Ives v QBE Insurance (Australia) Limited

[2023] NSWPICMP 212

DETERMINATION OF REVIEW PANEL

CITATION:

Ives v QBE Insurance (Australia) Limited [2023] NSWPICMP 212

CLAIMANT:

Martyn Ives

INSURER:

QBE Insurance (Australia) Limited

REVIEW Panel

MEMBER:

Alexander Bolton

MEDICAL ASSESSOR:

Shane Moloney

MEDICAL ASSESSOR:

Margaret Gibson

DATE OF DECISION:

18 May 2023

CATCHWORDS:

MOTOR ACCIDENTS – Review of certificate of Medical Assessor (MA) Home of 9 May 2022; claimant was riding a motorcycle with a pillion passenger when he was struck by a police car on his left side; claimant was thrown to the road injuring his left hip, left knee, right hand and right thumb; MA found whole person impairment (WPI) of 10% in his certificate but referred to methodology applied by American Medical Association Guides to the Evaluation of Permanent Impairment (AMA), 5^th edition and not 4^th edition AMA; clinical examination undertaken and claimant assessed as having 12% WPI; Held – certificate of MA revoked.

DETERMINATIONS MADE:  

CERTIFICATE OF DETERMINATION

The Review Panel revokes the certificate of Medical Assessor Home dated 9 May 2022.
The Review Panel finds that the claimant’s injuries to his;

(a)   left hip;

(b)   pelvis;

(c)   left knee;

(d)   right hand, and

(e)   right thumb.

Were caused by the accident.

The Review Panel assesses the total whole person impairment of the claimant at 12%.

STATEMENT OF REASONS

BACKGROUND

1. The claimant seeks a review of the assessment undertaken by Medical Assessor Home (the Medical Assessor) on 9 May 2022.

2. The challenge is made on the basis of;

   (a)   the application and use of the American Medical Association Guides to the Evaluation of Permanent Impairment, 5^th edition (AMA 5) in the assessment of the claimant’s injuries;

   (b)   the physical examination of the claimant’s right hand;

   (c)   the calculation of the claimant’s whole person impairment (WPI) with respect to his right hand, and

   (d)   the physical examination of the claimant’s left leg.

3. The following injuries were referred by the Personal Injury Commission (Commission) for assessment:

   (a)   left hip — dislocation, musculoligamentous strain injury, soft tissue injury;

   (b)   pelvis — avulsion fracture, musculoligamentous strain injury, soft tissue injury;

   (c)   left knee — rupture of posterior cruciate ligament, severe left posterior ligament laxity, musculoligamentous strain injury, soft tissue injury, and

   (d)   right hand — fracture at the base of the right 2nd metacarpal bone, musculoligamentous strain injury, soft tissue injury.

4. The Medical Assessor found the following injuries caused by the accident gave rise to a permanent impairment of 10%:

   (a)   left hip;

   (b)   left knee;

   (c)   right hand, and

   (d)   right thumb.

5. The Medical Assessor found no deformity of the right hand.

6. Measurements of the left wrist were recorded as follows:

Wrist Movements	Active ROM Measured RIGHT	Active ROM Measured LEFT
Flexion	60°	60°
Extension	70°	70°
Radial Deviation	25°	25°
Ulnar Deviation	30°	30°

1. Thumb movements were recorded as follows:

Thumb Movements	Active ROM Measured RIGHT	Active ROM Measured LEFT
§  CMC joint ·     Radial abduction ·     Adduction ·     Opposition	60° -1 cm 8 cm	60° -1 cm 8 cm
§  MCP joint
·     Flexion	60°	60°
·     Extension	-30°	0°
§  IP joint
·     Flexion	50°	60°
·     Extension	0°	0°

1. Left hip movements were recorded as follows:

Hip Movements	Active ROM Measured LEFT
Flexion	110°
Extension	0°
Adduction	25°
Abduction	35°
Internal Rotation	20°
External Rotation	35°

1. The Medical Assessor found that the claimant suffered the following injuries:

   (a)left hip fracture dislocation;

   (b)pelvis avulsion fracture directly related to the left hip injury. There is no separate injury to the pelvis beyond that set out for the left hip;

   (c)left knee rupture of the posterior cruciate ligament with residual laxity;

   (d)right hand fracture of the base of the second metacarpal bone, and

   (e)soft tissue injury to the right thumb at the level of the MCP joint.

