Journal of Forensic and Legal Medicine 32 (2015) 16e20
Contents lists available at ScienceDirect
Journal of Forensic and Legal Medicine j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / j fl m
Original communication
How reliable is the Spanish bodily harm assessment scale? n ~ ez-Maya n a, Carlos Represas a, Xoan Migue ns b, María Sol Rodríguez-Calvo a, c, Lucía Ordo d a Ignacio Mun ~ oz-Barús , c, * Manuel Febrero-Bande , Jose a
Institute of Forensic Sciences University of Santiago de Compostela, Spain ~ or Hospital University Hospital of Ourense, Spain Rehabilitation Service, Complexo Pin c Department of Pathology and Forensic Sciences, University of Santiago de Compostela, Spain d Department of Statistics and Operations Research, University of Santiago de Compostela, Spain b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 4 September 2014 Received in revised form 29 October 2014 Accepted 7 February 2015 Available online 17 February 2015
The use of scales to quantify or qualify bodily harm resulting from an unintentional car accident has been mandatory in Spain since 1995 and compensation for personal injuries resulting from a traffic accident is calculated according to a legal ruling established by Royal Decree 8/2004 (RDL). This present study assesses the reliability of the scale. Agreement between the evaluations for the same patient by 24 qualified observers following the Royal Decree 8/2004 was measured using the Kappa index. The variables assessed were the days of hospitalization, impeditive days, non impeditive days and the functional and aesthetic sequelae. The application of the Fleiss Kappa index obtained a result of 0.37, indicating a “fair agreement” according to the rating scale proposed by Landis and Koch. This study demonstrates the unreliability of the Spanish medical scale for the assessment of injury as described in the RDL 8/2004. The scale should adopt the measurement systems and clinical classifications of outcomes such as the ASIA, SCI scale or the Daniels scale of neurological injury and allow scientific discussion of the findings of the report. The resulting quantitative value should operate as a reliable indicator of a specific quality of the damage. © 2015 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
Keywords: Assessment bodily harm Scale RDL 8/2004 Reliability
1. Introduction The repercussions of an accident are of a varying nature and although it is not overly complex to calculate the direct economic impact1,2 such as loss of earnings or cost of present and future medical expenses, difficulties arise when dealing with noneconomic consequences such as pain, physical damage and disfigurement. These latter problems were recognised by initiatives of the European Union (EU) at the turn of the last century and, since then, a constant concern of research into bodily harm has been to seek a method capable of quantifying the loss of a person's biological patrimony or anatomic-functional capacity. The greatest complexity in this field lies in achieving a methodology which can assess the decline in physical and psychological integrity of the
* Corresponding author. Institute of Forensic Sciences University of Santiago de Compostela, 15782 Santiago de Compostela, Spain. Tel.: þ34 881812216; fax: þ34 881812459. ~ oz-Barús). E-mail address: [email protected] (J.I. Mun
individual within a system that can quantify the damage suffered by that most basic of all human values: one's life. The use of scales to quantify or qualify bodily harm is common practice and is frequently used to assess legal and social aspects of practical importance. In Spain, the use of such scales for medicolegal assessment of personal injury resulting from an unintentional car accident has been mandatory since 1995. Currently, compensation for personal injuries resulting from a traffic accident is calculated according to a legal ruling established by Royal Decree 8/2004 (RDL).3 The decree develops a series of explanatory rules with possible consequential damages and is set out in six tables, where Tables 2 and 4e6 are of forensic importance and require the intervention of a physician. The tables establish values for death, days required for healing or stabilization, physiological sequelae, permanent aesthetic damage and the impact of these on the working life or usual occupation of the injured person. According to the RDL, the days of healing should extend until lesions are stabilized and distinguishes between days of hospitalisation, impeditive days (when habitual activities are impeded) and
http://dx.doi.org/10.1016/j.jflm.2015.02.007 1752-928X/© 2015 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
n et al. / Journal of Forensic and Legal Medicine 32 (2015) 16e20 n ~ ez-Maya L. Ordo
