Smith v M & F Hames Pty Ltd
[2022] NSWPICMP 3
•11 January 2022
| DETERMINATION OF APPEAL PANEL | |
| CITATION: | Smith v M & F Hames Pty Ltd [2022] NSWPICMP 3 |
| APPELLANT: | Jason Smith |
| RESPONDENT: | M & F Hames Pty Ltd |
| APPEAL PANEL: | Member Catherine McDonald |
| DATE OF DECISION: | 11 January 2022 |
| CATCHWORDS: | WORKERS COMPENSATION- Worker suffered burns and fractured vertrbrae in truck accident; Medical Assessor observed no clinical findings in lumbar spine but failed to assess on the basis of fractures; assessment of scarring under the American Medical Association Guides to the Evaluation of Permanent Impairment, 5th ed Table 8-2 and under the Table for the Assessment of Minor Skin Impairment if in class 1 of that table; Held -error in referral; Medical Assessment Certificate revoked. |
STATEMENT OF REASONS FOR DECISION OF THE APPEAL PANEL IN RELATION TO A MEDICAL DISPUTE
BACKGROUND TO THE APPLICATION TO APPEAL
On 16 July 2021 Jason Smith lodged an Application to Appeal Against the Decision of a Medical Assessor. The medical dispute was assessed by Dr Tim Anderson, a Medical Assessor, who issued a Medical Assessment Certificate (MAC) on 22 June 2021.
The appellant relies on the following grounds of appeal under s 327(3) of the Workplace Injury Management and Workers Compensation Act 1998 (1998 Act):
· the assessment was made on the basis of incorrect criteria,
· the MAC contains a demonstrable error.
The delegate was satisfied that, on the face of the application, at least one ground of appeal has been made out, being that in s 327(3)(d) – that the MAC contains a demonstrable error. We have conducted a review of the original medical assessment, limited to the grounds of appeal on which the appeal is made.
The WorkCover Medical Assessment Guidelines 2006 set out the practice and procedure in relation to the medical appeal process under s 328 of the 1998 Act. An Appeal Panel determines its own procedures in accordance with the WorkCover Medical Assessment Guidelines 2006.
The assessment of permanent impairment is conducted in accordance with the NSW Workers Compensation Guidelines for the Evaluation of Permanent Impairment, 4th ed reissued 1 March 2021 (the Guidelines) and the American Medical Association Guides to the Evaluation of Permanent Impairment, 5th ed (AMA 5).
RELEVANT FACTUAL BACKGROUND
Mr Smith was employed by M & F Hames Pty Ltd (Hames) as a truck driver. On 16 October 2018 he was injured in a motor vehicle accident, suffering burns and an injury to his lumbar spine. He has since returned to full time truck driving.
The Medical Assessor assessed 9% whole person impairment (WPI), comprised of 0% in respect of the lumbar spine and 9% under the Table for the Assessment of Minor Skin Impairment (TEMSKI) for scarring.
PRELIMINARY REVIEW
The Appeal Panel conducted a preliminary review of the original medical assessment in the absence of the parties and in accordance with the WorkCover Medical Assessment Guidelines 2006.
As a result of that preliminary review, the Appeal Panel determined that the worker should undergo a further medical examination because there were errors in the MAC described below, which could not be resolved by the information in the file. The examination was delayed by the pandemic.
EVIDENCE
The Appeal Panel has before it all the documents that were sent to the Medical Assessor for the original medical assessment and has taken them into account in making this determination.
Dr Tommasino Mastroianni conducted an examination of the worker on 15 December 2021 and reported to the Appeal Panel. Dr Mastroianni’s report is attached to these reasons.
The parts of the medical certificate given by the Medical Assessor that are relevant to the appeal are set out, where relevant, in the body of this decision.
SUBMISSIONS
Both parties made written submissions. They are not repeated in full, but have been considered by the Appeal Panel.
Mr Hammond of counsel prepared submissions on behalf of Mr Smith. He summarised the medical evidence. He submitted that the Medical Assessor erred in not assessing Mr Smith in DRE Lumbar Category II and in not making an assessment of the impact of the back injury on the activities of daily living. Mr Hammond said that the spinal fractures suffered by Mr Smith mandated assessment in DRE Lumbar Category II.
