRE category I (0%WPI). The coccygeal fracture is not assessable and the fracture (if present) would have healed. Similarly, the fractures of the ribs and sternum have healed and of themselves are not assessable impairments (see paragraph 1.25 page 5, MAA Impairment Assessment Guidelines (October 2007). For the right upper extremity (shoulder), there is some restricted range of motion beyond a restricted range of motion associated with degenerative states in the left shoulder. The difference in impairment between the left and right shoulders is a

33 reasonable basis for allocating impairment of the right shoulder as a consequence of the subject MVA. On retesting each side separately, the range of motion by goniometer was as follows: Measurement UEI Measurement UEI RIGHT LEFT Flexion 80 7% 150 2% Extension 40 1% 40 1% Adduction 30 1% 30 1% Abduction 90 4% 160 1% Internal Rotation 60 2% 60 2% External Rotation 60 0% 60 0% 15% (9%WPI) 7% (4%WPI) The difference is therefore 5% and I determine that impairment for the right shoulder as a consequence of the subject MVA is 5% WPI. Against a background of bilateral degenerative disease of both shoulder joints, the impairment due to the right shoulder soft tissue injury is in keeping with the required methodology described under paragraph 2.5 page 9 of the MAA Permanent Impairment Guidelines, October For the scarring, anteriorly over the right knee, there was a 4.5cm curved scar, over the lateral inferior segment. It is slightly pigmented so there is minimal colour contrast with surrounding skin, it is not hypertrophic, there are no suture marks. Anatomic location is slightly visible, if attention is directed to the region with the usual clothing/hairstyle. There is no contour defect, there is no adherence, there is no effect on ADL s reported (pain on kneeling would not be related to the scar) and no treatment is required. She subsequently indicated that whilst she knew the scar was there, she was not particularly conscious of it and it did not interfere with any activities of daily living, nor was it of major concern. Therefore, turning to the Table for the Evaluation of Minor Skin Impairment (TEMSKI), the claimant is slightly conscious of the scars, only of the right knee, there is very mild pigmentary change, no trophic change, no suture marks, anatomic location is visible with the usual clothing, hairstyle, if attention is directed towards the region, there is no contour defect, no effect on any ADL, no treatment is required and there is no adherence, consistent with 1% WPI. The whole person permanent impairment of the injuries caused by the accident was calculated as follows: Body Part or System AMA Guides/ MAA Guidelines References (chapter/ page/table) Stabilised (YES/NO) Current %WPI* %WPI* from pre-existing OR subsequent causes %WPI* due to motor accident

34 Cervicothoracic spine AMA4 Ch 3, Table 73, pg 110, MAA , Table 4.1, pg 22 Lumbosacral spine AMA 4, Ch 3, Table 72, pg 110, MAA Table 4.1, pg 22 Thoracolumbar spin AMA 4, Ch 3, Table 74 pg 11, MAA Table 4.1 pg 22 Right upper extremity (shoulder soft tissue injury) Ch 3, pgs 15-65, incl Figs 38, 41, 44, pgs 43 45, Table 3, pg 20 Scarring injuries AMA4, Table 2, pg 280, MAA TEMSKI pg 53 Yes Yes Yes Yes Yes *%WPI = percentage whole person impairment Determination Regarding the Degree of Whole Person Impairment of the Injured Person as a Result of the Injuries Caused by the Motor Accident The total percentage whole person permanent impairment for assessed injuries caused by the motor accident is 11%. Therefore the total whole person impairment is greater than 10%.

35 Injuries: Comminuted fracture of the right radius and ulna A 61 year old male was a front seat passenger in a car involved in a motor vehicle accident. He sustained a comminuted fracture of the right radius and ulna. The claimant was admitted to hospital following the accident. The fracture required closed reduction and insertion of a K-wire. He had a second hospital admission in relation to the fracture, for open reduction and internal fixation with bone graft to occur. Physiotherapy treatment continued for some months following surgery. Reports indicate that the fracture healed well in a reasonable position. The claimant reported ongoing stiffness on the right wrist. Clinical Examination On examination the claimant reported he remains conscious of a restriction of movement in his wrist, which intensifies in cold weather. Range of Movement measures are recorded below. Direction of Movement degrees Flexion 50º Extension 50º Ulnar Deviation 20º Radial Deviation 15º No numbness or paraesthesia was present in the digits. The claimant reports a minor sensory disturbance along his radial dorsal scar and is conscious of reduced power of grip. The table below details the % Upper Extremity Impairment (UEI) attributable to the wrist range of movement measure recorded. Right Wrist UEI AMA 4 Reference Flexion 50 2 Fig 26, pg 36 Extension 50 2 Fig 26, pg 36 Ulnar deviation 20 2 Fig, 29, pg 38 Radial deviation 15 1 Fig, 29, pg 38 Sum of Upper Extremity Impairment = 7% ( ) UEI must then be converted into whole person impairment using Table 3 page 20 of AMA4. 7% UEI converts to 4% WPI. Final Whole Person Impairment is not greater than 10%.

