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23
Physical Impairment Ratings for Fractures

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Richard A. Saunders, M.D. Sam W. Wiesel, M.D.

Fractures account for only about 10% of all musculoskeletal traumatic injuries, but they cause a disproportionate amount of medical impairment. The costs of fracture care, including lost productivity, medical expenses, and disability payments, make this class of injury a signicant burden both to employers and to society in general. The role of physicians in the medical care of fractures is well established, but their job does not end when union has been achieved and rehabilitation is complete. Physician participation is equally vital in the impairment evaluation process. Many state and federal laws limit physician discretion in assigning permanent impairment ratings, and the physician is often caught between a desire to benet the patient and the need to comply with these laws. This chapter presents some generic issues of impairment, reviews the epidemiology of fractures in the United States, and comments on commonly used existing impairment guides.

a year elapse after the injury or most recent surgery related to the injury before determining that maximal medical improvement has been attained. Disability, which is assessed by nonmedical means, is an alteration of an individuals capacity to meet personal, social, or occupational demands because of an impairment. The determination of permanent disability is dependent on a number of nonmedical factors, among them the patients level of education, their work training and work history, their residual access to the workplace, and their socioeconomic background. Impairment reects only the patients limitations with respect to their activities of daily living, excluding work. Physicians, in general, are considered expert only in the determination of impairment.

Role of the Physician

The evaluation of permanent physical impairment is the sole responsibility of the physician. The functions evaluated in determining permanent impairment are self-care, communication, physical activity (including sitting, standing, reclining, walking, and stair climbing), sensory functions, nonspecialized hand activities, travel, sexual function, and sleep. Because musculoskeletal injuries account for the majority of impairment determinations, orthopaedists are frequently involved in this process.

GENERIC ISSUES OF DISABILITY AND IMPAIRMENT Denitions

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There is a certain amount of confusion about the role of the physician in determination of permanent disability and about the difference between impairment and disability. According to Guides to the Evaluation of Permanent Impairment, Fifth Edition, published by the American Medical Association (AMA), the following denitions apply. Impairment is a loss, loss of use, or derangement of any body part, organ system, or organ function. A permanent impairment exists when the patient has reached maximal medical improvement but such a loss or derangement persists. Maximal medical improvement has been achieved when the injury or illness has stabilized and no material improvement or deterioration is expected in the next year, with or without treatment. Many jurisdictions require that

Third-Party Payers
Impairment evaluations are most frequently requested by a third-party payer before settlement of a claim. The largest third-party payers are state workmens compensation boards, private insurance companies, the Social Security Administration, and Veterans Affairs.12 Each of these groups has its own requirements for and denitions of impairment. Workmens compensation laws vary widely from state to state, and federal agency regulations are
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SECTION I General Principles

amended yearly. The agency requesting the disability evaluation should specify which rules apply in the specic case, and the reviewing physician should abide by the specied rules. In some cases, older editions of the AMA guides have been incorporated in state laws, in which case the appropriate edition must be consulted. Tort law (civil litigation or lawsuits) in some states does not specify any particular body of rules; in these cases, the evaluating physician has considerably greater freedom to describe and quantify a given impairment. Correspondence is between the physician and the third-party payer. Updates should be in the form of letters mailed directly to the representative of the third-party payer. The patient should not act as an intermediary, although the patients right to review his or her chart in the presence of the attending physician should always be honored. In general, physicians acting as independent consultants in determination of impairment ratings do not establish a doctor-patient relationship with the patient being examined.

