401 Second Avenue South, Suite 110 Seattle, WA 98104 Telephone: 206.324.6622 Toll Free: 1.800.331.6622 Fax: 206.726.8605
Medical Examination of
Employer: Claim Number: Date of Exam: Date of Birth: Date of Injury:
Location of Exam: Examining Physician: Brian Tallerico, DO Dictated by: Dr. Tallerico
hank you for requesting OMAC to schedule an independent medical examination on ____. The following is a report of an orthopedic examination T performed by Dr. Tallerico.
This report is intended to provide you with a fair and objective review of the medical facts relating to the examinee's circumstance, including those particular issues presented for our consideration.
The opinions expressed in the report are solely those of the physician performing the examination.
A reminder letter was sent to the examinee that included an explanation of the purpose and procedures of the examination. The letter also informed the examinee that a written report will be sent to the agency requesting the examination. The examinee should contact that agency for information regarding the report.
The dictated report is as follows:
www.omacime.com Clinic Locations throughout the Northwest 1 Claimants Name Claim Number Date of Exam
INTRODUCTION ------
The history of present injury and record review was performed in the presence of the examinee so that Ms. ____ could add information or make corrections she felt necessary. Any records reviewed represent a summary of the available medical records and it is my recommendation they remain available for further consultation as needed.
CHART REVIEW------
Per the cover letter from ____, the claim is ____. The examinee is ____. The employer is ____. Date of injury was ____. History of present injury: ____ was walking in the parking lot to report to work when she tripped and fell, and landed on the concrete sidewalk with a contusion of her face, left knee, and fracture of her right hand. The fracture healed, but she continued to have ongoing pain. She saw several hand specialists and finally underwent surgery with Dr. ____, and had a good outcome from the surgery. On ____, she was deemed to be at maximum medical improvement as a result of the hand injury, with no work restrictions.
She also injured her left knee as a result of the fall, but no treatment occurred until several months after the injury. She continued to have left knee pain, and this was refractory to conservative treatment. She had knee surgery in ____ by ____, MD, which was a left knee arthroscopy, loose body removal and debridement of parameniscal cyst anteromedial meniscus, and was found to have significant chondromalacia of the patella, as well as medial femoral condyle that was débrided, but she continued to have pain postoperatively. She has had multiple cortisone injections, one in ____ and one in ____. The one in ____ eliminated most of her pain temporarily but it recurred. The second one did not help much. She underwent a series of Synvisc injections by ____, MD, without relief of her symptoms. Dr. ____ advised that the only option at this time would be a total knee replacement. Dr. ____ has indicated ____ is at maximum medical improvement.
Date The emergency report, status post fall on ____. The impression was facial abrasion and contusion, left knee abrasion, and right fifth metacarpal fracture. X-rays of the right hand showed a mildly displaced fracture at the base of the fifth metacarpal.
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Claimants Name Claim Number Date of Exam
Date An evaluation by ____, MD, on ____, showed that she had ecchymosis, swelling, and tenderness in her hand. He reviewed the x-rays and recommended a short arm cast.
Date She went to see ____, MD, for her hand after she came out of the cast. He stated that she apparently healed her fracture well, but had some pain at the fifth finger MP joint. He injected her tendon sheath at the A-1 pulley.
Date On ____, Dr. ____ noted she was still having problems. The cortisone shot helped her somewhat. Dr. Jones recommended a bone scan.
Date On the ____ visit, Dr. ____ felt that she had carpometacarpal arthritis of the fifth metacarpal joint, with separation of the extensor tendons at the metacarpophalangeal joint. He recommended a bone scan and discussed surgical options, but the examinee elected to proceed with conservative treatment.
Date She saw ____, MD, on ____. An MRI was ordered.
Date The MRI reported a healed fracture at the base of the fifth metacarpal, no evidence of edema, and no abnormality of the tendon or ligaments, by ____, MD.
Date She was starting to have pinpricks along the ulnar dorsal right hand.
Date Electrodiagnostics were carried out by Dr. Horan on ____, and reported as normal.
