French Public Health Code
In forceSCALE FOR ASSESSING THE DEGREE OF DISABILITY OF VICTIMS OF MEDICAL ACCIDENTS, IATROGENIC CONDITIONS OR NOSOCOMIAL INFECTIONS REFERRED TO IN ARTICLE D. 1142-2
VI. - LOCOMOTOR SYSTEM
FIRST PART: PREHENSION
The gripping function is performed by the hands. The mobility of the other segments of the upper limbs essentially has the effect of projecting the gripping system into the space surrounding the body. The disability rates proposed for the loss of mobility of these segments are therefore understood to reflect a reduction in the projection possibilities of a valid hand.
However, even if the hand is of little or no use, voluntary mobility of the arm and forearm is not without interest.
Although it requires the integrity of both upper limbs to be exercised to the full, the remaining gripping capacity in the event of functional loss of one of the upper limbs is not negligible, often allowing almost complete personal autonomy under current living conditions.
With advances in surgical techniques, major joint stiffness in the shoulder, elbow or wrist is increasingly rare. Major restrictions in mobility are most often due to peripheral neurological deficits or inflammatory and/or degenerative joint lesions.
Even in the absence of joint or muscle deficits, the gripping function may be more or less severely impaired by movement coordination problems. These disorders rarely occur in isolation; more often than not, they are part of a complex set of neurological deficits and must be assessed in this context (see the "Neurology" chapter).
Precise assessment of the functional deficit of the hand is particularly difficult given its multiple components:
mobility of the numerous joints, strength of mobilisation, sensitivity, trophicity of the integuments. Several quantified methods have been proposed to assess the functional value of the hand on the basis of all these elements, looking at the effectiveness of the various grips, from the thinnest objects to the heaviest and/or most bulky. By giving a precise figure for the percentage reduction in the overall functional value of a hand, they can be a valuable aid in proposing a rate of disability based on that adopted for total functional loss.
In chapters I and II, two rates are proposed, the higher being attributed to the dominant limb. In the case of bilateral impairment, the assessment should be made with reference to the total loss of function and not by adding the different rates or by applying a predetermined synergy coefficient.
Total loss of prehension function: 80%.
I. - Amputations
In current practice, replacement prostheses used in cases of amputation of the arm or forearm only very partially compensate for the loss of grip function. They therefore do not have a significant impact on the level of disability. Mechanical prostheses are difficult to use and are only really effective for a few gestures. Myoelectric prostheses offer more possibilities, but are not yet in widespread use.
Dominant | Non-dominant | |
Scapulothoracic disarticulation | 65 % | 55 % |
Amputation or total loss of function of an upper limb | 60 % | 50 % |
Amputation of the arm: depending on the quality of the stump and the residual mobility of the shoulder | 55 à 60 % | 45 à 50 % |
Forearm amputation: depending on the quality of the elbow | 45 à 55 % | 35 à 45 % |
Amputation of the hand: depending on the condition of the stump and elbow | 40 à 50 % | 30 à 40 % |
For amputations of the thumb and fingers, see Chapter III: "The Hand and Fingers".
II. - Joint sequelae (excluding hand and fingers)
A. - Shoulder
The shoulder region is defined by the 5 joints of the shoulder girdle: sternoclavicular, acromioclavicular, glenohumeral, subdeltoid and scapulothoracic.
Half of the overall active mobility in elevation-abduction-antepulsion is in the scapulothoracic joint and half in the glenohumeral joint.
Dominant | Non-dominant | |
Total loss of mobility in the glenohumeral and scapulothoracic joints | 30 % | 25 % |
Limitation of active elevation-abduction-antépulsion to 60o fixed in internal rotation | 25 % | 20 % |
Limitation of active elevation-abduction-impulsion to 85o | 20 % | 15 % |
Limitation of elevation-abduction-antepulsion between 130o and 180o | up to 10 | up to 8 |
Isolated internal rotation deficit | 6 à 8 % | 4 à 6 % |
Isolated external rotation deficit | 3 à 5 % | 1 à 3 % |
Swaying shoulder | 20 à 30 % | 15 à 25 % |
Post-traumatic instability of the shoulderafter discussion of imputability, given that the existence of constitutional instability | up to 8 | up to 5 |
Post-traumatic instability of the shoulder after discussion of imputability, given the existence of constitutional instabilities
Dominant: up to 8
Non-dominant: up to 5
Joint prosthesis.