With respect to the activities of daily living, Mr Hammond submitted that the Medical Assessor had not taken a proper history to allow the assessment to be made. He noted that Dr Clayton, qualified for Mr Smith, recorded that he suffered exacerbations of pain which restricted his ability to look after his garden.
Mr Hammond noted the difference of opinion between Dr Hamann, qualified for Mr Smith, and Dr Segal, qualified for Hames, about whether it is possible to combine an assessment under the TEMSKI and under AMA 5. He said that the Medical Assessor erred in not adopting Dr Hamann’s method. He said that the SIRA website did not show that the Medical Assessor was qualified to provide an assessment above 4% for an injury to the skin and that the Medical Appeal Panel should include a dermatologist or plastic surgeon.
In reply and in submissions prepared by its solicitor, Mr Michael, Hames submitted that the Medical Assessor was correct to assess Mr Smith in DRE Lumbar Category I where there was no complaint of pain and no clinical findings in the lumbar spine. In those circumstances, there was no need to provide a rating for the impact of the injury on activities of daily living.
With respect to scarring, Hames submitted that the Medical Assessor assessed the maximum amount under the TEMSKI. It noted that Mr Smith objected to the qualifications of the Medical Assessor but did not object when the referral was made, that the Medical Assessor said that the worker was not claiming compensation for any body system outside his expertise and that there was no evidence that the Medical Assessor had not undertaken the relevant training under paragraph 14.7 of the Guidelines.
FINDINGS AND REASONS
The procedures on appeal are contained in s 328 of the 1998 Act. The appeal is to be by way of review of the original medical assessment but the review is limited to the grounds of appeal on which the appeal is made.
In Campbelltown City Council v Vegan[1] the Court of Appeal held that the Appeal Panel is obliged to give reasons. Where there are disputes of fact it may be necessary to refer to evidence or other material on which findings are based, but the extent to which this is necessary will vary from case to case. Where more than one conclusion is open, it will be necessary to explain why one conclusion is preferred. On the other hand, the reasons need not be extensive or provide a detailed explanation of the criteria applied by the medical professionals in reaching a professional judgement.
[1] [2006] NSWCA 284.
The referral
The Application to Resolve a Dispute sought assessment of skin, “TEMSKI/Scarring” and the lumbar spine. The claim should only have sought an assessment of skin and the lumbar spine.
The referral prepared by a staff member of the Commission omitted the reference to the skin. We understand it is the Commission’s practice to send the proposed referral to the parties for comment. The referral should have been reviewed and the omission of skin brought to the Commission’s attention.
If Mr Smith sought to object to the appointment of the Medical Assessor or to query if the Medical Assessor had in fact undertaken training in the skin body system, the appropriate time was also when the referral was made.
The Medical Assessor is not listed on the SIRA website as having been trained in the assessment of the skin (as Dr Mastroianni is).
The MAC
The Medical Assessor described the event causing the injury:
“Mr Smith related that on 16/10/18, the truck he was driving appeared to have dysfunction, went out of control and drove straight into a tree. The truck then caught fire on the inside of the cab. The cab was full of smoke and he had the greatest of difficulty in getting out. Eventually he smashed open the left window of the sleeping compartment of the cab and literally tumbled out onto the ground. Before he had got out of the cab, he had been burnt, mostly on his right side. He has no recollection of what happened next, although apparently he was assisted by passers-by. He was taken to hospital and from there was transferred to the Royal Brisbane and Women’s Hospital. He remained there for about five weeks. The first two weeks was in the Intensive Care Unit.
He had extensive skin grafting over his left leg. The donor site was his right thigh. The graft took well and there was no infection. All of his subsequent clinical management has been conservative.”
The Medical Assessor briefly described Mr Smith’s present symptoms:
“His left knee is stiff and sore. He described that he has pins and needles which radiate below the left knee. There is also a lot of colour change and obvious differences between the area where it was burnt and normal skin. This concerns him.”