Date An independent medical examination (IME) for the right hand condition was done on ____, by ____, MD, a plastic surgeon. The reader is directed to that report for details. He did note that Dr. ____ was supposed to be doing the exam regarding the knee portion of the claim. After reviewing a CT scan of the wrist as well as an MR arthrogram of the wrist, and repeat nerve conduction test, Dr. ____ opined that she had a non-displaced healed fracture at the base of the fifth metacarpal, work-related. She had degenerative arthritis at the joint of the fifth metacarpal base and hook of the hamate, secondary to diagnosis number 1, no treatment needed at this time, as well as perforation of the radial attachment triangular fibrocartilage complex, right wrist secondary to number 1, work- 3
Claimants Name Claim Number Date of Exam
related, not fixed and stable, and recommended arthroscopy. He recommended no further treatment to the suspected tenosynovitis, right middle finger.
Date Follow-up with Dr. ____ for the knee arthroscopy. He injected the interlateral portal and the joint with Marcaine and Kenalog.
Date Visit with Dr. ____ for the left knee pain. He reviewed the most recent MRI of ____, showing small joint effusions, small cyst located posterior horn medial meniscus, widening of posterior capsule suggestive of a meniscal capsule separation but may represent a meniscal cyst rather than popliteal cyst, and mild chondromalacia of the patella. Arthroscopic photographs were also reviewed from ____, showing significant chondromalacia of the patella, at least grade 3, and significant chondromalacia of the medial femoral condyle at least grade 3, with loose chondral fragmentation and loose body. He felt that she had significant chondromalacia of the patella and medial femoral condyle, and that was where most of her symptoms were coming from. There was nothing that he felt could be treated successfully arthroscopically. He recommended viscosupplementation, possibly requiring a total knee replacement.
Date She was seen by ____, MD, for the hand and wrist. Dr. ____, on ____, performed a local injection in the ulnar side of the wrist at the radiocarpal or ulnocarpal joint, and it seemed to alleviate her pain significantly suggesting that the pain generator was the triangular fibrocartilage complex, but the pain returned when she was being fitted with a new splint. They did discuss the possibility of diagnostic wrist arthroscopy and possible fusion of the fifth carpometacarpal joint.
Date Dr. ____ saw her for the left knee on ____, and felt that the only surgery that would eliminate her symptoms would be a knee replacement. She did want to think about it and try to consider some weight loss.
Date Surgery was eventually carried out by Dr. ____ on ____, that being a right wrist diagnostic arthroscopy and debridement of the central triangular fibrocartilage tear, and right fifth metacarpal corrective osteotomy.
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Claimants Name Claim Number Date of Exam
Date Follow-up on ____, with ____, PA, for Dr. ____: Impressions were right wrist status post diagnostic wrist arthroscopy, status post central triangular fibrocartilage complex debridement, and status post right fifth metacarpal corrective osteotomy. They felt she was doing very well following the surgery with significant relief of her pre-surgical symptoms. She was fitted with a splint, and was to follow-up with Dr. ____ in four weeks for additional radiographs and re-evaluation.
HISTORY OF PRESENT ILLNESS ------
____ states that she was walking to work on the sidewalk, tripped and fell, and fell off the sidewalk onto the parking lot and landed hard with her right arm against her breastbone and scuffed the right side of her face, and landed hard on her knees.
She sought treatment and ultimately saw several hand specialists, coming under the care of Dr. ____ who performed surgery in ____ of this year on her right hand and wrist.
She also had arthroscopic surgery on her left knee, and has continued following with that including injections and activity modification.
CURRENT COMPLAINTS------
In regard to her right wrist and hand, at the very minimal she is at least 80 or 90 percent better. She still has some sensitivity over the scar of her hand, and some self-imposed limitations as she is getting back into it slowly.
In regard to her left knee, she still has swelling, catching, and symptoms of painful instability; in other words, the knee will suddenly give out on her after a sharp pain in the medial side. She also has some loss of motion, and her husband states that she limps.