Given the reliability of recent prostheses, the implantation of a joint prosthesis does not in itself justify a rate of PPI.
Its assessment will be based on the functional result of the joint after implantation.
B. - Elbow
The useful range of motion of the elbow joint in flexion-extension is 30° to 120°, prono-supination 0° to 45° either side of the neutral position. The combined stiffness of the elbow will not be assessed by adding up the figures proposed, but by combining them in a reasoned manner.
Dominant | Non-dominant | |
Arthrodesis around 90o in functional position: | ||
- prono-supination preserved | 20 % | 15 % |
- loss of pronation | 30 % | 25 % |
Lack of extension outside the useful sector | up to 3 | up to 2 |
Lack of prono-supination outside the useful area | up to 3 | up to 2 |
Flexion-extension deficits in the useful sector | 3 à 10 % | 2 à 8 % |
Combined stiffness, pronation-supination and flexion-extension | up to 20 | up to 15 |
Swaying elbow : | ||
- able to be fitted | 15 à 20 % | 10 à 15 % |
- non-tearable | 30 % | 25 % |
C. - Wrist
Mobility in the useful sector of the wrist for dorsal flexion is 0 to 45°, palmar flexion 0 to 60°, prono-supination 0 to 45°, lateral inclinations present.
Dominant | Non-dominant | |
Arthrodesis in functional position with slight extension, normal prono-supination in the useful sector : | 10 % | 8 % |
Loss of pronation | 20 % | 15 % |
Flexion-extension stiffness outside useful area | up to 3 | up to 2 |
Combined stiffness in the useful sector, flexion-extension, lateral inclinations (without affecting prono-supination) | 3 à 8 % | 2 à 6 % |
Combined stiffness in the useful sector, flexion-extension, lateral tilting and pronation-supination | 4 à 15 % | 3 à 12 % |
III. - The hand and fingers
The hand is the organ of prehension. Separate analysis of the function of each of its constituent parts is not sufficient, as there are multiple functional synergies between the hand and the overlying segments of the upper limb, between the fingers of a hand, and between the different segments of a digital chain. The hand is also the organ of touch: the total loss of sensitivity can lead to the virtual loss of function of the segment in question.
Examination of the hand necessarily includes an analytical study of the anatomical and functional sequelae of each finger, followed by a synthetic study of the main grips by which the grasping function is performed (opposition of the thumb, rolling of the fingers, fine grasp, strong grasp, hook grasp).
A. - Motor impairments
The rates should not be added together.
Dominant | Non-dominant | |
Total loss of grip : | ||
- fine | 20 % | 17 % |
- coarse | 15 % | 12 % |
Loss of spherical grip | 7 % | 5 % |
Total loss of hand function through amputation or ankylosis of all joints joints | 40 à 50 % | 30 à 40 % |
Average stiffness of hand joints | 25 % | 15 % |
Total loss of function of one finger through amputation or ankylosis of all joints | ||
Thumb : | ||
- thumb column (2 phalanges and 1st metacarpal) | 20 % | 15 % |
- with metacarpal preservation | 15 % | 12 % |
Long fingers : | ||
- index finger | 7 % | 5 % |
- middle finger | 8 % | 6 % |
- ring finger | 6 % | 4 % |
- auricular | 8 % | 6 % |
Several fingers : | ||
- thumb and index finger | 30 % | 25 % |
- thumb and middle finger | 32 % | 26 % |
- thumb, index and middle finger | 35 % | 28 % |
Amputation of the last 4 fingers, thumb not affected : | ||
- trans-metacarpal amputation | 20 % | 15 % |
- with metacarpal preservation | 15 % | 12 % |
Loss of a finger segment : | ||
- P2 of the thumb | 8 % | 6 % |
- P3 of index or ring finger | 3 % | 2 % |
- P3 of middle or little finger | 4 % | 3 % |
- P2 + P3 of index or ring finger | 4 % | 3 % |
- P2 + P3 of the middle and little fingers | 6 % | 4 % |
B. - Sensitivity disorders
The more elaborate the manual activity, the more troublesome the sensitivity defect.