2. The WPI was assessed as follows:

Body Part or System	AMA4 Guides/ Guidelines References (chapter/ page/table)	Permanent (YES/NO)	Current %WPI*	%WPI* from pre-existing OR subsequent causes	%WPI* due to motor accident
1	Left hip	Table 40, AMA 4, page 78	YES	2	0	2
2	Left knee	Table 17-33, AMA 5, page 546	YES	7	0	7
3	Right hand	Figures 26 and 29, AMA 5, pages 36 and 38	YES	0	0	0
4	Right thumb	Figures 26 and 29, pages 36 and 38	YES	1	0	1
Total WPI		10	0	10

The accident

1. The claimant sustained injuries in a motorbike accident on 7 October 2017 as the rider of a BMW 700 cc motorcycle, wearing a helmet, and travelling along King Street in Newtown when his bike was struck by a police car coming from his left on Enmore Road. His wife was a pillion passenger sitting behind him. It seems that after the impact, the claimant was thrown over the police car onto the road on the other side.

The claimant’s submissions

1. The claimant is critical of the methodology of assessment applied by the Medical Assessor.

2. The claimant says with respect to the assessment;

Pelvis - avulsion fracture of left acetabulum

1. The claimant submits that the Medical Assessor has assessed this injury using Table 17-33 - which relies upon range of motion assessments in the hip. However this Table is in the AMA 5 Guides, not the SIRA NSW Workers Compensation Guidelines for the Evaluation of Permanent Impairment, 4^th ed 1 March 2021 (AMA 4 Guides).

2. The claimant says that according to Paragraph 1.96 of the SIRA Permanent Impairment Guidelines:

   "Fractures of the acetabulum should be assessed using Table 64 (pages 85-86, AMA 4 Guides).”

Left knee - posterior cruciate ligament rupture

1. This injury was assessed as having "moderate" cruciate ligament laxity.

2. The claimant says that the Medical Assessor has made an error by referring to AMA 5 (Table 17-33, page 546) to determine a 7% WPI rating for this injury.

Left leg

1. The claimant submits that the Medical Assessor did not measure leg length or leg circumference of the claimant’s left leg.

2. The claimant says that no measurements were taken of his left leg length or circumference during the physical examination with the Medical Assessor.

3. The claimant submits that there are no measurements recorded by the Medical Assessor in the report.

Right hand - fracture at the base of the 2nd metacarpal

1. The claimant submits that the Medical Assessor has recorded no loss in the range of motion at the wrist and as such he has concluded that there is 0% WPI for the claimant's right hand injury.

2. However, the claimant says that given that the injury is at the base of the 2nd metacarpal, in order to make an accurate assessment of any potential impact of this injury on range of motion, the claimant submits that the Medical Assessor should have recorded measurements at both the joint below (i.e. wrist) and the joint above (i.e. the 2nd MCP joint - Using Figure 23, AMA 4 Guides, page 3/43).

3. The claimant submits that the Medical Assessor has omitted measurements of the claimant's limb circumference in his left leg and thigh, and also failed to record any measurements in the fingers (other than thumb) in the claimant's injured right hand.

4. The claimant submits that the injuries he sustained in the subject motor vehicle accident constitute a whole person impairment greater than 10%.

The insurers submissions

1. The insurer notes the following aspects of the decision challenged are as follows:

   (a)     the Medical Assessor did not carry out the assessment in accordance with the AMA4 and instead used AMA5 to assess the claimant's injuries;

   (b)    the Medical Assessor did not record measurements at both the joint below (wrist) and above (2nd MCP joint) during the physical examination of the claimant's right hand;

   (c)     the calculation of the claimant's WPI in respect of the right hand, and

   (d)     the Medical Assessor did not measure leg length or leg circumference during the physical examination of the claimant's left leg.