whose pain is great enough to warrant regular narcotic use, whose mobility is so severely compromised as to make getting from home to the workplace unreasonably difcult, or who are hospitalized in an inpatient unit. TEMPORARY PARTIAL DISABILITY LIGHT DUTY During the course of recovery from an injury, a patient may be employable in a light duty situation in which the physical requirements of the job do not compromise healing or cause unacceptable discomfort. The physician is responsible for identifying the level of safe activity, which may be limited to sedentary work during the early recovery phase of an injury. PERMANENT PARTIAL DISABILITY After maximal medical recovery has been achieved, the physician, possibly in cooperation with other occupational specialists, may be asked to recommend a permanent restricted activity level if the patient is unable to return to his or her original job. There are no widely accepted guidelines for determining the level of job restriction, but, in general, a patient who has any permanent partial impairment secondary to skeletal injury is unable to perform very heavy or heavy work safely.20, 21 If the permanent partial impairment is greater than 25%, most patients are unlikely to perform successfully in any but part-time or home-based occupations at the sedentary level. Between these two extremes, the physician must decide what is a reasonable expectation for the patient, taking into consideration the type of injury and impairment and the sorts of activities that are likely to exacerbate persistent pain. As an example, a well-healed 10% compression fracture of the lumbar spine with some chronic back pain may result in a 5% permanent partial impairment. The patient is likely to have exacerbation of pain with bending, twisting, stooping, lifting of more than 20 pounds, or prolonged overhead work. He or she would be qualied for a job involving light work, with the restrictions specied previously. The physician assigns impairment and species work restrictions, but the responsibility for nding an appropriate job lies with the patient or the third-party payer. With more aggressive job retraining and work hardening programs, patients with signicant impairment are now returning to the workplace. It is time consuming but often worthwhile for the physician to work with the social worker, nurse, or occupational therapist representing the third-party payer to nd an acceptable job for the patient or to encourage occupational retraining when appropriate.

Work Restrictions
In addition to assigning a rating of permanent partial impairment, the physician is often called on to give an estimate of residual work capacity. The physician is responsible for determining the level of physical activity that the patient can safely tolerate. The most widely accepted physical exertion requirement guidelines are those published by the Social Security Administration: Very heavy work is that which involves lifting objects weighing more than 100 pounds at a time, with frequent lifting or carrying of objects weighing 50 pounds or more. Heavy work involves lifting of no more than 100 pounds at a time, with frequent lifting or carrying of objects weighing up to 50 pounds. Medium work involves the lifting of no more than 50 pounds at a time, with frequent lifting or carrying of objects weighing up to 25 pounds. Light work involves lifting of no more than 20 pounds at a time, with frequent lifting or carrying of objects weighing up to 10 pounds. Sedentary work involves the lifting of no more than 10 pounds at a time and occasional lifting or carrying of articles such as docket les, ledgers, or small tools. TEMPORARY TOTAL DISABILITY In general, a patient is judged temporarily totally disabled if, in the opinion of the treating physician, the patient is incapable of performing any job, for any reasonable period of time, during the course of a workday. Note that, by this denition, a patients inability to perform his or her own job is not the primary issue. For example, a construction worker in a short arm cast for a Colles fracture may well be incapable of his or her usual work but capable of sedentary or one-handed light work, so the worker is not totally disabled. Temporary total disability is granted for patients

USEFUL GUIDES TO IMPAIRMENT DETERMINATION

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mination. Some states create their own unique guidelines, which are based on a variety of practical, idiosyncratic, or occasionally political considerations. Increasingly, most states and the District of Columbia have adopted the guidelines published by the AMA.2 Most federal agencies concerned with impairment determination also use the AMA guides. More widespread use of the AMA guides seems to be leading to increasingly uniform and probably fairer impairment determinations across most jurisdictions.

EPIDEMIOLOGY

zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz Little has been published on the epidemiology of fractures or on their economic signicance. The United States Public Health Service accumulated records on some aspects of fracture epidemiology between 1957 and the mid-1980s. Unfortunately, data collection has not resumed, and more recent national trends in the incidence of fractures are unknown.

When fractures are broken down into upper and lower extremity groups, a clear pattern of occurrence with age emerges. Men have a fairly stable rate of fractures of the lower extremities and a decreasing rate of upper extremity fractures with age. In contrast, women show no change in the incidence of upper extremity fractures and have a signicant increase in the incidence of lower extremity fractures with increasing age. These changes may be caused by the increased incidence of osteoporosis among older women. Fractures made up about 10.2% of all orthopaedic injuries during the years 1980 and 1981 (Fig. 232),19 compared with 8.2% between 1957 and 1961.18 Only injuries resulting in at least 1 day of limited activity were counted in this survey.