Protective thermo-algesic tactile sensitivity alone preserved :
loss of 50% of the functional value of the finger.
The retained PPI cannot exceed the level of the total lesion including neuroma, dystrophic scar, nail regrowth disorder.
Poor discriminative sensitivity: loss of 10 to 20% of the functional value of the finger.
Complete anaesthesia: loss of functional value of the finger.
Digital reimplantation and transplantation: good results correspond to a loss of 10 to 20% of the functional value of the finger, given the constant persistence of pain and hypersensitivity to cold.
The rate is higher when stiffness and sensitivity deficits are added, depending on the functional result. The rate cannot be higher than the rate of digital loss.
C. - Joint stiffness
Dominant | Non-dominant | |
Joint stiffness in the last four fingers: | ||
- metacarpophalangeal joints: area of optimal mobility, 20 to 80o for II and III, 30 to 90o for IV and V; rate depending on remaining mobility | up to 4 | up to 3 |
- P1-P2 joint: area of optimal mobility, 20 to 80o for II and III, 30 to 90o for IV and V (greater discomfort in the last two fingers) | up to 3 | up to 2 |
- P2-P3 joints | up to 2 | up to 2 |
Thumb : | ||
- trapeziometacarpal joint | up to 8 | up to 6 |
- metacarpophalangeal joint | up to 6 | up to 4 |
- interphalangeal joint | up to 2 | up to 2 |
The rate depends on the quality of the pollici-digital clamps.
IV. - Sensory-motor deficits
Dominant | Non-dominant | |
Total paralysis of an upper limb due to a major lesion of the brachial plexus including damage to the stabilisers of the scapula : | 60 % | 50 % |
Upper radicular syndrome: involves the C5 and C6 roots. This results in paralysis of the deltoid muscle (abduction, elevation of the arm), the biceps brachii, the brachialis anterior and the brachioradialis (flexion and supination of the forearm) and a sensory deficit of the shoulder, the outer surface of the forearm and thumb | 25 % | 15 % |
Middle radicular syndrome: involves the C7 root. The result is paralysis of the extensors of the elbow elbow (triceps brachii), wrist and fingers (common and proper extensors). The sensory deficit is localised to the posterior aspect of the arm and forearm, the dorsal aspect of the hand and the medius. | 30 % | 20 % |
Inferior radicular syndrome: involves the C8 and Th1 roots. This results in damage to the muscles of the hand (of the medio-ulnar type), and a sensory deficit of the medial aspect of the arm and forearm, as well as the ulnar border of the hand and the last two fingers. | 45 % | 35 % |
Inferior radicular syndrome: involves the C8 and Th1 roots. The muscles of the hand are affected of the hand (of the medio-ulnar type) and a sensory deficit of the medial aspect of the arm and forearm as well as the ulnar border of the hand and the last two fingers. | 45 % | 35 % |
Paralysis of the radial nerve : | ||
- above the tricipital branch (with loss of elbow extension) | 40 % | 30 % |
- below the tricipital branch | 30 % | 20 % |
- after tendon transplantation; depending on the result | 15 à 20 % | 10 à 15 % |
Ulnar nerve paralysis | 20 % | 15 % |
Median nerve palsy | ||
- in the arm ; | 35 % | 25 % |
- wrist | 25 % | 15 % |
Medio-ulnar paralysis | 40 à 45 % | 30 à 35 % |
Circumflex nerve palsy | 15 % | 10 % |
Musculocutaneous nerve palsy | 10 % | 8 % |
Spinal nerve palsy (trapezius and sternocleidomastoid deficits, shoulder stump elevation and head rotation, elevation-abduction limited to 85o) and rotation of the head, elevation-abduction limited to 85o) | 10 à 15 % | 8 à 12 % |
PART TWO. - LOCOMOTION
In the current state of medical and surgical techniques, the after-effects of traumatic lesions of the lower limbs only exceptionally result in a complete, inapparable deficit in the function of locomotion. The conventional maximum rate for such a loss is nevertheless an essential benchmark for assessing partial loss of function.