2. The insurer concedes that the Medical Assessor has referred to AMA 5 in the certificate assessing WPI of the pelvis, right hand and left knee, rather than referring to AMA 4 in the certificate. However, the insurer submits that this appears to be no more than a typographical error, noting the following:

   (a)     Tables 64 of the AMA4 and table 17-33 of the AMA 5 are identical. The insurer says that the claimant has pointed out that the Medical Assessor, in assessing the pelvis, ought to have referred to table 64 of the AMA 4 and not table 17-33 of the AMA 5. The insurer says that this would not have changed the outcome of the assessment at all;

   (b)     the claimant has pointed out that the Medical Assessor, in assessing the left knee, has erred in referring to table 17-33 of the AMA 5. The correct table is Table 64 of the AMA 4.

   However, the insurer says that as Tables 64 of the AMA 4 and table 17-33 of the AMA 5 are identical, once again, this would not have changed the outcome at all, and

   (c)     in the calculation of WPI of the right hand, at page 11 of his certificate, the Medical Assessor has referred to 'Figures 26 and 29, AMA 5, pages 36 and 38'. The insurer says that it is clear that the reference to AMA5 is a typographical error as these figures and page references relate to the AMA 4 and not AMA 5. The insurer submits that it is clear that the Medical Assessor has assessed the right hand using AMA 4 and not AMA 5. The insurer says that this error has not been raised by the claimant in submissions. The insurer submits that this indicates that the references to AMA5 are merely typographical errors in the certificate rather than indicating that the Medical Assessor has used the wrong guidelines in carrying out his assessment.

3. The insurer submits that, even if the Medical Assessor had referred to AMA  5 in assessing the pelvis, right hand and left knee, it would have had no material effect on his determination.

4. As to the physical examination of the claimant's right hand and the calculation of the claimant's WPI, the insurer notes that the claimant submitted that the Medical Assessor had erred by failing to record any measurement in the fingers (other than the thumb) in the claimant's right hand. The insurer notes that the claimant has submitted that the Medical Assessor erred by failing to record measurements at both the joint below (wrist) and above (2nd MCP joint) during the physical examination of the right hand.

5. In response, the insurer says that the Medical Assessor recorded at page 4 of his certificate that the claimant was reporting “decreased grip strength…difficulty opening jars and tight taps…intermittent pain extending across the dorsum of the hand, just above the wrist”. The claimant denied restricted motion of the fingers.

6. The insurer submits the following:

   (a)     the Medical Assessor assessed the right hand and noted no deformity;

   (b)     the Medical Assessor assessed the right wrist (flexion, extension, radial and ulnar deviation were normal). Range of motion was assessed, using a goniometer, and was recorded as full;

   (c)     the Medical Assessor assessed the forearms. The insurer notes that pronation and supination findings were recorded as preserved to 90 degrees in both directions;

   (d)     the Medical Assessor assessed the thumbs at the carpometacarpal (CMC) joint (adduction, abduction and opposition all normal), metacarpophalangeal (MCP) joint (flexion and extension normal) and interphalangeal (IP) joint (flexion and extension normal). The insurer says that the Medical Assessor noted restricted range of active right thumb motion and the CMC joint was maintained. The insurer notes that an assessment has occurred at both the CMC and MCP joint levels and also at the IP joint level, as required under the AMA 4, and

   (e)    the claimant denied restricted motion of the fingers, indicating that no further measurements were required.

7. The insurer submits that, even if the Medical Assessor had included measurements of the other fingers, it would have no material effect on his assessment of WPI, given he clearly noted the claimant's symptoms (and lack thereof, noting there was no report of restricted motion of the fingers) throughout his certificate and conducted a thorough examination.

8. The insurer submits that the Medical Assessor has carried out a thorough examination to investigate the claimant's reported symptoms and function of the right hand and no additional measurements were necessary.

9. The insurer says that the Medical Assessor was correct in assessing 0% WPI for the right hand as his examination findings recorded no impairment of the right hand. Following on from this, the insurer submits that the reference to AMA 5 in the certificate appears to be a typographical error and does not represent a material error in the certificate.

