Q&A: Rating Pubis Injury Using the Fifth Edition

Abstract

QUESTION: My question pertains to use of the AMA Guides, Fifth Edition, when providing an impairment rating for a woman who was involved in a motor vehicle accident, who has persistent pain in the pubis and groin consistent with aggravation of a preexisting degeneration of the symphysis pubis (confirmed by computed tomography [CT] scan of the pelvis). She appears to be a reliable historian, and it is my impression that she has impairment. Table 15-19, Whole Person Impairment Due to Selected Disorders of the Pelvis (5th ed, 428), provides only ratings for fractures and healed fractures. I am uncomfortable with assigning 0% for an obvious injury and ongoing symptoms that do not strictly conform with the provisions of Table 15-19. What should I do?ANSWER: In Section 1.5, Incorporating Science with Clinical Judgment, the AMA Guides states, “In situations where impairment ratings are not provided, the Guides suggests that physicians use clinical judgment, comparing measurable impairment resulting from the unlisted condition to measurable impairment resulting from similar conditions with similar impairment of function in performing activities of daily living. The physician's judgment, based upon experience, training, skill, thoroughness in clinical evaluation, and ability to apply the Guides criteria as intended, will enable an appropriate and reproducible assessment to be made of clinical impairment. Clinical judgment, combining both the ‘art’ and ‘science’ of medicine, constitutes the essence of medical practice” (5th ed, 11).First, one must determine an accurate diagnosis. The CT scan of the pelvis, presumably obtained after the motor vehicle collision (MVC), showed degeneration of the symphysis pubis and no other injury (eg, hip pathology, hernia). Second, is the diagnosis related to the injury via causation or aggravation (permanent worsening)? If this MVC involved a lap belt–restrained occupant in a moderate- to high-speed frontal impact, there may indeed have been aggravation of preexisting degeneration of the symphysis pubis. On the other hand, if the collision in question involved a low-speed frontal or a rear or side impact, such aggravation is unlikely. Another cofounding issue is reliability of the examinee. Assuming the diagnosis is accurate and causally related to the injury, the next question is whether there is permanent impairment, ie, “a loss, loss of use, or derangement of any body part, organ system, or organ function” (5th ed, 601). This is particularly problematic when there is only subjective evidence of impairment. Assuming no pre-collision CT scan was performed to enable comparison of the amount of symphysis pubis degeneration before and after, it would appear the basis for impairment is symptomatic, pain, and any resulting activity limitations. The AMA Guides are “guides.” Your clinical judgment is that she is a reliable historian, sustained a vehicular injury, and has permanent impairment causally related thereto. The question then becomes how to rate this fairly.A reasonable approach is to use analogy as the basis for defining impairment. For example, in Table 15-19, it is noted that a healed fracture of the symphysis pubis, without separation, which is “healed, with displacement and without residual sign(s)” is a 5% whole person impairment (WPI). This is also consistent with the range of impairments provided for diagnosis-related estimate lumbar category II of 5%–8%. You could use this analogy and assign 5% WPI. Alternatively, you might determine that her impairment is not this severe and assign half the value, 2.5% (rounding to 3%) WPI. This is consistent with Section 2.5g (5th ed, 20) that permits a 1%–3% WPI rating for injuries with “resolved” signs. As an alternative, you could use Chapter 18, in the Fifth Edition, and assign up to 3% WPI due to pain. Based on the limited information provided, a rating of 3% WPI is appropriate.