Victor Smith, D.O.

Generic Orthopedics, PLLC

15 West Road
Generic, New Hampshire 00000
August 31, 201605
Dori Tothill
New Hampshire Board of Medicine
Two Industrial Park Drive, Suite 8
Concord, NH 03301
Re:

Frances Jones

Dear Ms. Tothill:

Below is a summary, as you have requested, of the events surrounding my
participation in the care of Frances Jones. I understand from the complaint filed in
small claims court that there is no criticism with the care I provided. Rather, I
understand that Ms. Jones is critical of the partial permanent impairment calculation.
Therefore, I will address only that issue in this letter.
On September 19, 2002, Ms. Jones presented to Memorial Hospital with left wrist pain
resulting from a fall. Ms. Jones is right-hand dominant and was 58 years old at the
time of her injury. X-rays of Ms. Jones's wrist revealed a comminuted intra-articular
fracture of the left distal radius. Ms. Jones was admitted to my service for surgical
repair of her wrist on the same date.
The wrist surgery went well. I had several follow-up visits with Ms. Jones, and she
recovered well. Ms. Jones's fracture healed completely.
On April 10, 2003, I had a final follow-up visit with Ms. Jones. Ms. Jones had reached
maximum medical improvement at this time and had a residual permanent
impairment. Although her fracture had completely healed, she had some moderate
pain and some restriction with motion. Ms. Jones's x-ray revealed a slightly ulnar
positive variance and a slight amount of radial shortening. She did not have carpal
tunnel symptoms.
This was a workers' compensation claim. Therefore, I assessed Ms. Jones's partial
permanent impairment using the American Medical Association Guides to the
Evaluation of Permanent Impairment, 5th Ed., 2001. Ms. Jones's range of motion was
volar flexion to 40, dorsal to 30, radial deviation to 5, and ulnar deviation to 20.
Ms. Jones's pronation and supination was full. Based upon Figure 16-28 of the AMA
Guides, Ms. Jones's loss of extension represented a 5% wrist impairment, and her loss
of flexion represented a 3% wrist impairment. Based upon Figure 16-31, Ms. Jones's

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radial deviation represented a 3% impairment, and her ulnar deviation represented a

2% impairment.
After calculating the impairments, I added the total flexion and extension impairment
consistent with the AMA Guides 16.4g and reduced the value using a 42% conversion
factor. According to the AMA Guides, wrist flexion and extension comprise 42% of the
upper extremity function. The result was a 3.36% impairment, which I rounded up to
4%. I did the same calculation for the radial and ulnar deviation. I added their values
and reduced that value by a conversion factor of 18% because the AMA Guides states
that radial and ulnar wrist motion comprises 18% of upper extremity function. The
result was a 0.9% impairment, which I rounded to 1%. I then added the 4% converted
impairment rating for the loss of extension and flexion with the 1% converted
impairment rating for the radial and ulnar deviations to get a 5% upper extremity
impairment. I used Table 16-3 to convert this upper extremity impairment into a
whole body impairment of 3%. I sent a letter to the workers' compensation claims
adjuster on behalf of Ms. Jones to assist her in obtaining a partial permanent
impairment.
Ms. Jones subsequently wrote to me asking me to reconsider my permanency
assessment. She did not identify any particular problem. I confirmed my calculations
but asked her to have her lawyer contact me about any specific concerns regarding
my assessment because the AMA Guides are occasionally difficult to apply. I did not
hear from her lawyer but ultimately received a copy of a second opinion letter.
Ms. Jones obtained a second opinion on her permanency rating from Jeffrey A.
Clingman, M.D. Dr. Clingman found a smaller loss of extension and flexion than I did
and no ulnar deviation. Dr. Clingman did find the same 3% radial deviation. Dr.
Clingman found a 2% lack of pronation and a 2% lack of supination which I did not
find, and am not certain would relate to a wrist injury without involvement of the
elbow.
From the second opinion letter, I learned that the conversion factors had been
incorporated into the chart equating angle of wrist extension, flexion, and
radial/ulnar movement to impairment values. By applying the conversion factors a
second time, I had reduced the permanency to which Ms. Jones was entitled. When I
realized the error, I corrected it and sent a revised calculation to Ms. Jones's workers'
compensation carrier/representative.
I am sorry about the error made in calculating Ms. Jones's permanent impairment.
Using the AMA Guide to Evaluation of Permanency is sometimes difficult. I believe I
acted reasonably, and my error was based upon the wording of the charts. I am happy
Ms. Jones recovered so well from her surgery, and I understand that Ms. Jones is now
working full duty and functioning well without significant problems.
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If you have any further questions, please feel free to contact me.
Sincerely,

Victor Smith, D.O.

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