36 Injuries: Right shoulder lesion with secondary impingement syndrome; tendonopathy, partial tear of rotator cuff Neck contusion / strain; aggravation pre-existing degenerative changes Lower back contusion / strain aggravating pre-existing degenerative changes: multiple disc bulging Both legs- radiating pain The claimant was driving a motor vehicle. She was stationary in a line of cars when she was hit from behind by another vehicle. She was pushed into the car in front, which was also pushed into the car in front of it. She experienced immediate pain in neck, right shoulder and electricity passing into her right arm. Clinical Examination The claimant is 150cms in height and weighs 110kgs. Right shoulder lesion with secondary impingement syndrome; tendonopathy, partial tear of rotator cuff There is significant discomfort arising from the right shoulder with movements and she cannot hold her right shoulder in an elevated position for longer than a few minutes. Shoulder Measurements: AMA 4 Figures 38, 41 & 44 (Pages 43, 44 & 45) Shoulder movements Measurement RIGHT Measurement LEFT Flexion Extension Adduction Abduction Internal Rotation External Rotation The left shoulder had a full range of movement. Neck contusion / strain; aggravation pre-existing degenerative changes The neck was held a little forward. There was no particular tenderness on palpation. There was no obvious muscle guarding. I did not detect abnormal neurological signs in the upper limbs although there was difficulty in eliciting reflexes because of the claimant s size. I do not consider that there was any abnormality in sensation, although there was weakness of the grip of

37 the hands, which is likely to have been due to her age and her previous congenital deformity of Madelung s disease. CERVICAL SPINE RANGE EXHIBITED MOVEMENTS Forward flexion 45 Extension 40 Rotation to the right 40 Rotation to the left 70 Lateral bending to the right 40 Lateral bending to the left 40 It was noted that there was a degree of dysmetria of movements of the cervical spine. Lower back contusion / strain aggravating pre-existing degenerative changes: multiple disc bulging There was a loss of the lordosis. There was tenderness over the lower lumbar region and into the sacroiliac regions on either side. The claimant s gait was slow. She had some difficulty in walking on her toes but could walk on her heels. I did not detect any muscle guarding. Both legs- radiating pain The claimant had radicular pain passing into the lateral thigh of both legs. There was some alteration in feeling over the lateral side of the thighs. I did not detect other abnormal neurological signs in the lower limbs. Impairment Evaluation MAA Guides October 2007 and American Medical Association Guides to the Evaluation of Permanent Impairment, 4 th Edition Right Shoulder: Abnormal motion of shoulder Chapter 3, Section 1j, Page 41 Flexion / Extension Figure 38, page 43, shoulder flexion / extension. Flexion 90º - 6% UEI Extension 30º - 1% UEI Total UEI for flexion / extension equal 7% UEI. Abduction / Adduction Table 41, page 44 shoulder abduction / adduction Abduction 70º - 5% UEI Adduction 20º - 1% UEI Total UEI for abduction / adduction equals 6% UEI

38 Internal / External Rotation Figure 44, Page 45 Internal rotation 10º - External rotation 10º - 5% UEI 2% UEI Total UEI for internal / external rotation equals 7% UEI. Total upper extremity impairment for left shoulder equals = 20% UEI. Conversion to WPI Table 3, Page 20, 20% UEI equals 12% WPI Cervical spine: Chap. 3, Sec 3h, Page 103, Table 70 Page 108 & Table 73 Page 110 Page 104: DRE Cervico-thoracic Category 11: minor impairment. The history and findings are compatible with a specific injury and include muscle guarding, non-uniform loss of range of movement (dysmetria, differentiator 1, Table 71, p. 109), or non-verifiable radicular complaints. There is no objective evidence of radiculopathy. The assessment is DRE Category 11-5% WPI Lumbar spine: Lumbosacral spine Chapter 3, Section 3g, Page 101, Table 70 Page 108 and Table 72 Page 110 Page 102: DRE Lumbosacral Category 11: minor impairment. The history and findings are compatible with a specific injury and include muscle guarding, non-uniform loss of range of movement (dysmetria, differentiator 1, Table 71, p. 109), or nonverifiable radicular complaints. There is no objective evidence of radiculopathy. The assessment is DRE Category 11-5% WPI Both legs radiating pain This is a symptom and not a diagnostic entity. Body Part or System AMA Guides/ MAA Guidelines References (chapter/ page/table). Right shoulder Chapter 3 Section 1j Figure 39 Page 43 Table 41 Page 44 Figure 44 Page 45 Stabilised (YES/NO) Current %WPI* %WPI* from pre-existing OR subsequent causes Yes 12% 0% 12% %WPI* due to motor accident

39 . Cervical spine Chapter 3 Yes 5% 0% 5% Section 3h Page 103 Table 70, Page 108 Table 73, Page 110 DRE Category 11. Lumbar spine Chapter 3 Yes 5% 0% 5% Section 3g Page 101 Table 70, Page 108 Table 72, Page 110 DRE Category 11 * %WPI = percentage whole person impairment Determination Regarding the Degree of Whole Person Impairment of the Injured Person as a Result of the Injuries Caused by the Motor Accident The total percentage whole person permanent impairment for assessed injuries caused by the motor accident is 20%.

40 This matter was subject to review by a Medical Review Panel. These are the Review Panel s findings. Claimant s Date of Birth: 2 May 1964 Date of Motor Accident: 29 April 2003 Injuries: Left humerus dislocated transverse fracture Left shoulder injury to rotator cuff and deltoid Left tibia displaced fracture; fracture of the lateral malleolus Left fibula displaced fracture Cervical spine soft tissue injury; disc disruption at C6/7 and C7/T1 Left arm/ shoulder scarring Left lower leg scarring. Clinical Findings The claimant brought to the examination the following imaging films: X-ray left leg oblique fracture junction of middle and lower thirds of tibia with 10 varus angulation X-ray left humerus fracture mid shaft with intramedullary nail fixation and no deformity X-ray left humerus no evidence of union X-ray Left upper arm slow progress of union Type II acromion. She was noted to hold her left upper limb immobile by her side and was very reluctant to perform any undressing but did eventually remove her outer layer of upper clothing. The length of both of her lower limbs was measured to be equal. The circumferences of both of her thighs 10 cms above the patella were measured to be equal. The circumference of her left calf was measured to be 1cm less than that of the right. The active range of motion in her knees, measured by goniometer, was left equals and right equals and the active ranges of motion in both of her ankles and hind feet, measured by goniometer, were as follows:- Measurement RIGHT Measurement LEFT Ankle dorsiflexion Ankle plantar flexion Inversion Eversion 15 0 She had clinical varus angulation of her left mid tibial shaft which was measured by goniometer to be 13.