Restricted Activity and Bedrest

Fractures and dislocations during the period from 1963 to 1981 resulted in about 60 days of restricted activity per 100 people per year, with men accounting for more restriction than women (Fig. 233).16 The period of restricted activity included about 16 days spent in bedrest. Older women have a marked increase in the incidence of fracture-related restriction of activity with both upper and lower extremity fractures. Among men, however, the average number of restricted activity days is fairly constant for both upper and lower extremity injuries in all age classes. Despite the large increase in fracture rate among older women, men have a higher average number of restricted activity days when all ages are considered together.16, 19 The nding of increased musculoskeletal symptoms with age has been noted in other surveys as well.35

Incidence of Fractures
Data from the National Center for Health Statistics of the Public Health Service indicate that there is little uctuation in the incidence of fractures and dislocations from year to year (Fig. 231). Between 1963 and 1981, fractures and dislocations occurred at the rate of about 3 per 100 persons per year.16 Men consistently sustain signicantly more injuries than women. The type of fracture is not reported by the Public Health Service, and fractures and dislocations are not listed separately.

4.0

3.5

3.0 NUMBER/100 PERSONS/YEAR

2.5 Print Graphic 2.0

FIGURE 231. Incidence of fractures and dislocations per 100 persons per year in the United States from 1963 through 1981.

1.5 Presentation 1.0

0.5

0 1963 1965 1967 1969 1971 1973 1975 1977 1979 1981 YEAR

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SECTION I General Principles

Burns 3.6% Abrasions and contusions 25.5%

Fractures 10.2% Dislocations 2.2%

Impairment
Impairment resulting from injury is dened by the National Health Service as any limitation of function lasting longer than 3 months. Orthopaedic injuries, including fractures, were responsible for 64.3% of all impairments between 1980 and 1981, the most recent period for which data are available.19 Broken down by type of injury, orthopaedic problems of the lower extremity account for 24%, problems of the upper extremity for 13.7%, and those involving the spine for 26.6% of the total impairments noted in this period. About 44 million of the civilian, noninstitutionalized population reported at least one musculoskeletal disorder during 1980, a prevalence in this population of almost 20%.13 Musculoskeletal conditions account for 13% of restricted activity days, 8.8% of bed disability days, and 11.2% of work loss days overall. Lost productivity from musculoskeletal conditions totaled about $3.9 billion during 1980, and the medical cost of treating these conditions was more than $12 billion during the same period.5, 17

Print Graphic Sprains 28.4% Presentation

Open wounds 30.1%

FIGURE 232. Incidence of fractures compared with all other orthopaedic injuries in the United States in 1980 and 1981.

Work Loss Days

Fractures caused 28.6 days of work loss per 100 employed men per year between 1983 and 1986.17 There was no change in the number of work loss days with increasing age among men (Fig. 234). Women older than 45 years lost signicantly more days from work because of fractures than their younger peers (25.1 vs. 9.45 days per 100 employed women per year, respectively) (Fig. 235). Overall, women miss fewer days of work than men, but in the age group older than 45 the rates become equal.17

HISTORICAL PERSPECTIVE

zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz Before the 1930s, in both the United States and Europe, arbitrary disability values were assigned for individual injuries. The entire disability determination process was performed by physicians, despite their lack of special training in social, economic, and occupational evaluation. This practice may have simplied rendering a judgment of disability, but it led to the awarding of the same compensation to individuals with markedly different

90 80 70 NUMBER/100 PERSONS/YEAR 60 50 40 30 20 10 0 1963 1965 Males 1967 1969 Females 1971 1973 1975 1977 1979 1981 YEAR
FIGURE 233. Days of restricted activity caused by fractures and dislocations among men and women in the United States from 1963 through 1981.

Print Graphic

Presentation

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40

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DAYS/100 PERSONS/YEAR

30

25 Print Graphic 20

FIGURE 234. Days of work loss caused by fractures in men in the United States by age from 1983 through 1986.

15 Presentation 10

0 AGE GROUP 18-44 1986 1985 Over 44 1984 1983 All ages Mean

degrees of residual disability.6, 12 Beginning in the 1930s, new systems of classifying residual decits were introduced in the United States by individual authors in an effort to make the system of disability evaluation more equitable and objective. Kessler68 described evaluation based on objective criteria such as range of motion in degrees and motor strength measured in foot-pounds. McBride9, 10 published a 10-point scale based on ve anatomic and ve functional

criteria that, taken together, gave an estimate of overall impairment. In an effort to reduce the inuence of subjective and potentially biased data, Thurber15 published impairment scales based on range of motion alone. Development of the modern system for rating of permanent partial impairment by physicians began in 1956 with the introduction by the AMA of a series of guides designed to provide objective, reproducible impairment ratings.1, 2 These guides were intended to standard-

30 28 26 24 22 DAYS/100 WOMEN/YEAR 20 18 16 14 12 10 8 6 4 2 0 AGE GROUP 18-44 1986 1985 Over 44 1984 1983 All ages Mean Presentation Print Graphic

FIGURE 235. Days of work loss caused by fractures in women in the United States by age from 1983 through 1986.