Total loss of locomotor function compensated solely by the use of a wheelchair: 65%.
I. - Amputations
Significant progress has been made in fitting techniques, but not all amputees can benefit from them.
The quality of the functional result depends on the height of the amputation, the quality of the stump, muscle tone, age, general condition, the technical nature of the rehabilitation and the degree of motivation of the amputee.
In the best cases, some amputees can recover very satisfactory walking ability. But the quality of the functional result must not mask the reality of the handicap that the amputation itself represents.
It would be illusory to propose precise sliding scale rates according to the effectiveness of the equipment, as each case is unique.
The expert will assess the quality of the fitting and, if the results are unsatisfactory, the expert may refer to the PPI rate for the overlying amputation.
The same approach may be taken in the case of trophic disorders of the stump.
The degree of disability must therefore be assessed on the basis of precise clinical criteria and appropriate technical arguments, which the expert must clearly set out in his report.
report, and on the basis of the following indicative maximum rates:
Hip disarticulation | 55 % |
Amputation of the upper thigh without a prosthesis or with no ischial support | 55 % |
Well-fitted upper thigh amputation: depending on the length of the stump | 45 à 50 % |
Mid 1/3 thigh amputation with distal epiphyseal preservation | 40 % |
Well-fitted middle 1/3 leg amputation, intact knee, no trophic problems trophic disorder | 30 % |
Medico-tarsal foot amputation or perital equivalent : | |
- no equinus and good heel | 25 % |
- with equinus and poor heel | 30 % |
Transmetatarsal amputation: depending on the bearing qualities of the stump | 18 à 20 % |
Loss of all 5 toes | 15 % |
Amputation of all the toes with preservation of the big toe: depending on the support of the metatarsal support | 8 à 12 % |
Amputation of the big toe (loss of propulsion) : | |
- at 1st radius | 10 à 12 % |
- Loss of the head of the 1st phalanx (loss of rapid propulsion) | 7 à 8 % |
II. - Joint sequelae
A. - Pelvis
In the case of sequelae of trauma to the pelvis, the PPI will depend on any inequality in the length of the lower limbs, changes in the range of movement of the hips, and associated neurological and sphincter disorders.
Neurological sequelae with sphincter disorders are rare in sacral fractures (see section on the spine).
a) Painful sequelae of extra-articular fractures :
Distal extremities of the sacrum and coccyx: these are to be differentiated from congenital anomalies with integrity of the sacroiliac joints.
Intractable painful sequelae in the sacral region: up to 5%.
Iliac wing, iliopubic and ischiopubic branches: these fractures do not usually affect pelvic statics or walking. It is rare for pain or functional discomfort to persist.
If local pain persists during abduction movements or when sitting: up to 5%.
b) Painful sequelae of joint fractures (excluding acetabulum: see "hip" paragraph).
Isolated pubic disjunctions:
Up to 4 cm: up to 5%,
in the case of disjunctions of more than 4 cm, the PPI depends on the sequelae of associated lesions.
Isolated sacroiliac pain:
Depending on documented osteo-ligament lesions: 3 to 10%.
B. - Hip
The mastery of techniques for implanting hip prostheses and the quality of the materials used, together with the consistency of a very high proportion of excellent results, have broadened the indications for this operation to such an extent that certain types of sequelae, such as "ankylosis in a vicious position", have become exceptional.
However, given the currently accepted lifespan of prostheses (15 to 20 years) and the uncertainties of their renewal, it is still permissible to delay the implantation of a prosthesis in young patients until the pain and functional deficit become unbearable.
There may therefore be fairly long periods during which the sequelae have not really stabilised, with the sequelae remaining accessible to medical treatment that can significantly improve them. These situations do not lend themselves well to the determination of a permanent disability rate.
The current results of hip arthroplasty allow an assessment based solely on the functional result of the hip after implantation of the prosthesis.
Hip and useful mobility sector: flexion is the most important movement of the hip. Walking requires 30 to 45° of flexion. To cut your toenails, you need 100° of hip flexion.