non-impeditive days (when habitual activities are not impeded). Although the decree does not specify whether impeditive days should be equated with the granting of sick-leave, from a medicolegal point of view it is accepted that such days are those which impose major constraints on the ability of a patient to perform the basic activities of daily living such as bathing, dressing, eating and mobility.4,5 The RDL divides the sequelae into nine sections, and the first 8 sequelae are linked to a sliding scale from a minimum of 1 point to 100 points. If the same case has more than one functional sequel, a corrective formula, the formula of concurrent disabilities3 or the Balthazar formula, is applied so that the score for concurrent sequelae does not exceed 100 points. Chapter 9 is specific for aesthetic detriment independently of anatomic-functional damage. Six categories are proposed, to each of which a qualifier and a score is assigned with a range from 1 to 50 points. Assessment criteria are used for both the general rules of the Act well as for each of the sequelae. Since this Act came into force there has been an exaggerated disparity in medical-legal evaluation in the courts.4,5 Although no similar studies have been found, there are reports in the literature of forensic expert deviations of around 5% in evaluating biological damage,6,7 far below our preliminary observations. The need to measure the reliability of a quantitative assessment model of disability is a constant concern in the literature.8 The more reliable the measuring instrument (scale) used to assess, the more objective the expert model, even taking into account expected bias. The coming into force of these laws, together with subsequent modifications, has revealed a strong demand for training in this area, both from within the field of justice as well as from insurance companies. Consequently, training in this field has been offered by public universities and the University of Santiago de Compostela, through its Institute of Forensic Sciences, has developed ongoing training courses aimed at professionals in the Health Sciences. The main aim of these courses was to provide the necessary training to accredit the medical staff involved as MedicoLegal Experts in the Assessment of Bodily Damage. The courses consisted of four modules (I: Legal basis; Law of damages. II: Medico-legal basis for expert evaluation; Commonly used standards. III: Assesment in the different specialities; Supplementary tests. IV: The preparation and defence of an expert report). The teaching load is distributed over the academic year and includes training in a virtual setting and practical work outside class involving the writing up and defence of expert reports (http:// www.usc.es/cptf/Formacion/CursosFormacion/Datos2009/ Fc30052009-2010g.htm). In our assessment of the reliability of the Spanish scale we measured the concordance among qualified observers using the Kappa index.9
A 10 anteversion at the site of the fracture Swelling in thigh and knee Extensive atrophy of quadriceps A limp Hyperextended knee instability Lack of muscle strength in the affected leg Carrier of osteosynthesis material
A year later he underwent an operation to remove the osteosynthetic material. A physical and radiographic examination and MRI tests were performed, with the following findings: 2.1. Physical examination
Walked with obvious lameness Muscular atrophy Knee flexion of 120 Knee instability
2.2. Simple radiograph (Fig. 1) Alteration in the alignment of the distal third of the femoral shaft associated with medullar sclerosis and a lytic lesion Bone bridge formation Focal periosteal reaction Significant degenerative change, particularly in the internal tibiofemoral space Posttraumatic changes in proximal fibular epiphysis The radiologist reported that these findings are secondary to traumatic/post surgical changes and an associated osteomyelitic component could not be ruled out. 2.3. Magnetic resonance imaging of the knee
Rupture of anterior curiae ligament Fibro tic changes in the medial collateral Degenerative meniscopathy unbroken Degenerative osteochondral lesions in the internal tibiofemoral compartment. Changes relating to fasteners introduced at femur level. In their evaluation the experts considered the compensable aspects of RDL: days to heal injuries, days of hospitalization,
2. Material and method Twenty-four medical experts in the assessment personal injury with official recognition after passing a university course of specialization were asked to carry out an independent assessment of the same patient. To do this they were given the patient's medical history. A 50 year old male had an accident in which the right lower extremity was crushed. The initial hospital diagnosis reported a transverse fracture of the distal third of the right femur, oblique fracture of the head of the right fibula and a contusion of about 10 inches at the distal anterior aspect of the right thigh. He underwent surgery which consisted of fixation and osteosynthesis by GrossKemp nail, locked distally in the femur. After initial discharge from the orthopaedic surgery the following sequelae were established:
17
Fig. 1. Simple radiograph.