10. The insurer notes that the claimant submits that the Medical Assessor has erred by omitting measurements of the claimant's limb circumference in his left leg and thigh. Consequently the claimant submitted that the Medical Assessor erred by referring to AMA 5 (Table 17-33, page 546) to determine a 7% WPI rating for the left knee injury, noting that he assessed a moderate cruciate ligament laxity. However, the insurer submits that, as it is identical to Table 17-33 AMA 5, Table 64 AMA 4 also provides a 7% WPI for moderate cruciate ligament laxity.

Medical evidence
Report of Dr Bosanquet dated 30 September 2019

1. The claimant was reported as having ongoing physiotherapy and was off work for two months. He was on crutches for nine or ten weeks. In that time he noticed increasing pain in his left knee particularly squatting. An MRI scan revealed a tear in the posterior cruciate ligament, and he was referred to Dr Brett Fritsch, a knee surgeon. Dr Fritsch elected to manage this non-operatively with physiotherapy. The claimant attended physiotherapy twice a week for four to six months and then once a week for a year. He was given a thermoplastic splint for his right hand and physiotherapy commenced on that. By Christmas he was free of all splintage. At the time of this report he was not undergoing any treatment. The treating surgeon for his left hip, Dr Mark Horsley, had given the all clear in terms of the potential for an avascular necrosis in the left hip.

2. With the claimant’s right hand, he was tender in the first web space and at the base of his thumb. He had full movement in the thumb carpometacarpal (CMC) joint, metacarpophalangeal (MCP) and interphalangeal (IP) joint. He was able to fully oppose. He had full movement in his fingers including flexion/extension and abduction. There was slight diminution in grip strength compared to the left. There was no sensory deficit.

3. With the claimant’s left knee, there was no effusion, and he had a strong straight leg raise. He flexed to greater than 120°. He demonstrated a positive drop back sign and had a positive anterior draw with Grade II. He was tender over the medial side below the joint line. There was no retropatellar tenderness or crepitus. His quadriceps on the left measured 51cm and on the right 53cm, 10cm above the patella. There was a full range of movement in his right knee.

4. He was reported as having sustained an acute dislocation of his left hip, fractures involving the metacarpals of his right hand, a soft tissue injury to his right thumb and a posterior cruciate ligament tear in his left knee.

5. The diagnoses were:

   (a)     metacarpal fractures right hand;

   (b)     soft tissue injury right thumb;

   (c)     acute dislocation left hip, and

   (d)     posterior cruciate ligament tear left knee.

6. With reference to AMA 4, page 3/85, moderate cruciate ligament laxity is a 7% WPI. For quadriceps atrophy, Table 37, page 377, 2cm or more is moderate with a 4% WPI. Table 5 of the Permanent Impairment Guidelines (the Guidelines) requires that these disabilities cannot be combined. Thus, Dr Bosanquet said that the only measurable impairment was the moderate cruciate ligament laxity with a 7% WPI as a result of the motor accident.

Report of Dr Mitchell, occupational physician dated 18 May 2020.

1. The claimant was noted to have been transferred by ambulance to Royal Prince Alfred Hospital for assessment, complaining of pelvic pain together with abrasions to the lower back and left knee pain, left hip, and right hand.

2. He was diagnosed with dislocation of the left hip, avulsion fractures to the pelvis, a fracture to the metacarpal of the right hand, associated with a tendon tear, and a tear to the posterior cruciate ligament in the left knee. His left hip was reduced with sedation, under the care of orthopaedic surgeon, Dr Mark Horsley.

3. His right hand was placed in a splint.

4. The claimant was mobilised while non-weight bearing with crutches and was discharged a week later.

5. The claimant continued to have pain in his right hand and thumb and he was referred to hand surgeon, Dr Bernard Schick, whom he first saw on 14 November 2017.
   Dr Schick recommended that he continue with the hand splints until his symptoms settled.