The Medical Assessor said that Mr Smith made no complaint at all of lower back pain and there was no tenderness. He said:
“There was extensive scarring from the left hip all the way down to the left ankle over the anterolateral part of the leg. There was only a small longitudinal area of the posterior leg which had not been affected. There had been skin grafting from the donor site at the right anterior thigh. (Over this area there was a new animal head tattoo.)
The scarring over the left leg was mostly atrophic, wrinkled and the skin appeared very thin and delicate. There have been several occasions where minor abrasions have caused infective foci (as evidenced by the event which occurred about a month ago and left him in hospital for two days). The skin over this area was also very dry.
No features suggestive of radiculopathy were identified. The straight leg raise assessment was conducted in the sitting position on the edge of the couch. He could fully extend each knee without difficulty. Reflexes were present and equivalent at the knees (L4) and at the ankles (S1). Power of the extensor hallucis longus (L5) was equivalent.”
When summarising the injuries and diagnoses the Medical Assessor said:
“Mr Smith has sustained severe burns, predominantly to his left leg and to a lesser extent, his left forearm and to a least extent, his face when the cab of his truck caught fire in mid-October 2018 following a crash into a tree. As well as being burnt, mostly over the left leg, he also sustained an injury to his lower back on the left with reported fractures of the L1 to 4 transverse processes.
His major treatment in hospital was skin grafting, taken from the anterior of the right thigh and applied to the left leg. This has taken quite well, although he continues to have extensive scarring and atrophic features of the left leg.
Despite the extent of the injury to the left leg, he has managed to get back to his full duties and occupation of long distance driving.
In this event, he also injured his lower back. This was always managed conservatively and at this assessment there were no continuing features (at all) of any low back dysfunction.”
The Medical Assessor assessed 0% WPI in respect of Mr Smith’s lumbar spine and 9% for scarring. He said:
“The lumbar spine is addressed in AMA 5 Page 384, Table 15-03. There were no clinical findings (at all) with the lower back. Similarly, there was no complaint of pain or lower back dysfunction. Mr Smith is therefore assessed in DRE Lumbar Category I, which provides a whole person impairment of 0% WPI.
The scarring is assessed in the SIRA Guidelines Page 74, Table 14.1. (This is a detailed extension of ‘Grade I’. If his condition had been any more severe, it would have been appropriate for a greater grade to have been selected. In Mr Smith’s circumstances, Grade I with the further detail of the TEMSKI Table is appropriate. Mr Smith is very conscious of the scar of his left leg. This is easily located and is also easily visible since for most of the time he chooses to wear shorts. There is very obvious colour and texture distinction between the scarred area and the normal skin. The skin of the scarred area is also thin, tender and atrophic. There is relatively little influence in his activities of daily living, although he does need to protect this whole area from sunlight and also from even minor physical insults.
He freely admitted that he is supposed to apply moisturiser to the scarred area but chooses not to bother. With this constellation of features, the best fit in the TEMSKI Table is at the maximum of this table at 9% WPI.”The Medical Assessor commended on the reports of the independent medical examiners qualified by the parties:
“My assessment of scarring is closer to that of Specialist Dermatologist, Dr Alan Segal in his report of 28/09/20. I do believe that in all fairness, Mr Smith has a whole person impairment of 9% as opposed to 7%.
Specialist Dermatologist, Dr Ian Hamann in his reports of 06/08/20 and 10/12/20 initially provides a whole person impairment of 15% for the scarring which is subsequently revised to 14%. In studying his technique, it looks as though the results of the TEMSKI Table have actually been added (or possibly combined) to a further grading of scarring. With great respect, this looks a bit like ‘double dipping’.
So far as the lumbar spine is concerned, both Specialist Orthopaedic Surgeons, Dr James Clayton and Dr Raymond Wallace in their reports of 30/11/20 and 09/02/21 respectively arrive at a lumbar DRE II assessment. Dr Clayton provides a further 1% for activities of daily living, yet Dr Wallace provides no further impairment for this. At my assessment, which has been conducted over four months after the most recent of these assessments, I was unable to demonstrate any clinical findings with the lumbar spine at all. Similarly, there were no continuing complaints of low back dysfunction. Hence, my assessment is different at DRE Lumbar Category I as opposed to DRE Lumbar Category II.”