n et al. / Journal of Forensic and Legal Medicine 32 (2015) 16e20 n ~ ez-Maya L. Ordo
18
impeditive days, non-impeditive days and the resulting functional and aesthetic sequelae. Data from the 24 medical expert assessments were subjected to a statistical analysis consisting of an analysis of inter-observer agreement as measured by the Kappa de Fleiss index. In addition, the median and coefficient of variation with respect to the same were analysed, once converted into euros (following the tables in the RDL 8/2004) results of the assessments. The Kappa index was originally proposed by Cohen (1960)10 for a case of two raters or two methods and was generalized to the case of more than two reviewers and/or rating categories by Fleiss.9,11 This formula measures the degree of agreement between raters, not the “quality” of the assessment, so none of the reviewers can be considered as standard. A value greater than or equal to 0.40 is considered acceptable and those greater than 0.75 excellent.9,12 3. Results and discussion Table 1 shows the results of the various assessments made by the experts regarding the days of healing, distinguishing between days of hospitalization, impeditive days and non-impeditive days. The amount of compensation corresponding to the patient is established according to the assessment made by each expert. The number of days of healing is multiplied by the corresponding amount in euros per day specified by the standard. The coefficient of variation of the median of the 24 ratings was 0.28 (0.092 for hospital days, 0.43 for impeditive days and 1.31 for non-impeditive days) (see Table 2). Tables 3 and 4 show respectively the sequelae with corresponding ratings assigned by each of the reviewers to the patient and the final functional and aesthetic scores. Table 5 shows the number of reviewers who recognized/identified each sequela. The amount of compensation awarded (in euros) is arrived at by multiplying the points each assessor gave for the sequelae by the
Table 1 Days of healing. Observer
A A A A A A A A A A A A A A A A A A A A A A A A
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Table 2 Coefficient of variation of the median period of healing. Median V per day Total V Days hospitalized 16 Impeditive days 506 Non-impeditive days 146.5
66 53.66 28.88
Coefficient of variation of the median
1056 0.092873 27151.96 0.43169 4230.92 1.31522
Table 3 Sequelae assigned by each of the examiners with the corresponding score. Observer
Score assigned per sequel a
A A A A A A A A A A A A A A A A A A A A A A A A
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
5 8 5 5 5 5 5 5 5 5 5 3 5 5 5 5 5 4 2 5 5 5
b
c
d
e
f
g
h
2
10 8 7 10
I
j
k
L
10 5 5 8 5 10 2
2 5 2 2 8
5
3 2
20 10
3
8 10
5 1 5 2
10 5 10 3
4 5
8 10 15 15 12 7 10 10
5 5 2
1
8 4 20 20
3
1 8
2 1 2 3 3
6 1
15 13 8 15 15 9 5
2 4 3 2
2
a) Angular/Rotational deformities; b) Osteomyelitis of the femur; c) Knee Osteoarthritis; d) Osteosynthesis; e) Limit. Knee flexion; f) Limit. Knee extension.; g) Lateral knee instability; h) Cruciate Ligament instability i) Meniscus tears; j) Isolated muscular paresia; k) Non-specific Knee pain, l) Patellar Osteoarthritis.
Days Days hospitalized
Impeditive sick-leavea
Non-impeditive sick-leaveb
16 22 16 15 16 16 16 16 17 16 17 17 17 16 16 17 16 17 17 18 16 17 14 16
498 679 149 148 148 224 653 653 637 637 630 636 495 611 160 317 498 60 873 478 660 498 637 514
131 236 350 567 504 0 15 0 15 236 15 223 135 205 374 0 154 576 0 139 207 139 0 493
a Impeditive sick leave is when the victim either cannot work at all or is unable to accomplish usual tasks. b Non-impeditive sick leave is when there is no incapacity to perform usual tasks.
Table 4 Score allocated to sequelae. Observer
A A A A A A A A A A A A A A A A A A A A A A A A
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Score assigned Functional
Aesthetic
25 31 18 17 27 15 17 17 27 32 49 29 38 20 21 14 15 25 29 16 41 41 26 17
1 7 8 3 5 3 22 3 10 13 3 5 3 7 7 6 6 2 6 1 10 4 2 2
n et al. / Journal of Forensic and Legal Medicine 32 (2015) 16e20 n ~ ez-Maya L. Ordo Table 5 Number of assessors recognising each sequel.
19
Table 7 Kappa interpretation.