41 In her left upper limb she was noted to have an 11 cm scar on the antero-lateral aspect of her left shoulder and 5 cm scar on the anterior aspect of her upper left arm as well as small punctate scars on the postero-lateral aspect of her mid arm and the anterior aspect of her left shoulder. The circumference of her left arm midway between the shoulder and the elbow was measured to be 1 cm less than the same circumference of the right arm. The circumference of both of her proximal forearms was measured to be equal. On formal examination of the ranges of motion in her left shoulder the active ranges of motion, measured by goniometer, were:- o Flexion 70 o Extension 30 o Abduction 30 o Internal rotation 70 o External rotation 0 She was not prepared to attempt active adduction because of pain in her left shoulder. The degree of pain she stated occurred on attempting these active ranges of motion did cause her quite considerable emotional distress. In her cervical spine the active ranges of motion, measured by goniometer, were:- Measurement RIGHT Measurement LEFT Lateral rotation Lateral tilting Active flexion was to 45 and active extension to 10. These ranges of motion were associated with muscle guarding. There are no abnormal findings on neurological examination of either of her upper limbs. She had full active ranges of motion in her left elbow, left forearm, left wrist and in all joints of all of the digits in her left hand. She had rather widespread variable tenderness to palpation about her left shoulder joint and upper most left arm immediately below the shoulder. Panel Decision Cervical spine soft tissue injury; disc disruption at C6/7 and C7/T1: The findings of dysmetria and muscle guarding at the re-examination identify assessment of the present condition of her neck to be DRE Cervicothoracic Category II impairment with a 5% whole person impairment. Left humerus fracture/left shoulder- injury to rotator cuff and deltoid: The panel noted that at the time of the re-examination assessment of the left shoulder range of movement appeared to be compromised by pain which resulted in this claimant be unable to cooperate fully. In this regard the panel noted the instruction in the MAA Guidelines (Section 2.4 and 2.4(iv) page 9) which states the following: Although range of motion appears to be a suitable method for evaluating impairment, it can be subject to variation because of pain during motion at different times of examination and/or possible lack of co-operation by the person being assessed If there is such inconsistency in range of motion then it should not be used as a valid parameter of impairment evaluation. Refer to section 1.43 of these Guidelines.

42 The panel noted that Section 1.42, Page 7, MAA Impairment Assessment Guidelines, 1 st October 2007 states the assessor must ultilise the entire gamut of clinical skill and judgment in assessing whether or not the results of measurements or tests are plausible and relate to the impairment being evaluated. If, in spite of an observation or test result, the medical evidence appears not to verify that an impairment of a certain magnitude exists, the assessor should modify the impairment estimate accordingly, describing the modification and outlining the reasons in the impairment evaluation report. Taking this instruction into account including the information in the medical reports in the documentation provided the panel determined that it would be reasonable to assess the total permanent whole person impairment in the claimant s left shoulder at the level of 5% whole person impairment. The panel was satisfied that this level of impairment was determined by using the clinical acumen and experience of all the panel members. There was no assessable permanent whole person impairment attributable the fracture of the humerus which has been internally fixed in anatomical alignment and united. Left tibia fracture/left fibula fracture: The findings reported from the re-examination identify that the claimant has the following impairments:- o 1cm atrophy left calf - AMA 4, Table 37b mild, Page 3/77, 2% whole person impairment. o Varus angulation tibial shaft (10 radiologically, 13 clinically) AMA 4, Table 64 malalignment of tibial shaft fracture 10-14, 8% whole person impairment. o Hind foot eversion 0 AMA 4, Table 43 mild, Page 3/78, 1% whole person impairment. Reference to MAA Impairment Assessment Guidelines, 1 st October 2007, Table 3.3, page 19 identifies that muscle atrophy, diagnosis based estimates (tibial malalignment) and range of motion assessment are not permitted to be combined. The panel therefore selected the highest of the above assessments, namely 8% whole person impairment for tibial malalignment and determined that this assessment was permanent. Scarring left arm/left shoulder/left lower leg: The panel was in agreement with the assessment of a permanent 1% whole person impairment with reference to AMA 4, Chapter 13, Table 2, Page 13/280 and MAA Impairment Assessment Guidelines, 1 st October 2007, Section 8.31, Page 52 and TEMSKI. The whole person permanent impairment of the injuries caused by the accident was calculated as follows: Body Part or System AMA Guides/ MAA Guidelines References (chapter/ page/table) Stabilised (YES/NO) Current %WPI* %WPI* from pre-existing OR subsequent causes %WPI* due to motor accident

43 1. Cervical spine AMA 4, Table 73, Page 3/110, Section 3.3h, Page 2. Left upper extremity 3. Left lower extremity 4. Scarring left arm/left shoulder/left lower leg 3/104 AMA 4, Figure 38, Page 3/43, Figure 41, Page 3/44, Figure 44, Page 3/45, MAA Impairment Assessment Guidelines, 1 st October 2007, Section 1.42, Page 7 and 2.4 Page 9. AMA 4, Table 64, Page 3/85 AMA 4, Chapter 13, Table 2, Page 13/280, MAA Impairment Assessment Guidelines, 1 st October 2007, Section 8.31, Page 52, TEMSKI Yes 5% 0% 5% Yes 5% 0% 5% Yes 8% 0% 8% Yes * %WPI = percentage whole person impairment 1% 0% 1% Combining (AMA 4, Combined Value Chart, Page 322) the above permanent total whole person impairments the claimant has a total overall 18% whole person impairment. Determination Regarding the Degree of Whole Person Impairment of the Injured Person as a Result of the Injuries Caused by the Motor Accident The total percentage whole person permanent impairment for assessed injuries caused by the motor accident is 18%. Therefore the total whole person impairment is greater than 10%.