Ankylosis (i.e. tight stiffness without radiological fusion).......... | 30 % |
Ankylosis in a vicious attitude.......... | 35 à 40 % |
Arthrodesis (i.e. anatomical bone fusion).......... | 20 % |
Vicious arthrodesis.......... | 35 à 40 % |
Swaying hip.......... | 40 % |
Limitation of flexion, abduction and external rotation in the area of useful of useful hip mobility.......... | 8 à 15 % |
Stiffness of the hip in a vicious attitude: flexum, internal rotation, adduction.......... | 20 à 25 % |
Stiffness with preservation of hip flexion only.......... | 15 % |
Minimal limitation of joint range of motion; depending on the area of mobility affected.......... | up to 8 |
C. - Vicious callus of the femur
A malunion in valgus and external rotation is well tolerated.
A callus with varus and internal rotation or a combination of large deformities is poorly tolerated.
To determine the level of PPI, joint deformities and tilting of the pelvis must be taken into account (to be checked and quantified).
When there is a shortening :
- up to 10 mm compensated by a heel-piece: no disability;
- between 10 and 50 mm: up to 8%;
- over 50 mm: greater than 8%.
D. - Knee
To climb stairs, a minimum of 90° of flexion is required; to descend stairs, a minimum of 105° of flexion is required; to drive, a minimum of 30° of flexion is required; to sit comfortably, a minimum of 60° of flexion is required.
Ankylosis (tight stiffness without radiological fusion): 25 to 30%.
Arthrodesis (anatomical bone fusion): 25%.
Limitation of knee flexion with preservation of extension; flexion possible :
- from 0 to 30°: 20
- from 0 to 60°: 15
- from 0 to 90°: 10%;
- from 0 to 110°: 5 to 8%;
- above: up to 5%.
Flexum (isolated extension deficit) active or passive :
- from 0 to 10°: up to 5% ;
- from 10 to 20°: 5 to 10%.
Isolated anterior laxity :
- with typical anterolateral protrusion reproducing the alleged discomfort: 5 to 10% ;
- without protrusion: up to 5%.
Isolated posterior laxity well tolerated: up to 5%.
Mixed peripheral and anteroposterior chronic laxity: 5 to 15%.
Severe chronic laxity bordering on arthrodesis: 20%.
Swaying knee, including shortening (e.g. after removal of prosthesis): 30%.
Unstable knee. Effusion, amyotrophy and peripheral laxity in extension must be taken into account.
The functional state of the knee is assessed, whether or not it has been operated on (ligamentoplasty or osteotomy or arthroplasty).
The patella and patellofemoral syndromes:
Post-traumatic pathology of the patella must be differentiated from that of congenital extensor dysplasia (recurrent dislocation of the patella).
Furthermore, the arthroscopic classification of chondropathies cannot be superimposed on the radiological classification of osteoarthritis.
True traumatic dislocation is rare; the PPI should be assessed according to the residual capacity of the knee.
Patellofemoral syndrome is defined by anterior pain with instability on descending stairs and pain on prolonged sitting: Smillie's sign reproduces the alleged discomfort:
- post-contusion: up to 3%.
- after patella fracture (excluding osteochondral fracture): up to 8%.
Rupture of the extensor apparatus, injury to the patellar tendon or quadricipital tendon or up to 8% of their insertions:
PPI assessment will depend on persistent active flexion.
The presence of a prosthesis alone does not lead to permanent partial disability.
More often than not, lateral laxity is part of an overall symptomatology of knee joint function. When it is strictly isolated, it causes few problems and, as such, does not in itself justify a rate of PPI.
Axial deviations (genu varum, genu valgum) do not in themselves generate a disability rate: they should be included in the overall assessment of knee joint function.
E. - Ankle
Arthrodesis (anatomical bone fusion) :
- tibio-talar (in good position): 10 to 12% ;
- associated tibio-talar, medio-talar and sub-talar arthrodesis: 20%.
Ankylosis (tight stiffness without radiological fusion):
- tibio-talar: 10 to 15%.