Secuelae
Assessors
Kappa
Interpretation
Angular/Rotational deformities Osteomyelitis of the femur Knee Osteoarthritis Osteosynthesis Limit. Knee flexion Limit. Knee extension Knee lateral instability Cruciate Ligament instability Meniscus tears Isolated muscular paresia Nonspecific Knee pain Patellar Osteoarthritis
22 5 16 6 14 2 4 19 4 1 2 2
Contents lists available at ScienceDirect
Journal of Forensic and Legal Medicine j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / j fl m
Original communication
How reliable is the Spanish bodily harm assessment scale? n ~ ez-Maya n a, Carlos Represas a, Xoan Migue ns b, María Sol Rodríguez-Calvo a, c, Lucía Ordo d a Ignacio Mun ~ oz-Barús , c, * Manuel Febrero-Bande , Jose a
Institute of Forensic Sciences University of Santiago de Compostela, Spain ~ or Hospital University Hospital of Ourense, Spain Rehabilitation Service, Complexo Pin c Department of Pathology and Forensic Sciences, University of Santiago de Compostela, Spain d Department of Statistics and Operations Research, University of Santiago de Compostela, Spain b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 4 September 2014 Received in revised form 29 October 2014 Accepted 7 February 2015 Available online 17 February 2015
The use of scales to quantify or qualify bodily harm resulting from an unintentional car accident has been mandatory in Spain since 1995 and compensation for personal injuries resulting from a traffic accident is calculated according to a legal ruling established by Royal Decree 8/2004 (RDL). This present study assesses the reliability of the scale. Agreement between the evaluations for the same patient by 24 qualified observers following the Royal Decree 8/2004 was measured using the Kappa index. The variables assessed were the days of hospitalization, impeditive days, non impeditive days and the functional and aesthetic sequelae. The application of the Fleiss Kappa index obtained a result of 0.37, indicating a “fair agreement” according to the rating scale proposed by Landis and Koch. This study demonstrates the unreliability of the Spanish medical scale for the assessment of injury as described in the RDL 8/2004. The scale should adopt the measurement systems and clinical classifications of outcomes such as the ASIA, SCI scale or the Daniels scale of neurological injury and allow scientific discussion of the findings of the report. The resulting quantitative value should operate as a reliable indicator of a specific quality of the damage. © 2015 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
Keywords: Assessment bodily harm Scale RDL 8/2004 Reliability
1. Introduction The repercussions of an accident are of a varying nature and although it is not overly complex to calculate the direct economic impact1,2 such as loss of earnings or cost of present and future medical expenses, difficulties arise when dealing with noneconomic consequences such as pain, physical damage and disfigurement. These latter problems were recognised by initiatives of the European Union (EU) at the turn of the last century and, since then, a constant concern of research into bodily harm has been to seek a method capable of quantifying the loss of a person's biological patrimony or anatomic-functional capacity. The greatest complexity in this field lies in achieving a methodology which can assess the decline in physical and psychological integrity of the
* Corresponding author. Institute of Forensic Sciences University of Santiago de Compostela, 15782 Santiago de Compostela, Spain. Tel.: þ34 881812216; fax: þ34 881812459. ~ oz-Barús). E-mail address: [email protected] (J.I. Mun
individual within a system that can quantify the damage suffered by that most basic of all human values: one's life. The use of scales to quantify or qualify bodily harm is common practice and is frequently used to assess legal and social aspects of practical importance. In Spain, the use of such scales for medicolegal assessment of personal injury resulting from an unintentional car accident has been mandatory since 1995. Currently, compensation for personal injuries resulting from a traffic accident is calculated according to a legal ruling established by Royal Decree 8/2004 (RDL).3 The decree develops a series of explanatory rules with possible consequential damages and is set out in six tables, where Tables 2 and 4e6 are of forensic importance and require the intervention of a physician. The tables establish values for death, days required for healing or stabilization, physiological sequelae, permanent aesthetic damage and the impact of these on the working life or usual occupation of the injured person. According to the RDL, the days of healing should extend until lesions are stabilized and distinguishes between days of hospitalisation, impeditive days (when habitual activities are impeded) and
http://dx.doi.org/10.1016/j.jflm.2015.02.007 1752-928X/© 2015 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
n et al. / Journal of Forensic and Legal Medicine 32 (2015) 16e20 n ~ ez-Maya L. Ordo