Lumbar spine
The criteria in AMA 5 for assessing impairment in the spine are diagnosis related estimates. AMA 5 provides in paragraph 15.3:
“The DRE method has five diagnosis-related categories or each of the three spinal regions. In assigning the individual to the correct DRE category, one of two approaches is used. The first is based on symptoms, signs, and appropriate diagnostic test results. The second is based on the presence of fractures and/or dislocations with or without clinical symptoms. If a fracture is present that places the individual into a DRE category, no other verification is required.”
The CT scan undertaken when Mr Smith was admitted to hospital on 16 October 2018 was reported to show, among other things:
“Lumbosacral spine:
Undisplaced and minimally displaced fractures involving the right L 1 - L4 transverse processes.
Normal bony alignment. No fracture or bony abnormality. Mild de-generative change at the lumbosacral articulation. Incidental note of incompletely fused posterior elements at the S1/S2 level and lower sacrum”Mr Smith suffered a fracture and he therefore should have been assessed under the second method proposed by AMA 5.
The criteria with respect to fractures in DRE Lumbar Category II are:
“fractures: (1) less than 25% compression of one vertebral body; (2) posterior element fracture without dislocation not developmental spondylosis) which has healed without alteration of motion segment integrity; (3) a spinous or transverse process fracture without a vertebral body fracture which does not disrupt the spinal canal.”
The fracture shown on the CT scan falls into the third category.
Paragraphs 4.30 and 4.31 of the Guidelines describe how the criteria in AMA 5 are to be applied in certain circumstances. They do not change the assessment of Mr Smith’s injury.
Both Dr J Clayton who assessed Mr Smith at the request of his solicitors and Dr R Wallace who assessed him for Hames assessed him in DRE Lumbar Category II because of the fracture.
On the basis of clinical signs alone, Mr Smith may have fallen into DRE Lumbar Category I but the presence of the facture required assessment in DRE Lumbar Category II and the Medical Assessor was in error not to do so.
Activities of daily living
Mr Smith submitted that the Medical Assessor should have provided an assessment in respect of the activities of daily living. However the history he gave to the Medical Assessor and to Dr Mastroianni is that his back injury does not impact on his level of activity.
Mr Hammond said that the Medical Assessor did not take into account the history provided to Dr Clayton that Mr Smith is restricted by his back injury in his ability to look after his garden and property.
The Medical Assessor was required by paragraph 1.6 of the Guidelines to make an assessment of Mr Smith as he presented on the day of the assessment. Mr Smith told the Medical Assessor that he has no difficulty helping around the house. He does a lot of cooking. He is able to cut the grass and use the whipper snipper.
Mr Smith told Dr Mastroianni that he does normal domestic work, gardening and is independent in self care.
Neither of those histories warranted a rating for the impact of the injury on the activities of daily living and the Medical Assessor was not required to accept the history recorded in Dr Clayton’s report.
Campbell J described the task of the Medical Assessor (and of the Appeal Panel Member conducting a re-examination) in State of New South Wales v Kaur[2] (Kaur):
“In Wingfoot Australia Partners Pty Ltd v Kocak [2013] HCA 43; 252 CLR 480, the High Court of Australia dealt with the nature of the jurisdiction exercised by a medical panel under cognate Victorian legislation. The legislation is not entirely the same but it is broadly similar in purpose. Allowing for some differences, the High Court said at page 498 [47]:
‘The material supplied to a medical panel may include the opinions of other medical practitioners, and submissions to the Medical Panel may seek to persuade the Medical Panel to adopt reasoning or conclusions expressed in those opinions. The Medical Panel may choose in a particular case to place weight on the medical opinion supplied to it in forming and giving its own opinion. It goes too far, however, to conceive of the functions of the panel as being either to decide a dispute or to make up its mind by reference to completing contentions or competing medical opinions. The function of a medical panel is neither arbitral or adjudicative: It is neither to choose between competing arguments nor to opine on the correctness of other opinions on that medical question. The function is in every case to perform and to give its own opinion on the medical question referred to it by applying its own medical experience and its own medical expertise.’