Loss of isolated dorsiflexion measured with the knee flexed: up to 5%.
Residual post-traumatic equinus:
- less than 2 cm: 5% ;
- 2 cm or more with normal medio-tarsal: 5 to 10%;
- more than 2 cm with reduced medio-tarsal mobility: 10%;
- more than 2 cm without medial tarsal mobility: 15% ;
- requiring a device other than a heel cup: 12%.
F. - Foot
Given the anatomical complexity of the region and the difficulty of analysing the various functional segments, the expert will have to make an overall assessment based on the rates below, also taking into account pain, stability of the foot, circulatory and trophic disorders, the need to use one or two canes, and plantar impression disorders on weight-bearing.
Post-traumatic hallux rigidus: 4%.
Changes in plantar support :
- with hyperkeratosis and toe deformities: 3 to 10% ;
- without hyperkeratosis: 3%.
Ankylosis of the subtalar and medio-tarsal joint in good position: 10 to 15%.
Arthrodesis of the subtalar joint in good position: 8 to 10%.
Tarsometatarsal joint (Lisfranc):
- ankylosis: 8 to 15% ;
- arthrodesis: 8 to 12%.
Instep laxity:
- sequelae of benign "sprain": 0 to 3% ;
- chronic post-traumatic ankle laxity (documented) :
3 à 6 %.
III. - Root disorders
Total sciatic paralysis :
- high truncal form with gluteal paralysis (Tredelenbourg lameness). Allow for a reduction of 5 to 10% depending on the quality of compensation: 40 to 45% ;
- low form below the knee, not fitted with a brace: 35%.
Paralysis of the external popliteal sciatic nerve (fibular nerve) :
- total (levator and valgator): 20% ;
- compensated by orthopaedic devices or surgery, depending on the result: 10 to 15%.
Total paralysis of the medial popliteal sciatic nerve (tibial nerve) :
20 %.
Paralysis of the femoral nerve (crural nerve) :
- total: 35% ;
- fitted or partial: up to 20%.
Paralysis of the femoral-cutaneous nerve (or meralgia): less than 5%;
Paralysis of the obturator nerve: 5%.
PART THREE: SPINE
The painful after-effects of cervico-thoracolumbar spinal trauma have in common that they are not always proportional to the extent of the initial disco-osteoligamentous lesions, that they are often grafted onto a previous latent or patent arthritic condition of the spine, and that they have been the subject of numerous therapeutic attempts.
In order to assess the sequelae correctly, the expert must systematically combine a neurological examination with a locomotor examination. He will complete this examination by taking note of the data from the complementary examinations carried out, mainly imaging.
In the case of a spine that was previously arthritic, only an organic change in the evolutionary process can be taken into account in the assessment of the PPI.
I. - Cervical spine
A. - Without neurological complications
Several possibilities can be distinguished schematically:
Without documented initial bone or disco-ligament lesion ;
Intermittent pain triggered by specific causes, always the same, requiring analgesic and/or anti-inflammatory medication on demand, with minimal reduction in the amplitude of active movements: up to 3%;
With documented initial bone or disco-ligament lesions;
Frequent pain with clinically-objectifiable limitation of range of movement, real but intermittent therapeutic constraint: 3 to 10% ;
Very frequent pain with permanent functional discomfort requiring precautions during all movements, frequent dizziness and associated posterior headaches, significant stiffness of the neck: 10 to 15%.
B - With neurological or vascular complications
As the after-effects are essentially neurological, please refer to the relevant chapter.
II. - Thoracic, thoraco-lumbar and lumbar spine
A. - Without neurological sequelae (spinal syndrome)
Pain triggered intermittently by specific causes, requiring appropriate treatment on request, imposing the suppression of major and/or prolonged efforts associated with discrete active segmental stiffness: up to 3%.
Active stiffness and painful discomfort during all movements, in all positions, requiring regular treatment: 5 to 10%.
Permanent discomfort with inter-scapular pain, static problems, hollow back, loss of radiological thoracic kyphosis, with therapeutic constraints: 10 to 20%.
B. - With neurological complications of spinal cord or radicular deficits
Refer to the "Neurology" chapter.