44 This matter was subject to review by a Medical Review Panel. These are the Review Panel s findings. Claimant s Date of Birth: 15 September 1982 Date of Motor Accident: 25 November 2003 Injuries: Left and Right Hands bilateral fractures of numerous fingers Back Injury strain Right Patella Tendon rupture Clinical Findings On examination the claimant walked with a limp favouring her right leg. She appeared to be in some slight discomfort. She was 175 cm tall and weighed approximately 95kg. Hands Examination of her hands revealed a reduced range of movement and joint laxity at the right thumb. Right thumb Flexion (degrees) Extension (degrees) MP IP 30 0 Right CMC Joints Radial abduction Opposition Adduction 35 degrees 5cm 6cm Fingers The right little finger had reduced range of movement in the three joints. Her left hand little finger range of motion was also measured. There was a normal range of movement at the DIP, MP and PIP joints. Right middle finger (degrees) DIP Flexion Extension 0 +5 PIP Flexion Extension 0 0 MP Flexion Extension Left little finger (degrees)

45 Lumbar spine There was some tenderness in her lumbar spine, but no muscle spasm. She had trouble weight bearing on the right side causing a pelvic tilt. She could forward flex to approximately 70 degrees and extend to 10 degrees. Lateral flexion to the left and right appeared to be symmetrical. Heel/walk, toe/walk and squat were not attempted. Straight leg raise on the right was to 50 degrees with a positive Lasegue s test (sciatic stretch) on dorsiflexion of the right ankle. There was sensory loss in the right foot of the lateral aspect consistent with the S1 dermatome. Power and tone in the legs appeared to be normal. Thigh measurements were 50cm on both sides. Calf measurements were 40cm on both sides. Lower limb reflexes were normal. Panel Decision Left and right hand bilateral fractures The panel found that there was adequate contemporaneous medical evidence to support a fracture of the right thumb at the MCP joint with internal fixation, fracture of the right middle finger 3 rd proximal phalanx with internal fixation and fracture of the left little finger with internal fixation. The upper extremity impairment evaluation record was used and is attached. The impairment found that the right thumb was 22% digit impairment, which converted to 9% hand impairment. The impairment present for the right middle finger was 38% digit impairment which converted to 8% hand impairment. The impairment found at the left little finger was 0%. The total right hand impairment was 17% which converted to 15% upper extremity impairment. This converted to 9% whole person impairment. Right patella tendon rupture The range of motion of the right knee with 15 degrees flexion contracture. Referring to Table 41, Page 78, this allows 8% whole person impairment. There were no other lower extremity parameters giving rise to impairment. Back injury strain proceeding to right buttock area Clinical findings indicated a positive Lasegue s stretch test and a S1 dermatomal sensory loss. The panel referred to Paragraph 4.28 of the MAA Guidelines (1 October 2007) regarding radiculopathy where it indicates that: two or more of the following signs should be present to confirm radiculopathy: - loss or asymmetry reflexes - positive sciatic nerve root tension signs - muscle atrophy - muscle weakness - reproducible sensory loss. The panel found that there was a positive nerve root tension sign and reproducible sensory loss and thus, the claimant satisfied the criteria for the presence of radiculopathy. Referring to the AMA 4 under Table 72, Page 110, the findings are classified as DRE Lumbosacral Category III and receives 10% whole person impairment. The whole person permanent impairment of the injuries caused by the accident was calculated as follows:

46 Body Part or System 1. Lumbosacral spine 2. Right upper extremity 3. Right lower extremity AMA Guides/ MAA Guidelines References (chapter/ page/table) Table 72 page 110 Upper extremity chapter Lower extremity chapter Stabilised (YES/NO) * %WPI = percentage whole person impairment Current %WPI* %WPI* from pre-existing OR subsequent causes Yes Yes Yes %WPI* due to motor accident Determination Regarding the Degree of Whole Person Impairment of the Injured Person as a Result of the Injuries Caused by the Motor Accident The total percentage whole person permanent impairment for assessed injuries caused by the motor accident is 25%. Therefore the total whole person impairment is greater than 10%.