Alleviating factors include taking naproxen. When she does not take it, she definitely feels it more in her knee. The symptoms are there all the time, but worse if she is on her feet for extended periods of time. The injections did not help. The surgery really did not help much either.
PAST MEDICAL HISTORY------
Past/Recent illnesses: Reflux and non-insulin diabetes.
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Claimants Name Claim Number Date of Exam
Surgeries: Right carpal tunnel surgery, right hand osteotomy, right wrist arthroscopy, tubal ligation, left knee arthroscopy, and foot surgeries.
Allergies: Codeine and hydrocodone.
Medications: Prilosec, naproxen and metformin.
REVIEW OF SYSTEMS ------The review of systems is historical, based upon the medical documentation provided and an interview with the examinee.
Review of systems is noted through the intake record.
SOCIAL AND FAMILY HISTORY ------Information in the Social and Family History section of this report was obtained from a form completed by the examinee and an interview with the examiners.
Education level: None listed.
Habits: She denies the use of alcohol, tobacco, and illicit drugs.
Hobbies and activities: She enjoys gardening, hiking, and prospecting.
Exercise: She does water aerobics for exercise four or five times a week.
Military history: None listed.
Personal history: She is married.
Familial history: Positive for heart disease, hypertension, and hypoglycemia.
Work history: She is not currently working for ____, as there is no sedentary work available.
Benefits: “Insurance temporary total disability.”
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Claimants Name Claim Number Date of Exam
ORTHOPEDIC EXAMINATION ------
Height: Weight: Dominant hand:
The examinee was instructed not to participate in any painful activities during today’s examination. Present for the examination are myself, the examinee, a nurse case manager, her husband, and a female representative from OMAC acting as observer.
This is a very pleasant, well-developed, well-nourished, overweight white female in no acute distress. She is cooperative with the exam. She appears her stated age, and her height and weight are listed at ____ feet ____ inches, and ____ pounds.
She ambulates with a slightly antalgic gait favoring the left knee and does not fully extend the knee during swing phase, as she does on the right.
She has flattened arches bilaterally, and a mild valgus alignment to both lower extremities, but this may be due to her soft tissue appearance.
Seated examination: Her deep tendon reflexes are 2/4 and symmetric in the upper and lower extremities.
Sensory exam is intact to light touch and pinprick throughout the upper and lower extremities, with the exception of diminished pinprick on the dorsal aspect of the right hand, along the incision over the fifth metacarpal, and distally along the dorsum of the small finger. Palmar sensation is thoroughly intact.
Manual motor testing is 5/5 and symmetric in all groups tested in the upper and lower extremities. She does have some give-way weakness of the left hip flexors due to knee pain.
Her wrist range of motion: Palmar flexion and dorsiflexion are 70 degrees. Radial deviation and ulnar deviation are 20/30 degrees respectively. Pronation and supination is 70 degrees and 70 degrees symmetrically.
Grip strength testing: Using the Jamar hand dynamometer at the second rung, rapid exchange sequence with maximal effort, right is 42 kilograms and left is 41 kilograms of force.
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Claimants Name Claim Number Date of Exam
Supine examination shows 0 to 142 degrees of flexion on the right and 10 to 128 degrees of flexion on the left. Focused left knee examination does show a trace effusion. There is tenderness over the medial femoral condyle and pain with patellar femoral compression. She has some popliteal fullness, but no true cyst is appreciated. Ligamentous exam was very difficult to assess due to her guarding and discomfort, so it was not carried out. Meniscal grind testing and McMurray’s testing are difficult to attempt as well. She did have some medial joint line tenderness.
Focused right wrist examination shows well-healed arthroscopic portals and an incision over the shaft of the fifth or small finger metacarpal. There is no tenderness at the base of the fifth metacarpal, at the hook of the hamate, or in the fifth carpometacarpal joint articulation. She has no rotational deformity of the digit. There is some tenderness near the distal radial ulnar joint and triangular fibrocartilage complex region. There is no instability with piano keying of the distal radial ulnar joint. She has no scaphoid tenderness. Tinel’s testing is negative. She has a well-healed carpal tunnel incision as well on this side.