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SECTION I General Principles

ize evaluation of the result of industrial accidents for determining workmens compensation claims. The AMA series is now complete and is updated regularly. In addition to the guides for the spine and extremities, the AMA provides guides to the evaluation of other organ systems (e.g., neurologic, hematopoietic), but the evaluation of these systems is outside the area of training of orthopaedic surgery.

MODERN IMPAIRMENT SCALES

zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz The AMA guides rate impairment by a whole person concept. In this system, each part of the body is assigned a value reecting the contribution of that part to the patient as a whole. The percentage each part contributes to the whole is based on the notion of function. Loss of function of the extremity is expressed as a percentage of the value of the extremity as a whole, and impairment to the whole person is calculated from this value. The upper extremities are valued at 60% of the whole person, the lower extremities at 40%. As an example, amputation at the wrist results in a 90% loss of function of the arm and a 54% impairment of the whole person. The AMA guides historically relied solely on range-ofmotion measurements for the determination of partial impairments of the spine and extremities, offering no consideration of pain, atrophy, shortening, and other subjective and objective data. The fourth and fth editions of the guides incorporated a much broader range of evaluation criteria and also introduced the concept of diagnosis-related impairment estimates. Traditional range of motionbased estimates ignore causal issues and focus solely on measurable outcomes, specically motion of local joints or spine segments. Diagnosis-related impairment estimates attempt to overcome the inherent limitations of a one-dimensional motion-based estimating tool by focusing on the underlying diagnosis. For example, all patients with multiple operations for a herniated lumbar disc with residual, veriable neurologic residuals might be grouped together for the purpose of impairment determination, leading to a more uniform and ultimately fairer determination than would be possible using range-of-motion measures alone. Another advantage of diagnosis-based impairment determinations is the reduced dependence on subjective or difcult to measure variables such as range of motion, pain, weakness, or clumsiness.

homebound and require skilled nursing care are temporarily totally disabled. Patients who are dependent on crutches for ambulation are not necessarily totally disabled at all times unless they meet the other denitions of temporary total disability. Periodic evaluation in the physicians ofce is necessary during the period of temporary total disability. Most state workmens compensation laws mandate at least monthly visits during the period of temporary total disability, during which further documentation for ongoing temporary total disability status must be entered in the patients record.

Temporary Partial Disability

Temporary partial disability begins with the termination of temporary total disability and continues until rehabilitation is complete and the patient is back to full activities with no restrictions or until a permanent impairment is assigned. During the period of temporary partial disability, the patient is allowed to return to the workplace with certain restrictions judged appropriate by the treating physician. Periodic reevaluations of the patients clinical status are made, usually at 2- to 6-week intervals. State law varies considerably on the issue of mandatory frequency of reevaluations during a period of temporary partial disability. In general, state laws permit somewhat longer intervals between clinic visits for patients with temporary partial disability, often between 4 and 8 weeks. Again, documentation in the record of the reason for ongoing temporary partial disability is important. Physician records and occasionally physician testimony are required for insurance payments for disability determination. It is worthwhile periodically to record range of motion, functional restrictions, medication use, and degree of autonomy with activities of daily living; these data can be used later to document the patients degree of disability during any given period. Once the period of temporary total disability is lifted, appropriate restrictions must be instituted by the physician. Patients recovering from back and neck injuries may benet from a restriction on bending, twisting, stooping, lifting, and heavy overhead work. Upper extremity injury restrictions often include avoidance of heavy or repetitive use of the involved extremity. Restrictions after lower extremity injuries frequently include prohibitions against excessive walking, climbing, stooping, kneeling, running, and carrying. Many employers and third-party payers publish and distribute forms with a listing of possible activities for the physician to check off. To the extent that the listed activities are of concern to the physician, these forms may be used, but it is often more useful for the physician to attach a note on letterhead stationery outlining the restrictions rather than to try to make his or her best judgment about appropriate restrictions t within the connes of existing forms and classications. Temporary partial impairment restrictions should be modied as the patients symptoms warrant. This modication may require instituting greater restrictions and moving the patient back toward more sedentary activities