6. The claimant reported increasing pain in his left knee and further investigations were arranged including an MRI scan on 21 November 2017 which showed a tear in the posterior cruciate ligament. Then the claimant was referred to knee surgeon, Dr Brett Fritsch. He recommended against surgery and referred him to Sydney Physiotherapy Solutions to build up his quadriceps muscle strength.

Further report of Dr Bosanquet dated 14 April 2021

1. Dr Bosanquet reported that due to ongoing pain in the left knee an MRI scan revealed a posterior cruciate ligament tear and he was referred to Dr Brett Fritsch, a knee surgeon. Dr Fritsch managed the posterior cruciate ligament (PCL) tear non-operatively with physiotherapy. He was in a thermoplastic splint for his right hand and had physiotherapy. By Christmas 2017 all splints had been removed. There has been no evidence of avascular necrosis in his left hip.

2. With the right wrist it was reported that the claimant gets intermittent pain triggered by certain unpredictable movements. It may be painful for a month and then settles down. This causes difficulty typing, which involves most of his work. There is pain in the mid-dorsum of his left hand. He has some difficulty opening jars and difficulty twisting and gripping. He is no longer riding a motorbike. He is now playing golf only once a month.

3. With the right hand there was tenderness at the base of the right 2nd metacarpal and the base of his thumb. There was full movement in the thumb CMC joint, CMP and IP joint without instability. He had full opposition and full movement in his fingers with flexion, extension and abduction. There was slight loss of grip strength but no sensory deficit.

4. With the left hip he gets intermittent pain, which will occur when getting up from the floor or suddenly turning. He feels there is some restricted movement causing difficulty tying his shoelaces. He has a stool in the shower to elevate his foot and there is a feeling of instability on stairs. If he goes hiking, there is pain after 30 minutes. He is best walking on flat ground. He has intermittent hip pain at night.

5. With the left knee he describes anterior and infrapatellar knee pain without swelling and with full movement. There is pain kneeling and squatting, some grating and grinding and instability on stairs. He can drive a manual vehicle but is unable to run comfortably. The knee feels “wobbly”.

6. In summary, the claimant has sustained an acute dislocation of his left hip, a fracture involving the metacarpal of his right hand, soft tissue injury to his right thumb and a posterior cruciate ligament tear to his left knee, which has been managed non-operatively. He has been able to return to work with some restrictions.

1. With regards to his acute on chronic back pain, it was reported that at no time during the two occasions when the claimant was seen did he mention back pain. He was treated for this in 2014. The doctor reported that it was his opinion that any symptoms the claimant was having from his back were unrelated to the motorbike accident.

Report of Dr Robin Mitchell – occupational physician

1. On physical examination, the claimant’s responses were said to be consistent and appropriate. All movements were carried out in an active manner by the claimant.

2. Regarding the head, neck and spine - spinal alignment was normal, and the range of movement was normal in the neck and near normal in the thoracolumbar back.

3. Cervical spine movement were reported as follows:

   (a)   flexion – normal;

   (b)   extension - normal;

   (c)   lateral flexion to right – normal;

   (d)   lateral flexion to left – normal;

   (e)   rotation to right – normal, and

   (f)    rotation to left – normal.

4. Thoracic spine movements were reported as follows:

   (a)   flexion – normal;

   (b)   extension – normal;

   (c)   rotation to right normal, and

   (d)   rotation to left - normal

5. Lumbar spine movements were reported as follows:

   (a)   flexion - ¾ of normal;

   (b)   extension - ¾ of normal;

   (c)   lateral flexion to right – normal, and

   (d)   lateral flexion to left – normal.

6. Muscle tone was normal to palpation.

7. Straight leg raising was normal at 90° on the left and right sides, and neurologically the lower limbs were normal, for both tendon reflexes and skin sensation.

8. The shoulders, elbows, wrists, and hands examined normally apart from some tenderness at the base of the right thumb. Joint movements throughout were normal, in the right wrist, hand and fingers.

9. Regarding the diagnosis, it was said that the claimant had made a reasonable recovery from dislocation of the left hip, with ongoing hip joint pain experienced.

10. There was ongoing pain and some minor instability in the left knee joint following partial resolution of the posterior cruciate ligament injury.