47

48 Injuries: Fractured Left Femur Fractured Right Scapula The claimant was a 70 year old male motor cyclist knocked off his bike by a car. The claimant was admitted to hospital with a diagnosis of Trochanteric fracture of the left femur and fracture of the right scapula. The Assessor documented a history that the claimant was admitted to hospital where he underwent an open reduction and internal fixation of the femoral fracture. He was otherwise treated conservatively and remained in hospital for about a fortnight. He went home on a walking frame, eventually progressing to a cane and attended follow-up physiotherapy. The claimant complains of occasional aching in his left hip and can no longer walk fast. He has given up dancing, has a limp and also has a leg length discrepancy. His shoulder has settled and he has full range of movement. Clinical Examination On examination, the claimant was found to have 2cm muscle wasting of the left thigh, measured at 10cm above the patella with the knee fully extended and the muscles relaxed. There was 1.5cm of left calf wasting, measured at the same level of the maximum calf circumference on the unaffected right side. There was a 2cm limb length discrepancy, due to shortening of the left lower extremity, measured several times. The claimant walked with a limp. Standing posture showed a compensatory slight hip and knee flexion. He no longer requires the use of a cane. There was some external rotation deformity which restricted internal rotation slightly, but otherwise there was normal hip range of motion. The left shoulder range of motion was normal. Investigations A series of X-rays showing a per-trochanteric fracture of the left hip, going on to firm union were viewed. There was some slight increase in neck shaft angle of the left hip following internal fixation and operative films showed slight over distraction. CT measurements of leg length discrepancy on two occasions were reported as 1.3 cm and 1.6cm, however when these films were viewed, leg lengths were marked as (left) and (right), a difference of 1.92cm, which compared with the simple measurements with a tape measure. The Assessor concluded that there had been a slight underestimation in the degree of leg length discrepancy.

49 Impairment Evaluation The final diagnosis was per-trochanteric fracture of the left femur with lengthening and muscle wasting involving the thigh and calf. There was also a slight external rotation deformity with slight alteration of movement. The percentage whole person impairment was calculated as follows: The right shoulder had no abnormality noted in function and was assessed as giving rise to no permanent impairment. Left lower limb can be assessed by several means: Leg length discrepancy: The discrepancy determined after viewing the films was 1.92cm. Note in Table 35, page 75 that up to 1.9cm yields 0% WPI and 2 2.9cm yields 3%WPI. In this case, the Assessor chose to be beneficent and assessed as 3% WPI as the leg length discrepancy was greater than 1.9cm. Muscle wasting: Page 77, Table 37. Thigh: 2cm of wasting equates to a moderate impairment of 4%. Calf: 1.5cm of wasting equates to a mild impairment of 2% WPI. The combined impairment as a result of muscle wasting is 6%. Hip motion impairment: Page 78, Table 40. Internal Rotation is restricted to 9 degrees, equating to a moderate impairment of 4%. Femoral fracture: Page 85, Table 64. Diagnosis based estimate, pertrochanteric fractures are classed as a femoral neck fracture, healed in malunion equals 12% plus range of motion criteria, 4%, equals 16%. Gait derangement: Page 76, Table 36. Cannot be assessed with this method as walking aid would need to be permanent and not temporary, and as mentioned in clause 3.11 MAA Guides, this is should always be used as the method of last resort. The MAA Guidelines at clause 3.3 state that: There are several different forms of evaluation that can be used as indicated in sections 3.2a to 3.2m (pages AMA 4 Guides). Table 3.3 in these MAA Guidelines indicates which evaluation methods can and cannot be combined for the assessment of each injury. This table can only be used to assess one combination at a time. It may be possible to perform several different evaluations as long as they are reproducible and meet the conditions specified below and in the AMA 4 Guides. The most specific method or combination of methods, of impairment should be used. When more than one equally specific method or combination of methods of rating the same impairment is available, the method providing the highest rating should be chosen. Table 3.4 can be used to assist the process of selecting the most appropriate method(s) of rating lower extremity impairment. The Assessor referred to the MAA Guidelines, page 19, Table 3.3, for permissible combinations of lower extremity assessment methods. ROM (4%) can combine with limb length discrepancy (3%), but not muscle atrophy (6%) to equal 7% WPI.

50 Limb length discrepancy (3%) can combine with muscle atrophy (6%) to equal 9% WPI. Diagnosis-based estimates (16%) cannot combine with muscle atrophy, or ROM, but under MAA Guidelines October 2007 (Table 3.3 p 20) can be combined with limb length discrepancy (3%). In accordance with point 3.3 of the MAA Guidelines, the highest value WPI is selected, in this case the Diagnosis Based Estimate 16% WPI, combined with 3% for the limb length discrepancy = 19% WPI. The permanent Whole Person Impairment caused by the MVA is greater than 10%.

51 This matter was subject to a review by a Medical Review Panel. These are the Review Panel s findings. Injuries: Left shoulder Cervical spine Lumbar spine On 23 September 2007, a 54 year old female was a front seat passenger wearing her seatbelt in a stationary car. The car was hit from behind by another car and pushed into the car in front. The airbags did not deploy. She was transferred by ambulance to hospital, complaining of left sided neck pain radiating to the left shoulder and left sided anterior chest wall tenderness. Clinical Findings The MAS Assessor determined that the cervical spine was 0% whole person impairment (WPI), the lumbar spine was 5%WPI, the left shoulder was 6% WPI, giving a total whole person impairment of 11%. Examination of the left shoulder revealed tenderness over the anterior aspect of the shoulder. There was no obvious wasting. The shoulder was generously covered. The impingement sign in the left shoulder was positive. The active ranges of motion were measured with a goniometer in both shoulders. The Assessor determined 10% upper extremity impairment (6% WPI) for the left shoulder and made no reference to his findings in respect of the impairment of the right shoulder. The Review Panel confirmed that the cervical spine was 0% WPI and the lumbar spine 5% WPI. In regard to the left shoulder, the Panel concurred with the Assessor that the restriction of movement of the left shoulder resulted in 10% upper extremity impairment (6% WPI) The Panel found no history of an injury to the right shoulder or any evidence of a disorder of the right shoulder. The Panel concluded that it would be more appropriate to consider the range of movement of the right shoulder to be normal for the claimant, and that there was a reasonable expectation that the left shoulder joint would have had similar findings to the uninjured right shoulder joint before the injury. The Panel noted that the calculation using the right shoulder measurements revealed a 1% upper extremity pre-injury baseline measurement, and was of the opinion that this should be subtracted from the calculation of 10% upper extremity impairment of the left shoulder.

