The impairments assessed for each region in each upper extremity are combined (that is, hand, wrist, elbow, shoulder). The WPI rating for one upper extremity may be combined with a WPI rating for the other upper extremity, except in the case of assessments under Table 9.14, where the notes appearing prior to Table 9.14 are to be followed.

WPI ratings from the following tables must not be combined with a WPI rating under Table 9.14 if they assess the same condition in the same upper extremity:

Tables 9.8.1a, 9.8.1b, 9.8.1c, 9.8.1d (tables dealing with abnormal motion of digits);
Tables 9.8.2a, 9.8.2b, 9.8.2c, 9.8.2d (tables dealing with sensory losses in thumb and fingers);
Tables 9.9.1a, 9.9.1b (tables dealing with wrists);
Tables 9.10.1a, 9.10.1b (tables dealing with elbows);
Tables 9.11.1a, 9.11.1b, 9.11.1c (tables dealing with shoulders).

If the medical assessor feels that the impairment is not adequately assessed using one of Tables 9.9, 9.10, and 9.11, and the condition involves radiographically demonstrated joint instability, radiographically demonstrated arthritis or where the employee has had an arthroplasty, the medical assessor may consider the effect of the injury on upper extremity function instead and determine the WPI rating using Table 9.14.

Where a condition cannot be assessed under a specific table in the Upper Extremities group, an assessment may be made under the provisions of the edition of the American Medical Association?s Guides to the Evaluation of Permanent Impairment current at the date of the assessment.

All ankylosis assessments from tables in the Upper Extremities group are alternative assessments to those for abnormal motion of the individual joints.

The maximum WPI rating for a single upper extremity is 60%, including combined WPI ratings.

Steps in Calculating Upper Extremity Impairment

Note that sensory loss in the digit is assessed either as a digit impairment or as a peripheral nerve impairment as appropriate, but not both.

Step 1	Add abnormal motion/ankylosis impairment values within an individual joint.
Step 2	Add abnormal motion/ankylosis impairment values for different joints in the thumb.
Step 3	Combine impairment values for different joints in the other four digits.
Step 4	Combine impairment values for each digit for sensory loss due to digital nerve injury and/or amputation.
Step 5	Add impairment values for each digit to obtain the total hand assessment.
Step 6	Combine with impairment values for different regions in the upper extremity.

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9.8 Hands and Fingers

Add the WPI ratings for each individual digit to obtain the total WPI rating for the hand.

WPI ratings for abnormal motion or ankylosis of digits are combined with those for sensory losses in the same digits.

9.8.1 Abnormal Motion of Digits

Table 9.8.1a, Table 9.8.1b, Table 9.8.1c and Table 9.8.1d assess impairments to range of motion of the digits of the hand, including ankylosis of one or more joints.

Impairment values from flexion and extension losses in each individual joint are added to obtain the total WPI rating for loss of range of motion of that joint.

Where there is abnormal motion or ankylosis of more than one joint of the same finger, the WPI ratings for abnormal motion or ankylosis are combined to obtain the WPI rating for that finger.

Where there is abnormal motion or ankylosis of more than one joint of the thumb, the WPI ratings for abnormal motion or ankylosis are added to obtain the WPI rating for the thumb.

Table 9.8.1a: Abnormal Motion/Ankylosis of the Thumb ? IP and MP joints

See notes to Table 9.8.1a.

Direction	IP Joint			MP joint			Direction
Extension/ Hyperextension	Ankylosis	Loss of Extension	Loss of Flexion	Ankylosis	Loss of Extension	Loss of Flexion	Extension/ Hyperextension
Extension/ Hyperextension	%WPI	%WPI	%WPI	%WPI	%WPI	%WPI	Extension/ Hyperextension
				2	0	2	40?
30?	3	0	3	2	0	2	30?
20?	3	0	3	2	0	2	20?
10?	2	0	2	2	0	2	10?
0?	2	0	2	1	0	1	0?
10?	2	1	1	1	0	1	10?
20?	2	1	1	1	0	1	20?
30?	2	1	1	1	1	1	30?
40?	2	2	1	2	1	1	40?
50?	2	2	1	2	2	0	50?
60?	3	2	0	2	2	0	60?
70?	3	3	0
80?	3	3	0
Flexion							Flexion

Table 9.8.1b: Radial Abduction/Adduction/Opposition of the Thumb ? Abnormal Motion/Ankylosis

See notes to Table 9.8.1b.

% WPI

Criteria (ONE required ? different conditions may be assessed separately)

Loss of less than 10? of radial abduction;

Loss of less than 35? of radial adduction.

Lack of less than 3cm adduction.

Thumb opposition of greater than 6 cm.

Loss of 10? -20? of radial abduction.