11. There was ongoing pain in the right hand and thumb from the injuries sustained in the subject motor vehicle accident including fracture of the base of the index metacarpal bone.

12. It was reported that with no significant radiological abnormality present in the left hip or knee joint a reasonable prognosis should be expected, with only intermittent pain symptoms when remaining on his feet for extended periods of time.

13. Dr Mitchell said that his right hand will probably be painful at times but should not significantly restrict his physical capabilities.

Report from Dr Fritsch to Dr Uppal, general practitioner, dated 23 November 2017

1. The claimant was reported to have sustained a fracture dislocation of his left hip, and injury to the first metacarpal and thumb of the right wrist, and a left knee injury. The hip injury was the most significant at that time, and had been managed by Dr Horsley, and was recovering nicely. With regard to the knee, the claimant complained of a deep-seated pain particularly if he kneels at the front of the knee. It feels stable although the claimant is not as mobile as he would normally be at this stage due to the hip injury.

2. Clinical examination demonstrated a small effusion and a full range of motion. He had a grade 2 posterior cruciate ligament injury with the PCL sitting at the grade one station. His medial collateral ligament (MCL), posterolateral corner and anterior cruciate ligament (ACL) were intact.

3. It was reported that the claimant’s MRI scan showed a high grade injury to the mid-substance of the PCL. Some anterior bone was seen.

4. In summary, the claimant’s injury appeared to Dr Fritsch to be an isolated PCL rupture. He was reported to have great to laxity evident but no clinical instability at the time of the report.

Medical records of Dr Schick 13 November 2017

1. This included a report dated 14 November 2017.  The claimant was noted to have sustained a left hip dislocation was treated in hospital for a week or so and then it became clearer that his right hand and particularly thumb MCP joint were very sore.

2. It was noted on a CT scan he had an intra articular base of index finger metacarpal fracture and although the print out CT scans were not very good quality, it could be seen that the fracture was not out of place. The claimant’s thumb MCP was bothering him more and he was tender over the on the outside of the joint and clearly, he had sustained a skier’s thumb which was said to be common after motorbike injuries.

3. On examination he was tender over the on the collateral ligament only.  The thumb was well-positioned and he had mild laxity on stressing this ligament.  The main concern was when the ligament was completely lax, indicating a Stener lesion that needed repair.

4. It was reported that he was only mildly unstable with a partial ulnar collateral ligament tear, and this should settle with non-operative treatment and continuing with splints with the physiotherapist, Adrian Jollow until his symptoms settled and he could gradually wean out of this.

5. A CT of the right hand of 10 November 2017 showed a near completely healed fracture in the base of the metacarpal index finger.

6. Dr Fritsch in a report of 22 May 2018 regarding the claimant’s PCL injury said that the knee was performing quite nicely. The claimant still had some laxity in the sagittal plane with his PCL but it was said to be solid and with normal activities it did not give him any sense of instability. The claimant complained of a distal pain on the lateral side but no pathognomonic anterior knee pain and surgery was not recommended.

7. A further report of 23 November 2017 confirmed a grade 2 PCL injury.

Report of Adrian Jollow, physiotherapist, 13 November 2017

1. The claimant was seen first on 13 November 2017 following the accident on
   5 October 2017 where it was said he suffered multiple injuries including a left hip dislocation and an index finger metacarpal fracture. He had been managed with a wrist splint.

2. Range of motion in the right finger was said to be good with full flexion and extension. There was some tenderness in the base of the index finger metacarpal, that was quite mild. The thumb appeared more symptomatic with some tenderness over the on the collateral ligament of the MCP joint, pain on MCP joint hyperextension (dorsal pain) and a lateral pinch on the right at 2.5 kg compared to 7.5 kg the left.

3. There are several reports from Dr Gehr. He found dysmetria and evidence of guarding. He also found significant thigh muscle wasting.

4. Dr Gehr reported that the claimant sustained the following injuries:

   (a)   dislocation of left hip, closed reduction performed, left with residual pain and stiffness of the left hip;

   (b)   fracture of second metacarpal right hand left with residual pain over the region of the second metacarpal and decreased range of motion of the right wrist;

   (c)   left knee injury with a PCL injury; left with residual pain, instability, and loss of range of motion of the left knee, and

   (d)   lumbar spine, he states lumbar spine pain from the time of the subject accident.