52 Subtracting the baseline measurement of 1% (right shoulder) results in a figure of 9% (left shoulder) upper extremity impairment, or 5% whole person impairment (AMA 4, Table 3, page 20). The Panel arrived at this conclusion with reference to clause 2.5 of the MAA Guidelines in regard to a contralateral uninjured joint. The Panel determined the cervical spine 0%, the lumbar spine 5%, the left shoulder 5% = Total WPI of 10%.

53 This matter was subject to a review by a Medical Review Panel. These are the Review Panel s findings. A 45 year old woman was involved in a head on collision and received a right elbow fracture, left patellar fracture/dislocation and right shoulder fracture. Surgical treatment included an open reduction and internal fixation to the fractured olecranon of the right elbow (the point of the elbow) and open reduction and external fixation of the patella. She subsequently underwent arthroscopic debridement of the patella with lateral release and excision of a medial fragment. At that time she also had manipulation under anaesthetic of the right shoulder which had developed post-traumatic capsulitis. The Panel decided additional information would assist them to make a decision in regard to right shoulder causation and the nature of the left knee injury and the consequent surgery. Accordingly, the Panel instructed the secretary to issue a notice to the parties requesting the operative report, physiotherapy notes in regard to the right upper extremity, and new weight-bearing x-rays of the left knee with sunline views according to the requirements for assessment of arthritis in the AMA Guides 4 th Edition at page 82. Clinical Findings The claimant confirmed injury to the right elbow and left knee in the motor accident. She stated her right shoulder became stiff and painful during a period of immobilisation of the right elbow following surgery. Although she had a manipulation under anaesthetic, the discomfort and restricted movement persisted. The Panel noted no impingement or crepitation on shoulder movement. The left shoulder appeared normal and shoulder motion is recorded below. Movement Right shoulder AMA 4 reference UEI Left shoulder Flexion 140 Figure 38 p Extension 50 Figure 38 p Abduction 130 Figure 41 p Adduction 50 Figure 41 p Internal rotation 80 Figure 44 p External rotation 60 Figure 44 p Total 6

54 The Panel also found elbow extension restricted by 20 and flexion to 130. The Panel found normal pronation and supination. The Panel noted a slightly broad surgical scar, but this had not been listed for assessment. Similarly, the Panel noted surgical scarring around the left knee. On examination of the left knee, the Panel recorded full range of motion, equal to the right knee, and no ligamentous laxity or wasting. Crepitus was present in both knees, but patella compression was only painful in the left knee. The Panel viewed the weight-bearing x-rays of the left and right knees, measuring a cartilage interval of 2mm in the left patellofemoral joint and greater than 4mm in the right. The Assessors could not identify changes consistent with a united or nonunited patella fracture involving the articular surface with displacement of more than 3mm. The Panel found evidence to support a small avulsion type fracture of the medial margin of the patella, associated with dislocation of the patella. The Panel could not find evidence of a fracture involving the articular surface and was satisfied the surgery undertaken to the left knee was not excision of a fragment of the patella consistent with partial patellectomy, but was excision of a medial osteophyte. The Panel considered there was no evidence of a direct injury to the right shoulder in the documents, but agreed the immobilisation of the right upper limb to allow for healing of the fractured right elbow had lead to a frozen right shoulder, as submitted by the claimant s representative in response to the Panel s notice. The right shoulder adhesive capsulitis secondary to right elbow fracture was accepted as casually related to the motor accident. The Panel considered the injuries had stabilised. The Whole Person Impairment of the injuries caused by the accident was calculated as follows: Right shoulder totalled 6% Upper Extremity Impairment (see Table above) and the right elbow resulted in 3% UEI, 2% UEI for lack of extension and 1% UEI for reduced flexion. These two values combine to give a total 9% UEI for the right upper extremity which converts to 5% WPI using Table 3 page 20 AMA 4 Guides. The Panel considered the left knee was best assessed as arthritis of the patellofemoral joint using Table 62, page 83 of the AMA 4 Guides. A 2mm cartilage interval measured in accordance with the x-rays designated in the Guides is equivalent to 4% WPI. The Panel considered it was not permissible to combine this with the footnote to Table 62, page 83, where there is a history of direct trauma, crepitus and complaint of patellofemoral pain, as it is specified that this is without joint space narrowing and the Panel regarded that as double-dipping. There were no other applicable methods of impairment evaluation in relation to the left knee. The total WPI for the right upper extremity and left knee was therefore 9% WPI, using the Combined Values Chart, p 322, AMA 4 Guides.

55 This matter was subject to a review by a Medical Review Panel. These are the Review Panel s findings. Injuries: Left Shoulder rotator cuff strain Cervical spine musculoligamentous strain Lumbar spine musculoligamentous strain Panel Deliberations Cervical Spine Lumbar Spine

56

57 Panel Decision

58 This matter was subject to a review by a Medical Review Panel. These are the Review Panel s findings. Injuries: Cervical spine soft tissue injury Left shoulder - soft tissue injury Right shoulder - soft tissue injury Left wrist - soft tissue injury Right wrist - soft tissue injury Right hip - soft tissue injury Clinical Findings

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60

61

62 Panel Deliberations

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64

65 Panel Decision

66 This matter was subject to a review by a Medical Review Panel. These are the Review Panel s findings. Injuries: Neck soft tissue, fracture, facet joint Sternoclavicular joint dislocation, soft tissue injury Panel Deliberations Cervical Spine Sternoclavicular Joint

