Functional Outcomes

and Physical

Impairment Rating

Tools in Orthopedic

Trauma

David Hubbard, MD

West Virginia University, Morgantown, WV

Created March 2004; Revised June 2006

Definition of Terms

• Disability
• Permanent impairment
• Handicap

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

.

Definitions

• Permanent Impairment

– any anatomic loss or functional

abnormality persisting after
maximum medical improvement
has been achieved.

Definitions

• Handicap

– disadvantages that limit

fulfillment of the an individual’s
usual role.

Your Role as Physician

• Identify objective findings
• Sole responsibility of the physician

to determine permanent
impairment

• Most impairment is caused by

musculoskeletal injuries

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

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

Third- Party Payers

• Will ask specific questions about

permanent impairment

• Physicians usually send letters

directly to these payers to provide
updates

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

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

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

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

.

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.

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

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.

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

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

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

Temporary Impairment

• Temporary total disability
• Temporary partial disability

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

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

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

Fractures and Associated

Impairments

5) Infection
6) intra articular involvement
7) Associated neurological injury
8) Preexisting osteoarthritis
9) Spine fractures

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

Functional Outcomes

• Disadvantage is that they do not

consider the patient’s opinion of
the success or failure of treatment

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!

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.

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

Functional Outcomes

• Health-related functions are the

patient’s perception of how they
are functioning based on their
overall health.

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

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

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

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

Quality-of-Life Instruments

(cont)

• Quality of Well-Being Scale (QWB)
• Musculoskeletal Functional

Assessment (MFA)

• AAOS Instruments

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

Thank You

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