5. Dr Gehr diagnosed:

   (a)   left hip dislocation managed nonoperatively with residual pain and stiffness of the left hip;

   (b)   left knee PCL injury with residual pain and instability;

   (c)   right hand residual pain over the second metacarpal of the right hand with decreased range of motion of the right wrist, and

   (d)   lumbar spine soft tissue injury.

6. Dr Gehr had assessed 27% WPI.

Medical examination of the claimant on behalf of the Panel

1. The claimant was examined on behalf of the Panel by Medical Assessor Moloney. The findings of Medical Assessor Moloney are adopted by the Panel. His report follows:

   “Mr Ives attended the medical suite at the Personal Injury Commission and was unaccompanied.
   Preaccident history
   Mr Ives lives with his wife and stepdaughter. Prior to the accident he was working full-time as a TV producer and writer. He was a keen hiker, regular swimmer and played tennis and golf. He stated there were no previous injuries of those assessed today.
   History of motor accident and subsequent treatment
   Mr Ives was riding his motorcycle with his wife as a pillion passenger when an unmarked police car failed to give way and hit him on the left side of the bike. His wife and him were both knocked unconscious and he was unable to move his left leg. He was treated by the ambulance officer at the scene and taken by ambulance to Royal Prince Alfred Hospital. There was a dislocation of the left hip which was reduced at the hospital and he was admitted for about 8 days. CT scan showed a fracture of the left acetabulum and a fracture at the base of the 2nd metacarpal bone. He was subsequently diagnosed as having a right thumb ulnar collateral ligament tear at the MCP joint. This was treated by a splint and hand therapy. There was a 2nd admission due to the development of diverticulitis associated with constipation.
   Following the accident instability of the left knee was noted and an MRI reported a rupture of the posterior cruciate ligament. The orthopaedic surgeon, Dr Fritsch recommended conservative treatment.
   Since the accident, he has had persistent pain at the base of the right 2^nd metacarpal phalangeal joint which has not responded to physiotherapy.
   Current symptoms
   Mr Ives has persistent instability in the left knee which sometimes gives way resulting in falls. This continues to be painful and clicks at times and he states that he is unable to swim due to this. The left hip clicks and get uncomfortable when sitting. He is able to walk for up to 30 minutes before the hip and knee ache. He also has difficulty kneeling. The right wrist is stiff and occasionally he gets a severe sharp pain in the wrist joint. The right thumb is not painful but slightly unstable. There is an ache in the right shoulder which has improved and he was told it was osteoarthritis with no treatment needed.
   At present, He is working full-time mainly from home and is able to drive. His typing which is necessary for work is somewhat impeded due to stiffness in the right wrist. He also states that his PTSD makes it difficult for him to concentrate at work.
   Current treatment
   Mr Ives tend to avoid analgesics but takes an occasional Panadol. He states that he has mirtazapine at night to help sleeping. No manual therapy is being undertaken at present and he sees his GP when needed. He is under the care of a psychiatrist for his PTSD.
   Clinical examination
   Mr Ives walked into the rooms with a normal gait and sat comfortably during the interview.
   Right hand/wrist
   On inspection of the wrist there is a bony swelling at the base of the 2^nd MCP joint.

Thumb Movements	Active ROM Measured RIGHT	Active ROM Measured LEFT
·     CMC joint ·     Radial abduction ·     Adduction ·     Opposition	60° 1 cms 6cm	60° 2 cms 8 cm
·     MP joint ·     Flexion ·     Extension	60° -20°	60 ° 0°
·     IP joint ·     Flexion ·     Extension	60° 0°	60 ° 0°

Wrist Movements	Active ROM Measured  RIGHT	Active ROM Measured LEFT
Flexion	40°	60 °
Extension	60 °	60 °
Radial Deviation	20 °	30 °
Ulnar Deviation	30°	30°