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68 Panel Decision

69 This matter was subject to a review by a Medical Review Panel. These are the Review Panel s findings. Injuries: Right wrist fracture of styloid with deformity Right arm carpal tunnel syndrome Right thumb stiffness secondary to cast immobilisation Clinical Findings

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71 Panel Deliberations

72 Panel Decision

73 This matter was subject to a review by a Medical Review Panel. These are the Review Panel s findings. Injuries: Left shoulder fractured clavicle Left pubic bone fracture Right forefoot fractures Clinical Findings In regard to the injury to her left clavicle, she recalled having surgery and then the arm being placed in a body binder. She does not recall any specific treatment for the fractured pelvis or the right foot. She recalled mobilising on a frame and on the day prior to discharge from hospital being transferred to Canadian crutches and negotiating 20 metres. By this stage there was a brace on her right foot. On examination of both shoulders there was a well healed linear scar over the lateral clavicle. The metal was easily palpable. There was 2.5cm of wasting of her left arm at the axillary apex. Active shoulder movements were as follows; Right shoulder Left shoulder Flexion Extension Internal rotation External rotation Abduction Adduction In regard to the fractured pelvis, she walked in the surgery without a limp. She was able to execute a near full squat and stand with support and complained of some discomfort over the dorsum of the right foot at the level of the metatarsophalangeal junction. Hip movements were to normal range and symmetrical. She was able to rise onto tiptoes and rock back onto her heels. In regard to the right foot, it was normal to inspection. Movements of both feet, both ankles and the toes of both feet were normal except there was only 10 degrees of flexion of the IP joint of the right great toe. Investigations The following films were reviewed; Plain x-ray Pelvis [ ] showed fracture involving the body of the left pubis. There was slight proximal displacement of the main proximal fragment but no obvious diastasis. There was no other obvious fracture of the pelvic ring or sacrum to be seen on this view.

74 Plain x-ray right foot [ ] showed fracture of the distal phalanx of the hallux involving the lateral joint line of the distal phalanx. There was a small avulsion fracture from this point. There was a comminuted fracture of the 3rd distal phalanx that did not involve the joint and there was possibly a comminuted fracture of the 5th distal phalanx alternatively. She had a longer middle phalanx in the adjacent 3rd and 4th toes and it was difficult to confirm on the films whether there was a distal phalanx or whether she was in fact missing one phalanx, in which case on the 5th ray there was a metatarsal, a proximal phalanx and a distal phalanx, and that distal phalanx appears to show some comminution and fracture at its most distal portion, and there was no actual distal phalanx, but just two phalanges in the 5th ray. It was also possible that the toe was curled under and the distal phalanx not visible. The proximal phalanx may have an undisplaced crack fracture through the distal one quarter. Plain x-ray chest [ ] showed fracture of the distal end of the left clavicle 2cm from the acromioclavicular joint. There was approximately 5mm of separation of the fragments and the proximal clavicle has ridden up by 3mm or 4mm. Panel Decision Left shoulder fractured clavicle Movements were measured as below. Total upper extremity impairment (8%) was calculated with reference to Chapter 3, Fig 38, 41, 44, AMA 4 and then converted to Whole Person Impairment (5%) using Table 3, p 20, AMA 4. Left shoulder %Upper extremity impairment Flexion Extension 30 1 Internal rotation 70 1 External rotation 70 0 Abduction Adduction 50 0 The panel had not been asked to assess scarring, however noted that the claimant would attract an impairment based upon the TEMSKI scale. This was because she had a significant surgical scar which would be visible with light clothing. Left pubic bone fracture Plain x-ray of the pelvis [ ] had shown fracture of the body of the left pubic bone. There was some separation of the fracture fragments. There was no diastasis of the symphysis pubis on plain films, and this was confirmed on viewing the CT scan of the pelvis [28 March 2008]. Based on AMA 4, p131, s3.4, this would satisfy the descriptor at 2(e), thus 5% WPI. The panel found not convincing radiological evidence for a fractured left sacral ala. Right forefoot fractures The reduced range of flexion at the IP joint of the right great toe would yield 1% WPI based upon AMA 4, Table 45, p78.

75 Body Part or System 1. Brain - traumatic brain injury (mental status/emotional/ behavioural status) 2. Left shoulder fractured clavicle AMA Guides/ MAA Guidelines References (chapter/ page/table) MAA Impairment Guidelines,1 October 2007, Chapter 5 AMA 4, chapter 4, p 142, Tables 2 and 3. MAA Impairment Guidelines,1 October 2007, Chapter 2 AMA 4, Chapter 3, Fig 38,41,44 3. Pelvis - fracture MAA Impairment Guidelines,1 October 2007, Chapter 3 AMA 4, Chapter Right forefoot fractures MAA Impairment Guidelines,1 October 2007, Chapter 3 AMA 4, Chapter 3, Table 45, pg 78 * %WPI = percentage whole person impairment Permanent (YES/NO) Current %WPI* %WPI* from pre-existing OR subsequent causes %WPI* due to motor accident YES YES YES YES Determination Regarding the Degree of Whole Person Impairment of the Injured Person as a Result of the Injuries Caused by the Motor Accident The total percentage whole person permanent impairment for assessed injuries caused by the motor accident is 11 %.