non-impeditive days (when habitual activities are not impeded). Although the decree does not specify whether impeditive days should be equated with the granting of sick-leave, from a medicolegal point of view it is accepted that such days are those which impose major constraints on the ability of a patient to perform the basic activities of daily living such as bathing, dressing, eating and mobility.4,5 The RDL divides the sequelae into nine sections, and the first 8 sequelae are linked to a sliding scale from a minimum of 1 point to 100 points. If the same case has more than one functional sequel, a corrective formula, the formula of concurrent disabilities3 or the Balthazar formula, is applied so that the score for concurrent sequelae does not exceed 100 points. Chapter 9 is specific for aesthetic detriment independently of anatomic-functional damage. Six categories are proposed, to each of which a qualifier and a score is assigned with a range from 1 to 50 points. Assessment criteria are used for both the general rules of the Act well as for each of the sequelae. Since this Act came into force there has been an exaggerated disparity in medical-legal evaluation in the courts.4,5 Although no similar studies have been found, there are reports in the literature of forensic expert deviations of around 5% in evaluating biological damage,6,7 far below our preliminary observations. The need to measure the reliability of a quantitative assessment model of disability is a constant concern in the literature.8 The more reliable the measuring instrument (scale) used to assess, the more objective the expert model, even taking into account expected bias. The coming into force of these laws, together with subsequent modifications, has revealed a strong demand for training in this area, both from within the field of justice as well as from insurance companies. Consequently, training in this field has been offered by public universities and the University of Santiago de Compostela, through its Institute of Forensic Sciences, has developed ongoing training courses aimed at professionals in the Health Sciences. The main aim of these courses was to provide the necessary training to accredit the medical staff involved as MedicoLegal Experts in the Assessment of Bodily Damage. The courses consisted of four modules (I: Legal basis; Law of damages. II: Medico-legal basis for expert evaluation; Commonly used standards. III: Assesment in the different specialities; Supplementary tests. IV: The preparation and defence of an expert report). The teaching load is distributed over the academic year and includes training in a virtual setting and practical work outside class involving the writing up and defence of expert reports (http:// www.usc.es/cptf/Formacion/CursosFormacion/Datos2009/ Fc30052009-2010g.htm). In our assessment of the reliability of the Spanish scale we measured the concordance among qualified observers using the Kappa index.9
A 10 anteversion at the site of the fracture Swelling in thigh and knee Extensive atrophy of quadriceps A limp Hyperextended knee instability Lack of muscle strength in the affected leg Carrier of osteosynthesis material
A year later he underwent an operation to remove the osteosynthetic material. A physical and radiographic examination and MRI tests were performed, with the following findings: 2.1. Physical examination
Walked with obvious lameness Muscular atrophy Knee flexion of 120 Knee instability
2.2. Simple radiograph (Fig. 1) Alteration in the alignment of the distal third of the femoral shaft associated with medullar sclerosis and a lytic lesion Bone bridge formation Focal periosteal reaction Significant degenerative change, particularly in the internal tibiofemoral space Posttraumatic changes in proximal fibular epiphysis The radiologist reported that these findings are secondary to traumatic/post surgical changes and an associated osteomyelitic component could not be ruled out. 2.3. Magnetic resonance imaging of the knee
Rupture of anterior curiae ligament Fibro tic changes in the medial collateral Degenerative meniscopathy unbroken Degenerative osteochondral lesions in the internal tibiofemoral compartment. Changes relating to fasteners introduced at femur level. In their evaluation the experts considered the compensable aspects of RDL: days to heal injuries, days of hospitalization,
2. Material and method Twenty-four medical experts in the assessment personal injury with official recognition after passing a university course of specialization were asked to carry out an independent assessment of the same patient. To do this they were given the patient's medical history. A 50 year old male had an accident in which the right lower extremity was crushed. The initial hospital diagnosis reported a transverse fracture of the distal third of the right femur, oblique fracture of the head of the right fibula and a contusion of about 10 inches at the distal anterior aspect of the right thigh. He underwent surgery which consisted of fixation and osteosynthesis by GrossKemp nail, locked distally in the femur. After initial discharge from the orthopaedic surgery the following sequelae were established:
17
Fig. 1. Simple radiograph.