Hip Movements	R	L
Flexion	100°	120°
Extension	0°	0°
Adduction	20°	30°
Abduction	30°	40°
Internal Rotation	20°	30°
External Rotation	30°	40°

Lumbar spine
Mr Ives walked with a normal gait but was unable to walk on his toes or heels. He was unable to squat. On testing range of movement, flexion/extension of 80% of expected range as was side bending with no asymmetry.
The neurological examination of the lower limbs showed reflexes equal bilaterally with normal power. There is slight muscle wasting in the left thigh with the circumference of the lower thigh 39 cm on the right and 38 cm on the left (10 cm above the superior patella pole) and at the maximum circumference of the calves 37 cm bilaterally.
Knees
On testing range of movement, right knee had a flexion of 130° on the left 120° with 0° extension. On palpation, there was  tenderness over the left fibula head but no tenderness on compression of the patella. On ligament testing there is a moderate laxity of the posterior cruciate ligament but no instability in the media lateral plane. No crepitus noted on passive movement of the left knee.
WPI
Moderate laxity of PCL left knee is 7 % WPI with table 64, page 85.
Lumbar spine .
Lumbar spine is DRE l classification which is 0 % WPI according to Table 72, page 110 of AMA 4^th . This because there is no dysmetria on testing ROM, no guarding on palpation and no signs of radiculopathy or non-verifiable radicular complaints in the lower limbs.
 Hip ROM Internal rotation 20° is  2% WPI ( no extra for external rotation which is the same) table 40, page 78.
Right wrist is 3% UEI for 40° flexion with figure 26, page 36.
Right thumb 6cm opposition is 3 % thumb + extension loss -20 is 1 % thumb + extension 0 of IP joint is 1 % thumb  = 5 % thumb  = 2 % hand ( table 1) = 2 % upper extremity impairment (UEI). Using figures 10,13, tables 5,6,7 pages 28/29  of AMA 4^th chapter 3
Add right wrist 3 % UEI + 2 % UEI for thumb = 5 % UEI = 3% WPI using Table 3.

Body Part or System	AMA4 Guides/ Guidelines References (chapter/ page/table)	Permanent (YES/NO)	Current %WPI*	%WPI* from pre-existing OR subsequent causes	%WPI* due to motor accident
1	Left hip	AMA table 40	Yes	2%	0%	2%
2	Left Knee	AMA table 64	Yes	7 %	0 %	7 %
3	Right wrist	AMA figure  26	Yes	3 % UEI	0 %	3% UEI
4	Right thumb	AMA figure 10,13 and tables 5,6,7	Yes	2 % UEI	0 %	2 % UEI 2+3 % UEI= 3 % WPI

The total whole person impairment of the claimant is 12 %.

Causation

1. The Panel accepts that given the circumstances of the accident where the claimant was riding a motorbike and which was collided into by the insured car, throwing him off the bike, over the bonnet of the car and onto the road, the injuries suffered by him are causally related to that incident occurring on 7 October 2017.

CONCLUSION

1. The claimant says that the Medical Assessor has applied the incorrect AMA 5 guides. The Panel confirms that this reference is made within the Medical Assessor’s certificate. In any event, the insurer has submitted that table 64 of AMA 4 and table 17-33 of AMA 5 are identical.

2. The Panel has based all of its measurements on AMA 4.

3. Regarding the claimant’s acetabular fracture, the estimate is based on range of motion.

4. The Panel has also included details of the circumference of the thigh and wrist range of motion.

5. With table 6.5 of MAA Guidelines thigh muscle atrophy can’t be added to DRE estimates or ROM. ROM was used for the left hip and DRE estimate for left knee.

6. The total of the claimant’s WIP is 12%.

Determination

1. The Review Panel revokes the certificate of Medical Assessor Home dated
   9 May 2022.

2. The Review Panel finds that the claimant’s injuries to his:

   (a)   left hip;

   (b)   pelvis;

   (c)   left knee;

   (d)   right hand including wrist and thumb, and

   (e)   right thumb.

   Were caused by the accident.

94.The Panel assesses the total WPI of the claimant at 12%.