TEMPORARY IMPAIRMENT Temporary Total Disability

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Patients are temporarily totally disabled from the moment of occurrence of the skeletal injury until they achieve a reasonable degree of mobility and independence, are able to perform their own activities of daily living to a reasonable degree, and are no longer dependent on narcotic analgesics. Obviously, patients who are hospitalized, are inpatients in a rehabilitation facility, or are

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if symptoms become excessive or gradual liberalization of activities as clinical status permits. Occasional periods of temporary total disability may be warranted, particularly after surgical procedures or operative manipulations of fractures.

excess of the half inch generally considered to be normal.11 Thus, a leg length discrepancy of 2 inches after fracture would result in a 15% limb impairment on the basis of this factor alone.

Malunion IMPAIRMENT AND FRACTURES

zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz Fractures cause several kinds of permanent changes, any of which may lead to a degree of partial impairment. Each element of fracture healing must be considered separately in determining the overall level of impairment caused by a given injury. Existing impairment scales address some but not all of these factors. Traditionally, some incremental percentage of increased impairment is assigned for sequelae of fracture healing such as limb length discrepancy, loss of joint motion, or ankylosis. Some complications, including nonunion, infection, and secondary soft tissue injury, are not addressed explicitly in the literature, and the practitioner is left to his or her own discretion in assessing permanent impairment. A fracture healing with angulation may result in loss of motion at the joint above or below it, in which case the AMA guide pertaining to motion decit provides a correct estimate of impairment.2 If symptoms other than loss of motion are present, some additional degree of impairment should be allowed. If the malunion causes signicant symptoms, such as weakness, skin breakdown, altered gait, or rotational deformity, an additional 10% impairment should be allowed.

Infection
If chronic osteomyelitis occurs, some additional level of impairment should be assigned to compensate for the well-recognized potential complications and daily inconvenience of this disease. If symptomatic osteomyelitis exists at the time permanent impairment is determined, an additional impairment of 10% of the limb value is assigned. If the infection is minimally symptomatic or quiescent at the time of determination, an additional impairment of 5% is assigned.

Handedness
The AMA does not allow for handedness or side dominance in the determination of impairment, the contention being that activities of daily living, the functional standard by which medical impairment is judged, are not affected by handedness. Therefore, no increased impairment value is allowed for impairments in the dominant upper extremity. Obviously, disability determination must take handedness into consideration. Traditionally, 5% extremity impairment is added for impairments of 1% to 50% of the dominant extremity and 10% for impairments greater than 50% of the dominant upper extremity.

Intra-articular Involvement
Long-term sequelae of fractures may not be apparent at the time of determination of impairment. Degenerative changes are far more likely to develop in a joint that has sustained an intra-articular fracture, especially in the presence of residual articular displacement. The determination of permanent impairment after a fracture must therefore include an allowance for the occasional development of post-traumatic arthritis. As an example, a well-healed, nonpainful fracture of the medial malleolus with no residual intra-articular displacement warrants a nding of 5% impairment of the limb because of the anticipated future disability such an injury could cause. A similar fracture with intra-articular displacement would merit a 10% impairment of the limb.

Nonunion
Occasionally, a fracture fails to unite despite optimal medical and surgical intervention, or a patient may legitimately choose not to accept the risks associated with surgical intervention for treatment of a nonunion. Because joint motion above and below the nonunion is compromised, the AMA system recognizes increased impairment in this situation. The impairment resulting from nonunion can be more profound than simple loss of joint motion. Pain, motion at the fracture site, and weakness may complicate nonunion. It is reasonable to add 5% to the limb impairment for an asymptomatic nonunion and 10% for a nonunion that causes signicant compromise beyond loss of joint motion.