n et al. / Journal of Forensic and Legal Medicine 32 (2015) 16e20 n ~ ez-Maya L. Ordo
18
impeditive days, non-impeditive days and the resulting functional and aesthetic sequelae. Data from the 24 medical expert assessments were subjected to a statistical analysis consisting of an analysis of inter-observer agreement as measured by the Kappa de Fleiss index. In addition, the median and coefficient of variation with respect to the same were analysed, once converted into euros (following the tables in the RDL 8/2004) results of the assessments. The Kappa index was originally proposed by Cohen (1960)10 for a case of two raters or two methods and was generalized to the case of more than two reviewers and/or rating categories by Fleiss.9,11 This formula measures the degree of agreement between raters, not the “quality” of the assessment, so none of the reviewers can be considered as standard. A value greater than or equal to 0.40 is considered acceptable and those greater than 0.75 excellent.9,12 3. Results and discussion Table 1 shows the results of the various assessments made by the experts regarding the days of healing, distinguishing between days of hospitalization, impeditive days and non-impeditive days. The amount of compensation corresponding to the patient is established according to the assessment made by each expert. The number of days of healing is multiplied by the corresponding amount in euros per day specified by the standard. The coefficient of variation of the median of the 24 ratings was 0.28 (0.092 for hospital days, 0.43 for impeditive days and 1.31 for non-impeditive days) (see Table 2). Tables 3 and 4 show respectively the sequelae with corresponding ratings assigned by each of the reviewers to the patient and the final functional and aesthetic scores. Table 5 shows the number of reviewers who recognized/identified each sequela. The amount of compensation awarded (in euros) is arrived at by multiplying the points each assessor gave for the sequelae by the
Table 1 Days of healing. Observer
A A A A A A A A A A A A A A A A A A A A A A A A
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Table 2 Coefficient of variation of the median period of healing. Median V per day Total V Days hospitalized 16 Impeditive days 506 Non-impeditive days 146.5
66 53.66 28.88
Coefficient of variation of the median
1056 0.092873 27151.96 0.43169 4230.92 1.31522
Table 3 Sequelae assigned by each of the examiners with the corresponding score. Observer
Score assigned per sequel a
A A A A A A A A A A A A A A A A A A A A A A A A
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
5 8 5 5 5 5 5 5 5 5 5 3 5 5 5 5 5 4 2 5 5 5
b
c
d
e
f
g
h
2
10 8 7 10
I
j
k
L
10 5 5 8 5 10 2
2 5 2 2 8
5
3 2
20 10
3
8 10
5 1 5 2
10 5 10 3
4 5
8 10 15 15 12 7 10 10
5 5 2
1
8 4 20 20
3
1 8
2 1 2 3 3
6 1
15 13 8 15 15 9 5
2 4 3 2
2
a) Angular/Rotational deformities; b) Osteomyelitis of the femur; c) Knee Osteoarthritis; d) Osteosynthesis; e) Limit. Knee flexion; f) Limit. Knee extension.; g) Lateral knee instability; h) Cruciate Ligament instability i) Meniscus tears; j) Isolated muscular paresia; k) Non-specific Knee pain, l) Patellar Osteoarthritis.
Days Days hospitalized
Impeditive sick-leavea
Non-impeditive sick-leaveb
16 22 16 15 16 16 16 16 17 16 17 17 17 16 16 17 16 17 17 18 16 17 14 16
498 679 149 148 148 224 653 653 637 637 630 636 495 611 160 317 498 60 873 478 660 498 637 514
131 236 350 567 504 0 15 0 15 236 15 223 135 205 374 0 154 576 0 139 207 139 0 493
a Impeditive sick leave is when the victim either cannot work at all or is unable to accomplish usual tasks. b Non-impeditive sick leave is when there is no incapacity to perform usual tasks.
Table 4 Score allocated to sequelae. Observer
A A A A A A A A A A A A A A A A A A A A A A A A
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Score assigned Functional
Aesthetic
25 31 18 17 27 15 17 17 27 32 49 29 38 20 21 14 15 25 29 16 41 41 26 17
1 7 8 3 5 3 22 3 10 13 3 5 3 7 7 6 6 2 6 1 10 4 2 2
n et al. / Journal of Forensic and Legal Medicine 32 (2015) 16e20 n ~ ez-Maya L. Ordo Table 5 Number of assessors recognising each sequel.
19
Table 7 Kappa interpretation.
Secuelae
Assessors
Kappa
Interpretation
Angular/Rotational deformities Osteomyelitis of the femur Knee Osteoarthritis Osteosynthesis Limit. Knee flexion Limit. Knee extension Knee lateral instability Cruciate Ligament instability Meniscus tears Isolated muscular paresia Nonspecific Knee pain Patellar Osteoarthritis
22 5 16 6 14 2 4 19 4 1 2 2