76 This matter was subject to a review by a Medical Review Panel. These are the Review Panel s findings. Injuries: Right hand fractures 3 rd /4 th metacarpal bones Clinical Findings He confirmed the symptoms reported to Assessor X and emphasized his difficulty using his right hand since the accident, particularly in relation to his normal work duties as the owner/builder of a construction company. He also confirmed that he experienced constant pain in relation to his hand and indicated that he had developed a restricted range of movement of his index, middle and ring fingers as a result of the injuries sustained. He reported that in cold weather his fingers go white and cold and he experiences an occasional tingling sensation particularly in the tips of his fingers. He reported that he had sustained an injury to his right little finger in 1989 following which he had developed a deformity of the finger. He acknowledged that the shape of the right little finger and the range of movement had not been influenced adversely by the subject accident. On examination, the right hand was noted to have a relatively bluish discolouration and to be noticeably colder than the left hand on examination. The discolouration was noted to largely resolve with movement of the fingers of the right hand associated with the examination. He was noted to have evidence of some thickening of the palmar fascia of the right hand as compared to the left. He reported normal sensation. The right fourth metacarpal was slightly shorter than the other finger metacarpals and the head of the metacarpal was somewhat depressed in relation to the heads of the other metacarpals. There was some palpable thickening of the shaft of the fourth metacarpal. He had a restricted range of movement of the right index, middle and ring fingers. Active movements of the thumb and fingers of both hands were measured with a goniometer on more than one occasion to establish reliability. Thumb Right Left movements IP Flexion IP Extension MP Flexion 70 70

77 MP Extension Radial Abduction Adduction 1cm 1cm Opposition 5cm 5cm Finger Index Middle Ring Little movements R L R L R L R L MP Flexion Extension PIP Flexion Extension DIP Flexion Extension Review of the x-rays of the right hand taken following the subject accident revealed a spiral fracture of the distal shaft of the middle finger metacarpal which extended to the margin of the metacarpal head resulting in some incongruity of the articular surface. He had a spiral fracture of the proximal part of the shaft of the fourth metacarpal with some shortening and mild displacement. He was noted to have a small punched out cystic lesion in relation to the radial side of the proximal phalanx of the middle finger and in the ulnar styloid. Panel Deliberations The panel assessed impairment relating to the injuries of the right hand using the ranges of active movement of the relevant fingers with reference to AMA4 Figs 19, 21 and 23 pp 32, 33 and 34. The Upper Extremity Impairment Evaluation Record-Part 1 from page 16 of the AMA Guides, with the impairment calculations, is appended to the report. The panel noted the following relevant conclusions: The restriction of movement of the right index finger results in 42% impairment of the finger which equates with 8% impairment of the hand (AMA 4 Table 1, Page 18),

78 The restriction of movement of the right middle finger results in 41% impairment of the finger which equates with 8% impairment of the hand (AMA 4 Table 1, Page 18), The restriction of movement of the right ring finger results in 58% impairment of the finger which equates with 6% impairment of the hand (AMA 4 Table 1, Page 18), The total right hand impairment for the right index finger (8%), right middle finger (8%), and right ring finger (6%) is 22%. The restriction of movement of the left index finger results in 5% impairment of the finger which equates with 1% impairment of the hand (AMA 4 Table 1, Page 18), The restriction of movement of the left middle finger results in 5% impairment of the finger which equates with 1% impairment of the hand (AMA 4 Table 1, Page 18), The restriction of movement of the left ring finger results in 3% impairment of the finger which equates with 0% impairment of the hand (AMA 4 Table 1, Page 18), The total left hand impairment for the index finger (1%), and middle finger (1%) is 2%. Taking into account the fact that there was no history of an injury to the left hand, the ranges of movement of the fingers of the left hand are considered to be normal for him and there is a reasonable expectation that the injured right hand fingers would have had similar findings to the uninjured left hand fingers before the injury. The appearance of his uninjured left hand was consistent with his occupational activity as a builder. The calculation using left hand finger measurements reveals a 2% preinjury left hand baseline measurement, which should be subtracted from the calculation for impairment of the right hand. Subtracting the baseline measurement of 2% results in a figure of 20% impairment of the right hand. This equates with 18% upper extremity impairment (AMA 4 Table 2, Page 19) and 11% whole person impairment (AMA 4 Table 3, Page 20). This calculation takes into account Clause 2.5 Page 9 of the MAA Guidelines which states the following: If the contralateral uninjured joint has a less than average mobility, the impairment value(s) corresponding with the uninjured joint can serve as a baseline and are subtracted from the calculated impairment for the injured joint only if there is a reasonable expectation the injured joint would have had similar findings to the uninjured joint before injury. The rationale for this decision should be explained in the impairment evaluation report Panel Decision The degree of whole person permanent impairment of the injuries caused by the accident was calculated as follows:

79 Body Part or System 1. Right upper extremity AMA Guides/ MAA Guidelines References (chapter/ page/table) AMA4: Fig 19, 21, and 23 Pages 32, 33 and 34 MAA Pgs 9 to 12 Permanent (YES/NO) * %WPI = percentage whole person impairment Current %WPI* %WPI* from pre-existing OR subsequent causes Yes 11% Nil 11% %WPI* due to motor accident The panel concluded that there was no evidence to indicate that the limited range of movement of the right little finger was causally related to the subject accident. The panel also noted that the ranges of movement of the right thumb were essentially the same as those of the left thumb, and that there was no discrepancy between the right and left thumb in terms of calculated impairment (AMA 4 Figs. 10 and 13, Tables 5, 6, and 7, pages 26 to 29). Determination Regarding the Degree of Whole Person Impairment of the Injured Person as a Result of the Injuries Caused by the Motor Accident The total percentage whole person permanent impairment for assessed injuries caused by the motor accident is 11%. Therefore the total whole person impairment is greater than 10%.