Preexisting Conditions and Apportionment

Preexisting medical conditions need to be apportioned before assignment of a scheduled loss-of-use rating. Apportionment is the process of dividing the degree of impairment detected at the time of examination between current and prior injuries or conditions. Apportionment generally implies a preexisting condition that has been made materially or substantially worse by a second injury or illness. Numerous methods can be used to assess apportionment, and no universal standard seems to have been adopted. The AMA guides recommend subtracting

Limb Length
Limb length discrepancy after fracture is of much greater signicance in the leg than in the arm. One convention for dealing with leg length discrepancy is to allow 5% permanent impairment for each half inch of shortening in

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SECTION I General Principles

the whole person impairment established for the preexisting condition from the current impairment rating. This recommendation clearly assumes that perfect, incontrovertible data exist about the preexisting condition, a circumstance rarely encountered. In most cases, a somewhat more arbitrary division is needed. A reasonable starting place is a 50%-50% apportionment between preexisting and current causes unless objective new data show a worsening of the condition after onset of the current injury or illness. For example, a patient with a preexisting arthritic knee and a subsequent tibial plateau fracture on the affected side with subjective complaints of worsening symptoms after the fracture warrants an apportionment of 75% to the current injury and 25% to the preexisting condition. A patient with chronic low back pain made subjectively worse after a lifting injury warrants a 50%-50% apportionment in the absence of magnetic resonance imaging, electromyographic, or radiographic evidence of a new condition. If new test ndings cannot be reliably assigned to the new or old injury or illness, the 50%-50% apportionment rule should be applied.

Preexisting Osteoarthritis
Some fractures inevitably occur in individuals already suffering from musculoskeletal disease, most often osteoarthritis. Injuries are slower to heal and residual loss of joint motion may be greater in such patients.7, 21 Symptoms caused by the osteoarthritis are often perceived to be more disabling after a fracture. Assuming that radiographs taken at the time of injury show degenerative changes or that late lms show changes in excess of what might reasonably be expected to develop in the elapsed time, an allowance for exacerbation of the preexisting disease should be made. To compensate fairly for the contribution of the injury to preexisting arthritis, a 5% additional impairment should be added to the limb impairment for patients who are subjectively worse and a 10% additional impairment to those who are both subjectively and objectively worse after their injury.21 SPINE FRACTURES Individual investigators have offered various schemes for determining impairment related to spinal fracture. Miller,11 for instance, allowed 5% whole person impairment for lumbar compression fractures up to 25%, 10% impairment for compression of 25% to 50%, and 20% impairment for lumbar compression fractures greater than 50%. He halved these values for fractures of the thoracic spine and allowed no impairment assignment for healed compression fractures of the cervical spine unless some other factor such as nerve injury is present.11, 14 In an effort to provide a fair and uniform assignment of impairment for spine injuries, Wiesel and colleagues20, 21 collected data from 75 members of the International Society for Study of the Lumbar Spine and from 53 American members of the Cervical Spine Research Society. The objective was to establish diagnosis-related impair-

Neurologic Injuries
The AMA guides outline appropriate standards for evaluating combined skeletal and neurologic injuries. In general, impairment secondary to joint stiffness after fracture is considered separately from nerve injuries caused by the same injury. Loss of motion related to nerve injury, such as limited shoulder abduction following axillary nerve injury, is not considered separately, as the neurologic injury is solely responsible for the motion decit. Neurologic loss resulting from spine fractures should be evaluated with the diagnosis-related estimates because of the difculty of evaluating spine range of motion in the paralyzed patient.

TABLE 231

Permanent Partial Impairment and Work Restriction after Fractures of the Cervical and Lumbar Spine
Fracture Type CERVICAL SPINE Odontoid, external xation Odontoid, surgical fusion Hangmans, external xation Hangmans, surgical fusion Burst or compression, lower cervical spine, external xation, no neurologic decit Burst or compression, lower cervical spine, surgical fusion, no neurologic decit LUMBAR SPINE Acute spondylolysis or spondylolisthesis, conservative care, complete recovery Acute spondylolysis or spondylolisthesis, conservative care, residual discomfort Spondylolysis or spondylolisthesis, laminectomy and/or fusion, complete recovery Spondylolysis or spondylolisthesis, laminectomy and/or fusion, residual discomfort Compression fracture, healed, with 10% compression 25% compression 50% compression 75% compression Transverse process fracture, no displacement or malunion

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Percent Impairment Work Allowed

10 20 10 15 15

Medium Light Medium Light Light

0 10 10 20 5 10 20 20 0

Heavy Light Light Sedentary Medium Light Sedentary Sedentary Heavy

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ment ratings for a variety of common spinal disorders. The results as applied to spinal fractures are presented in Table 231. The AMA offers the most widely used spine impairment guidelines. Again, the AMA guides are used in more than three out of four states and most federal agencies. Starting with the third edition and extending through the fth, the AMA algorithm has included diagnosis-related impairment estimates, with range of motionbased estimates used only in a few situations where diagnosis-related categories t the situation poorly. Spine fractures are generally amenable to diagnosis-related grouping, the major exception being multiple fractures within an anatomic region, for example, two compression fractures occurring simultaneously in the lumbar spine. In the case of poor applicability of diagnosis-related categories, the AMA allows impairment determination on the basis of range-of-motion measures.