IMAGING STUDIES ------
There are multiple radiographs available for review brought in by the examinee, as well as arthroscopic pictures. I did review these and concur with the above interpretations in the body of my report.
Of particular note are the arthroscopic photos from her surgery that show grade 3 chondromalacia of the undersurface of the patella and the medial femoral condyle.
DIAGNOSES------
1. Right small finger metacarpal fracture, related to the industrial injury on a more-probable-than-not basis.
2. Triangular fibrocartilage complex tear right wrist, related to the industrial injury on a more-probable-than-not basis.
3. Left knee contusion with loose body, related to the industrial injury on a more-probable-than-not basis.
4. Surgical treatment of 1, 2, and 3 above, all related to the industrial injury on a more-probable-than-not basis.
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Claimants Name Claim Number Date of Exam
5. Pre-existing degenerative changes of the left knee, temporarily aggravated by the industrial injury on a more-probable-than-not basis. This is confirmed with the loose body removal during arthroscopy; in other words, she had pre-existing chondromalacia that probably resulted in a temporary aggravation with “knocking off” some of the loose cartilage pieces. This was treated arthroscopically.
RECOMMENDATIONS AND DISCUSSION ------
1. Please provide an impairment rating for both knee and the wrist based on the American Medical Association Guides to the Evaluation of Permanent Impairment , Sixth Edition. Please note this is an Idaho workers’ compensation claim. Please apportion any pre-existing factors that may be applicable.
The examinee does have permanent partial impairment related to the industrial injury. According to the American Medical Association Guides to the Evaluation of Permanent Impairment, Sixth Edition, when rating the knee on Table 16-3 under knee contusion, the CDX is a class 1, and a default is 1 percent.
When calculating our adjustments, her grade modifier for functional history is 0, her grade modifier for physical examination is 0, and her grade modifier for clinical studies is 1 for documentation of chondral loose bodies upon arthroscopy. Using the formula (GMFH-CDX) + (GMPE-CDX) + (GMCS-CDX) gives us minus 1, plus minus 1, plus 0, which is minus 2.
Due to the minus 2 adjustment, this then shifts down to grade A rather than C, and this would be 0 percent permanent partial impairment. This examiner feels that all of her findings on examination and her subjective complaints are due to the underlying arthritic changes and therefore are not ratable in this fashion.
As far as the upper extremity is concerned, she does have permanent partial impairment related to the right wrist. Again using the Sixth Edition Guides, the wrist table is represented in Table 15-3. There is a diagnosis of triangular fibrocartilage complex tear. The default for triangular fibrocartilage complex tear is 8 percent or class 1. Again using the same formula as above for the knee, her grade modifier for functional history is a 1, grade modifier for physical examination is a 1, and a grade modifier for clinical studies is a 2 due to diagnosis upon MRI of a triangular fibrocartilage complex tear. Using the same calculations, this ends up 9
Claimants Name Claim Number Date of Exam
being 0, plus 0, plus 1, which gives us a grade D going up 1 point to a 9 percent permanent partial impairment of the upper extremity. This takes into account the healed metacarpal fracture and the triangular fibrocartilage complex tear.
2. A job site evaluation has been submitted to you for your review. Please advise if ____ can return to her pre-injury job. If so, does she have any work restrictions?
She can return to her pre-injury job. She has no work restrictions related to the industrial injury.
3. Please note that Dr. King has advised that ____ is a candidate for a total knee replacement. Please advise if you feel the need for this is a direct result of the industrial injury or is it due to pre-existing factors?
Dr. ____ states that she is a candidate for a total knee replacement and I agree, but it is not related to the industrial injury at all. The arthroscopy was related, but certainly in this lady with pre-existing chondromalacia grade 3, and possibly grade 4 of the patella medial femoral condyle, this did not happen from a slip-and-fall on the sidewalk or parking lot. These were not acute chondral injuries as noted in the arthroscopic pictures.
If she does eventually come to a total knee replacement, it will not be related to the slip-and-fall.
Fortunately, she has had a good result in regard to her right hand injury and subsequent surgery.
OMAC/wew
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