Not all of this, as I have said, is apposite in the context of the New South Wales legislation. In particular it is obvious that approved medical specialists are required to decide disputes referred to them by the process of medical assessment. Even so, it is not necessary that approved medical specialists should sit as decision makers choosing between the competing medical opinions put forward by the parties. Essentially, the function is the same as that described by the High Court in Wingfoot Australia. That is to say, their function is in every case to form and give his or her own opinion on the medical question referred by applying his or her own medical experience and his or her own medical expertise. It is sufficient, as their Honours pointed out at [55], that:
‘The statement of reasons… explain the actual path of reasoning in sufficient detail to enable the Court to see whether the opinion does or does not involve any error of law.’”
[2] [2016] NSWSC 346.
Paragraph 4.34 of the Guidelines contemplates that an 0% may be assessed for activities of daily living and based on Mr Smith’s history, that is the appropriate assessment.
Scarring
Campbell J’s comments in Kaur are also relevant to the submissions made on behalf of Mr Smith with respect to the assessment of his skin. Mr Hammond submitted that it was outside the Medical Assessor’s “expertise to quell the controversy that exists as between Dr Hamann and Dr Segal.” His task was not to resolve controversy or choose between the assessments but to make his own assessment in accordance with the Guidelines.
Dr I Hamann, dermatologist, assessed Mr Smith on behalf of his solicitors. He said:
“Having reviewed the Guidelines and clinical examples provided by the WorkCover Guides, 4th Edition and AMA 5 I consider Mr Smith to fall into a Class 2 category of whole person impairment. This is due to the combination of WPI ratings for his scarring and ongoing skin symptoms.
He has a Class 1, 5 % impairment of whole person related to his symptoms of dryness, hypersensitivity and discomfort associated with his scarring. These symptoms are present constantly, with limitations in performance of some activities of daily living and requires intermittent treatment.
His scarring has been assessed according to the TEMSKI WorkCover Guides at the highest end of the 5-9% WPI as he fulfills all criteria for this level of assessment.
Mr Smith's WPI is 15%.”
Dr A Segal, also a dermatologist, assessed Mr Smith on behalf of Hames. He assessed Mr Smith at 7% WPI under the TEMSKI. With respect to Dr Hamann’s assessment he said:
“It does appear that Mr Haman has added the WPI for skin to the Temski modification using the combined value tables.
My understanding of the use of the Temski modification is that this is to MODIFY Class 1 (0%to9%) WPI for skin. It is my understanding that this is a modification of the Class 1 assessment and not to be added to the original AMA's assessment. Generally, Dr Haman's assessment of the WPI falls closely together but I believe the disparity is due to this error in combination of the Temski with the AMA's Class 1 assessment.”
Dr Hamann provided a detailed response and said:
“Unfortunately, the WorkCover Guides are not entirely clear on this type of assessment. Dr Segal is correct that the TEMSKI scale, Table 14.1, replaces AMA 5 in assessment of scarring. However, my interpretation has been that this assessment is of the cosmetic effect of the scarring, as the assessment criteria deal exclusively with these aspects.
The limitations of ADL mainly address restrictions in grooming, dressing and physical exposures as one would be expect with sensitive and unsightly skin. In my opinion this does not exclude assessment of other symptoms and signs of impairment related to other aspects of the worker’s injuries.”
Dr Hamann said that because there was no clear direction in the Guidelines, he sought assistance from another doctor whose opinion was that the Guidelines were unclear and that the use of the TEMSKI did not preclude other assessments of the skin injury.
The Guidelines are in fact clear on their face as to the application of AMA 5 and the TEMSKI.
Dr Hamann’s confusion may have arisen from an assumption that Chapter 14 of the Guidelines and the TEMSKI only apply to scarring. That is the most common use of the chapter and TEMSKI but not their only purpose.
