The aim of this study was to identify psychosocial factors associated with pain intensity and disability following distal radius fracture (DRF).

We prospectively followed up 216 adult patients with DRF for 9 months. Demographics, injury and treatment details and psychological measures (Hospital Anxiety and Depression Score (HADS), Pain Catastrophising Scale (PCS), Post Traumatic Stress Disorder Checklist – Civilian (PCL-C), Tampa Scale for Kinesiophobia (TSK), Illness Perception Questionnaire Brief (IPQB), General Self-efficacy Scale (GSES) and Recovery Locus of Control (RLOC)) were collected at enrolment. Multivariable linear regression was used to identify factors associated with DASH and Likert pain score.

Ten week DASH was associated with age (β-coefficient (β)= 0.3, p < 0.001), deprivation score (β=0.2, p = 0.014), nerve injury (β=0.1, p = 0.014), HADS depression (β=0.2, p = 0.008), IPQB (β=0.2, p = 0.001) and RLOC (β= −0.1, p = 0.031). Nine month DASH was associated with age (β=0.1, p = 0.04), deprivation score (β=0.4, p = 0.014), number of medical comorbidities (β=0.1, p = 0.034), radial shortening (β=0.1, p = 0.035), HADS depression (β=0.2, p = 0.015) and RLOC (β= −0.1, p = 0.027). Ten week pain score was associated with deprivation score (β=0.1, p = 0.049) and IPQB (β=0.3, p < 0.001). Pain score at 9 months was associated with number of medical comorbidities (β=0.1, p = 0.047).

Psychosocial factors are more strongly associated with pain and disability than injury or treatment characteristics after DRF. Identifying and treating these factors could enhance recovery.

This fiducial role implies special duties imposed where one person (the fiduciary) must act in the best interest of the other (the beneficiary), even if it is in the fiduciary's detriment to do so.

While a doctor/patient relationship is not generally a fiduciary relationship, part of the relationship may involve a fiduciary role for the surgeon.

The fiduciary duties include:

Keeping a patient's medical information confidential.

While the doctor–patient relationship requires a duty of care, a fiduciary duty implies a duty of loyalty and honesty. As per using navigation techniques in hip and knee surgery, the surgeon can use the above fiducials (markers) to navigate his way through his fiduciary role in managing patients; whether it is disclosing emergent risks arising during treatment, with new products or during clinical trials.

Fiduciary roles are independent of informed consent, which occurs before the event, but mitigate a risk that occurs after the event. It is an inbuilt quality assurance mechanism in risk management.

The current 6th Edition of the AMA Guides presents a paradigm shift from objective impairment assessment to one of disability rating based not only on functional activity but on participation in a life situation. AMA 6 evaluates disability more strongly than previous editions.

The methodology is to base assessment on diagnosed based impairment (DBI) using DBI grids that have been formulated for each diagnosed condition, each as a class of diagnosis (CDX) eg. rotator cuff injury. These grids are further modified internally by using grade modifiers for:

Functional History (GMFH).

These internal grades allow the assessor to grade each DBI within its class and fine tune the assessment to promote greater reliability. NB. Adjustment factors only allow change within that class. The 6th Edition emphasises the importance of causation in forming the diagnosis and it differs from previous guides in that it allows for impaction on activities of daily living to apply not just to the spine but to the upper and lower limbs. These ADL’s can be normal activities such as swimming and bathing, or Instrumental ADL’S such as meal preparation.

Considerable weight is given to functional assessment and aids the functional history and includes:

QuickDash for the upper limb.

Pain Rated Impairment (PRI) allows up to a 3% modifier in certain circumstances. Burden of Treatment Compliance (BOTC) allows an additional modifier up to 2 of 3% when it can be reasonable assessed that but for medication, the claimant would have had a higher WPI.

There are special tables for entrapment syndromes, amputation impairment and complex regional pain syndrome (CRPS). Mental and behavioural problems and chronic pain resulting from musculo-skeletal disorders is usually captured within the rating of that disorder itself and, as such, independent mental health impairment rating is considered to be double dipping.

The final figure for impairment is based on the net adjustment formula as set out in the guides. (GMFH−CDX) + (GMPE − CDX) + (GMCS − CDX)

The AMA 6th Edition, relies on diagnosis based impairment, rated on disability, and certain unreliable physical examinations have been excluded, such as the range of motion in the spine, grip strength measurements and using certain operative procedures to delineate assessment rather than the functional outcome of that procedure. A comparison of range of motion bilaterally is now mandatory and sensory deficit is based on two point discrimination when there has been nerve division and monofilament testing when there is decreased light touch. Here nerve conduction studies have assumed particular importance with entrapment syndromes.

AMA 6 guides represents a new approach to impairment assessment based on disability rating which requires greater clinical acumen and cannot be achieved without adequate medical knowledge. ComCare is obliged to use the new guides under current legislation and this is already in use in several jurisdictions around the world.