SUMMARY

zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz Establishing a fair level of permanent partial disability after fracture requires the expertise of many professionals, including the orthopaedist, social worker, and vocational and rehabilitation therapists, as well as input from the patient and third-party payer. The evaluation of permanent partial impairment is the sole responsibility of the physician; this chapter is intended to evaluate some of the factors involved in making impairment determinations. By considering all the factors that contribute to the outcome of fracture care, a level of permanent impairment can be established that is fair to the patient, the third-party payer, and society in general.
REFERENCES 1. American Academy of Orthopaedic Surgeons. Manual for Orthopaedic Surgeons in Evaluating Permanent Physical Impairment. Chicago, American Academy of Orthopaedic Surgeons, 1962. 2. American Medical Association. Guides to the Evaluation of Permanent Impairment, 5th ed. Chicago, American Medical Association, 2001.

3. Cunningham, L.S.; Kelsey, J.S. Epidemiology of musculoskeletal impairments and associated disability. Am J Public Health 74:574, 1984. 4. Kelsey, J.S. Epidemiology of Musculoskeletal Disorders. Monographs in Epidemiology and Biostatistics, Vol. 3. Oxford, Oxford University Press, 1982. 5. Kelsey, J.S.; White, A.A.; Pastides, H. The impact of musculoskeletal disorders on the population of the United States. J Bone Joint Surg Am 61:960, 1979. 6. Kessler, E.D. The determination of physical tness JAMA 115:1591, 1940. 7. Kessler, H. Low Back Pain in Industry. New York, Commerce and Industry Association of New York, 1955. 8. Kessler, H.H. DisabilityDetermination and Evaluation. Philadelphia, Lea & Febiger, 1970. 9. McBride, E.D. Disability Evaluation. Philadelphia, J.B. Lippincott, 1942. 10. McBride, E.D. Disability evaluation. J Int Coll Surg 24:341, 1955. 11. Miller, T.R. Evaluating Orthopedic Disability, 2nd ed. Oradell, NJ, Medical Economics Books, 1987. 12. Mooney, V. Impairment, disability, and handicap. Clin Orthop 221:14, 1987. 13. Murt, H.A.; et al. Disability, utilization and costs associated with musculoskeletal conditions, United States, 1980. National Medical Care Utilization and Expenditure Survey. Series C, Analytical Report No. 5. DHHS Publication 8620405. National Center for Health Statistics, Public Health Service. Washington, DC, U.S. Government Printing Ofce, 1986. 14. Nordby, E.J. Disability evaluation of the neck and back: The McBride system. Clin Orthop 221:131, 1987. 15. Thurber, P. Evaluation of Industrial Disability. New York, Oxford University Press, 1960. 16. Vital and Health Statistics Series 10. Current Estimates from the National Health Interview Survey. Washington, DC, U.S. Government Printing Ofce, 19621981. 17. Vital and Health Statistics Series 10. Current Estimates from the National Health Interview Survey. Washington, DC, U.S. Government Printing Ofce, 19831986. 18. Vital and Health Statistics Series 10. Types of Injuries and Impairments Due to Injuries, 19571961. Washington, DC, U.S. Government Printing Ofce, 1964. 19. Vital and Health Statistics Series 10. Types of Injuries and Impairments Due to Injuries, 19801981. Washington, DC, U.S. Government Printing Ofce, 1986. 20. Wiesel, S.W.; Feffer, H.L.; Rothman, R.H. Industrial Low Back Pain: A Comprehensive Approach. Charlottesville, VA, The Michie Company Law Publishers, 1985. 21. Wiesel, S.W.; Feffer, H.L.; Rothman, R.H. Neck Pain. Charlottesville, VA, The Michie Company Law Publishers, 1986.

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