The Guidelines provide that AMA 5 applies to the assessment of permanent impairment of the skin subject to the modifications on Chapter 14. It applies to all aspects of impairment, not merely scarring. Paragraph 14.4 says:
“AMA5 Table 8-2 (p 178) provides the method of classification of impairment due to skin disorders. Three components – signs and symptoms of skin disorders, limitations in ADL and requirements for treatment – define five classes of permanent impairment. The assessing specialist should derive a specific percentage impairment within the range for the class that best describes the clinical status of the claimant.”
Table 8-2 in AMA 5 is a simple table, which also applies to all skin disorders and not merely scarring. For class 1 it assesses whether:
“Skin disorder signs and symptoms present or intermittently present
and
no or few limitations in performance of activities of daily living; exposure to certain chemical or physical agents may temporarily increase limitation
and
requires no or intermittent treatment.”
Paragraphs 14.7 and 14.8 of the Guidelines provides;
“The table for the evaluation of minor skin impairment (TEMSKI) (see Table 14.1) is an extension of Table 8-2 in AMA5. The TEMSKI divides class 1 of permanent impairment (0–9%) due to skin disorders into five categories of impairment. The TEMSKI may be used by trained assessors (who are not trained in the skin body system), for determining impairment from 0–4% in the class 1 category, that has been caused by minor scarring following surgery. Impairment greater than 4% must be assessed by a specialist who has undertaken the requisite training in the assessment of the skin body system.
The TEMSKI is to be used in accordance with the principle of ‘best fit’. The assessor must be satisfied that the criteria within the chosen category of impairment best reflect the skin disorder being assessed. If the skin disorder does not meet all of the criteria within the impairment category, the assessor must provide detailed reasons as to why this category has been chosen over other categories.”
Even though the Medical Assessor was only asked to assess Mr Smith’s skin under the TEMSKI, he was in error in determining that he was able to assess more than 4% in the absence of training in the skin body system. He was also in error to make the assessment without considering the application of Table 8-2, given the extent of the skin grafting undergone by Mr Smith. Both of those matters required him to refer the assessment back to the Commission.
The task of any doctor assessing Mr Smith’s skin was to determine which of the classes in Table 8-2 in AMA 5 applied. Section 8.1 of AMA 5 requires the assessor to:
“…evaluate the severity of the skin condition on the ability to perform the activities of daily living see Table 1-2). Determine the appropriate percentage within any impairment class by considering the frequency, intensity and complexity of the medical condition and the treatment regimen. In general, the more frequent and intense the symptoms, signs, and medical treatment, the higher the estimated impairment rating within any impairment class. Table 8-2 lists the impairment classes and percents of whole person impairment for all dermatologic disorders.”
If class 2 or above applied, then the assessment is made under Table 8-2. If class 1 applied, then the TEMSKI provided how the range of percentages appropriate to that class (0 to 9%) applied.
Given the extent of skin grafting undergone by Mr Smith, assessment in class 1 and therefore under the TEMSKI was clearly inappropriate.
The criteria for the application of class 2 in Table 8-2 are:
“Skin disorder signs and symptoms present or intermittently present
and
limited performance of some activities of daily living
and
may require intermittent to treatment.”
The range of percentages applicable to class 2 is 10 to 24%
We agree that Dr Mastroianni’s assessment under Table 8-2 accurately reflects the impact of the injury to Mr Smith’s skin for the reasons set out in his report.
For these reasons, the Appeal Panel has determined that the MAC issued on 22 June 2021 should be revoked, and a new MAC should be issued. The new certificate is attached to this statement of reasons.
PERSONAL INJURY COMMISSION
APPEAL PANEL
MEDICAL ASSESSMENT CERTIFICATE
Injuries received after 1 January 2002
This Certificate is issued pursuant to s 328(5) of the Workplace Injury Management and Workers Compensation Act1998.
