Physical Impairment Ratings for Fractures

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 significant 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 benefit 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 reviews the process of assigning an impairment rating.

Generic Issues of Disability and Impairment

Definitions

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 the sixth edition of the Guides to the Evaluation of Permanent Impairment, published by the American Medical Association (AMA), the following definitions apply :

- Impairment: a significant deviation, loss, or loss of use of any body structure or body function in an individual with a health condition, disorder or disease
- Disability: activity limitations and/or participation restrictions in an individual with a health condition
- Impairment rating: consensus-derived percentage estimate of loss of activity reflecting severity for a given health condition, and the degree of associated limitations in terms of activities of daily living (ADLs)

Determining the difference between disability and impairment is challenging, if not impossible. In some conditions, there is a predictable correlation between the injury and the expected degree of functional loss (complete spinal cord injury). In other conditions, it is harder to predict (radial nerve palsy after humerus fracture). 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. Disability is context specific and can change over time. For example, an orthopaedic surgeon would be much more disabled by a finger amputation than an endocrinologist would be. If adaptations can be made to the work environment or task in question, a particular impairment may not limit an individual from performing the task. Physicians, in general, are considered experts only in the determination of impairment.

Impairment ratings enable the physician to estimate the quantitative losses to individuals as a result of their health condition, disorder, or disease. Impairment ratings are defined by anatomic, structural, and diagnostic criteria with which physicians are usually familiar. These ratings are determined by accepted diagnostic procedures. Most physicians, however, are not familiar with the full array of functional activities and participations that are required for comprehensive disability determinations. Impairment ratings are a physician-determined estimate that attempts to link impairment with a quantitative estimate of patients’ functional losses in their personal world of activity.

A permanent impairment exists when the patient has reached maximal medical improvement yet 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 a year elapse after the injury or most recent surgery related to the injury before determining that maximal medical improvement has been attained.

Role of the Physician

According to the AMA guidelines, determining whether an injury or illness results in a permanent impairment requires a medical assessment performed by a physician. The functions evaluated in determining permanent impairment are those that allow the individual to perform common ADLs, excluding work. These include 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.

Depending on local regulations, the physician determining impairment may be the treating physician with whom the patient has an established doctor-patient relationship or an independent physician who examines the patient only for the purposes of determining impairment and is not otherwise involved in the patient's care. In general, physicians acting as independent consultants for determination of impairment ratings do not establish a doctor-patient relationship with the patient being examined. If new diagnoses are uncovered during the course of an impairment evaluation, the physician has a medical obligation to inform the requesting party and the individual about the condition and advise the individual to seek appropriate medical treatment.

Third-Party Payers and the Workers’ Compensation System

The concept of compensation for personal injuries is not a modern one. Historical evidence shows that social justice and compensation systems for injured parties have been around since recorded history. These systems attempted to legislate the exchange of money for losses resulting from personal injury. The workers’ compensation system in the United States was started in 1906 with the passage of the first law covering federal employees. By 1917, workers’ compensation insurance was mandatory for a business to operate.

Prior to the passage of the workers’ compensation law, employees who were injured at work were required to sue and prove employer negligence to receive compensation. In essence, it is a form of insurance providing wage replacement and medical benefits to employees injured in the course of employment in exchange for mandatory relinquishment of the employee's right to sue for the tort of negligence. The workers’ compensation system in the United States has evolved into a complex entity regulated by each state and representing approximately 1.5% of all employers’ compensation expenditures.

Impairment evaluations are most frequently requested by a third-party payer before settlement of a claim. The largest third-party payers are state workers’ compensation boards, private insurance companies, the Social Security Administration, and the Department of Veterans Affairs. Each of these groups has its own requirements for and definitions of impairment. Workers’ compensation laws vary widely from state to state, and federal agency regulations are amended yearly. The agency requesting the impairment evaluation should specify which rules apply in the specific case, and the reviewing physician should abide by the specified 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 patient's right to review his or her chart in the presence of the attending physician should always be honored.

Work Restrictions

In addition to assigning impairment ratings, the physician is often called on to give an estimate of residual work capacity. In this role, 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 files, ledgers, or small tools.

Types of Disability

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 definition, a patient's 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 distal radius 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 also granted for patients 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 difficult, or who are hospitalized in an inpatient unit.

Patients are temporarily totally disabled from the moment of occurrence of a skeletal injury until they achieve a reasonable degree of mobility and independence, are able to perform their own ADLs 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 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 definitions of temporary total disability.

Periodic evaluation in the physician's office is necessary during the period of temporary total disability. Most state workmen's 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 patient's 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.

Once the period of temporary total disability is lifted, appropriate restrictions must be instituted by the physician. These may allow the patient to return to work 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.

Patients recovering from back and neck injuries may benefit 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 fit within the confines of existing forms and classifications.

Periodic reevaluations of the patient's 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 than for those with temporary total 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 ADLs; these data can be used later to document the patient's degree of disability during any given period.

Temporary partial disability restrictions should be modified as the patient's symptoms warrant. This modification may require instituting greater restrictions and moving the patient back toward more sedentary activities 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.

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