The Appeal Panel revokes the Medical Assessment Certificate of Dr Tim Anderson and issues this new Medical Assessment Certificate as to the matters set out in the Table below:
Table - Whole Person Impairment (WPI)
| Body Part or system | Date of Injury | Chapter, page and paragraph number in WorkCover Guides | Chapter, page, paragraph, figure and table numbers in AMA 5 Guides | % WPI | Proportion of permanent impairment due to pre-existing injury, abnormality or condition | Sub-total/s % WPI (after any deductions in column 6) |
| Lumbar spine | 16.10.18 | Chapter 4 Pages 24-29 | Chapter 15 Table 15-3 | 5% | 0 | 5% |
| Scarring | 16.10.18 | Chapter 14 Pages 73-74 | Page 178 Table 8.2 | 13% | 0 | 13% |
| Total % WPI (the Combined Table values of all sub-totals) | 17% | |||||
Catherine McDonald
Member
Dr Tommasino Mastroianni
Medical Assessor
Dr Brian Noll
Medical Assessor
10 January 2022
REPORT OF THE EXAMINATION BY MEDICAL SPECIALIST MEMBER OF THE APPEAL PANEL
Matter No: M1-889/21
Appellant: JASON SMITH
Respondent: M & F Hames Pty Ltd
Examination Conducted By: Tommasino Mastroianni
Date of Examination: 15 December 2021
1. The workers medical history, where it differs from previous records
The worker confirmed the history as recorded by Dr Tim Anderson on 22 June 2021.
2. Additional history since the original Medical Assessment Certificate was performed
Mr Smith states that his back is sore on and off. He says his leg gets itchy. He said that in the last 6 months he had cellulitis in the left leg on two occasions needing antibiotic treatment. The left knee throbs after he sits for a period. He says the grafts bleed if he bumps them. If he goes out in the sun the grafts get hot and burn. He says he has to use sunscreen to protect the grafts.
3. Findings on clinical examination
He is a man of stated age of large frame and build. He walked with a normal gait. He sat comfortably whilst relaying the history. He relays the history in a straight forward manner. There is consistency in the history and examination.
Examination of the back reveals normal lordosis. There is no muscle guarding or muscle tenderness. There is generalized discomfort on palpating the small of his back.
Back movements were slightly restricted in flexion and extension. Tilt is restricted by one-third bilaterally whilst rotation was normal.
Neurology of the lower limbs was normal. He has normal sensation, normal reflexes and normal power. Straight leg raise is normal.
Examination of the right leg donor site for the grafts revealed a large pale scar measuring 25cm x 24cm.
The left leg has been grafted with the graft extending 27cm above the knee with a width of 18cm. The area below the knee to the ankle has been grafted sparing only the back of the calf.
There are hypertrophic changes in the graft. The grafted area has a purplish discolouration. There were a number of scabs on the leg and he says that the leg bleeds and then scabs as the graft is easily traumatized. There was no dysaesthesia in the grafts.
4. Results of any additional investigations since the original Medical Assessment Certificate
There have been no additional investigations since the original Medical Assessment Certificate.
The claimant has tenderness in the back and asymmetric loss of range of movement.
No x-rays were reviewed however there are x-ray reports on file which report undisplaced and minimally displaced fractures involving the right L1 to L4 transverse processes.
The claimant falls into DRE Lumbar Category II (AMA 5, Page 384, Table 15-3) as he has multiple displaced fractures of the transverse processes. ADLs are not affected by the back injury. The claimant does normal domestic work and gardening and is independent in self-care. I assess 5% whole person impairment. No deduction is applicable for pre-existing condition.
The claimant has significant scarring in the left leg and also the donor site. The grafted areas impact ADLs and he has to take extra care to not traumatise the leg as the grafted area is fragile and easily traumatised. He had two episodes of cellulitis needing antibiotic treatment. He has to protect the scars from sunlight to avoid sunburn. He gets an abnormal sensation in the grafts which irritate the leg, and he has to move the leg after he sits for long periods.
In my opinion under the criteria for rating permanent impairment due to skin disorders, he falls into Class 2 (AMA 5, Page 178, Table 8.2). He has skin disorder signs and symptoms. There is limited performance of some activities of daily living such as exposing the leg to direct sunlight and needing to protect the leg from trauma as the graft is fragile and is easily traumatised. He requires treatment, moisturisers and sunscreen.
Class 2 is 10% to 24% impairment of the whole person. In my opinion he falls into the lower end of that Class, and I assess 13% whole person impairment.
There is no deduction applicable for pre-existing condition.
Signed:
Tommasino Mastroianni
Date: 15/12/21
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