Loss of 35? -40? of radial adduction.

Lack of 3-5 cm adduction.

Thumb opposition of 5-6 cm.

Ankylosis in 30? or 35? of radial abduction.

Loss of 25? or more of radial abduction.

Loss of 45? or more of radial adduction.

Lack of 6cm adduction.

Ankylosis in 15? -25? , or 40? -50? of radial abduction.

Ankylosis in 4cm of adduction.

Thumb opposition of 4cm.

Lack of 7cm adduction.

Thumb opposition of 3cm.

Ankylosis in 3cm or 5cm of adduction.

Lack of 8cm adduction.

Ankylosis in 0-2cm or 6-8cm of adduction.

Thumb opposition of 2cm.

Ankylosis in thumb opposition of 5-6cm.

Ankylosis in thumb opposition of 4cm or 7cm.

Thumb opposition of 1cm.

Ankylosis in thumb opposition of 3cm or 8cm.

Ankylosis in thumb opposition of 1 or 2cm.

Thumb opposition of 0cm.

Ankylosis in thumb opposition of 0cm.

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Table 9.8.1c: Abnormal Motion/Ankylosis of the Fingers ? Index and Middle Fingers

See notes to Table 9.8.1c.

Direction	Index and Middle Fingers									Direction
Extension/ Hyperextension	DIP joint			PIP joint			MP joint			Extension/ Hyperextension
	Ankylosis	Loss of Extension	Loss of Flexion	Ankylosis	Loss of Extension	Loss of Flexion	Ankylosis	Loss of Extension	Loss of Flexion
	%WPI	%WPI	%WPI	%WPI	%WPI	%WPI	%WPI	%WPI	%WPI
30?	5	0	5	8	0	8				30?
20?	4	0	4	8	0	8	7	0	7	20?
10?	4	0	4	7	0	7	6	1	6	10?
0?	4	0	4	7	0	7	6	1	5	0?
10?	4	0	3	6	1	6	5	1	5	10?
20?	3	1	3	6	1	5	5	1	4	20?
30?	4	1	2	6	1	4	5	1	4	30?
40?	4	2	2	5	2	4	6	3	3	40?
50?	4	3	1	6	3	3	7	4	2	50?
60?	4	4	1	7	4	3	8	6	2	60?
70?	5	5	0	7	5	2	8	8	1	70?
80?				8	7	1	10	9	1	80?
90?				8	8	1	11	11	0	90?
100?				8	8	0				100?
Flexion										Flexion

Table 9.8.1d: Abnormal Motion/Ankylosis of the Fingers ? Ring and Little Fingers

See notes to Table 9.8.1d.

Direction	Ring and Little Fingers									Direction
Extension/ Hyperextension	DIP joint			PIP joint			MP joint			Extension/ Hyperextension
	Ankylosis	Loss of Extension	Loss of Flexion	Ankylosis	Loss of Extension	Loss of Flexion	Ankylosis	Loss of Extension	Loss of Flexion
	%WPI	%WPI	%WPI	%WPI	%WPI	%WPI	%WPI	%WPI	%WPI
30?	3	0	3	4	0	4				30?
20?	2	0	2	4	0	4	3	0	3	20?
10?	2	0	2	4	0	4	3	0	3	10?
0?	2	0	2	3	0	3	3	1	3	0?
10?	2	0	2	3	0	3	3	1	2	10?
20?	2	0	2	3	1	3	3	1	2	20?
30?	2	1	1	3	1	2	3	1	2	30?
40?	2	1	1	3	1	2	3	2	2	40?
50?	2	2	1	3	2	2	3	2	1	50?
60?	2	2	1	3	2	1	4	3	1	60?
70?	3	3	0	4	3	1	4	4	1	70?
80?				4	3	1	5	5	1	80?
90?				4	4	1	5	5	0	90?
100?				4	4	0				100?
Flexion										Flexion

Notes to Tables 9.8.1a, 9.8.1b, 9.8.1c and 9.8.1d

1. Abbreviations.

IP = interphalangeal.

MP = metacarpo-phalangeal.

CMC = carpometacarpal.

PIP = Proximal Interphalangeal.

DIP = Distal Interphalangeal.

2. Thumb Adduction is the smallest possible distance from the flexor crease of the IP joint of the thumb

to the distal palmar crease over the level of the MP joint of the little finger. The normal range of adduction of the thumb is from 8 cm to 0 cm.

3. Thumb Radial abduction is the largest angle of separation actively formed between the first and

second metacarpals in the coronal plane. The normal angle of radial abduction is 50? . The smallest angle of thumb radial adduction is 15? .

4. Opposition of the thumb is measured as the largest achievable distance between the flexor

crease of the IP joint of the thumb to the distal palmar crease directly over the third MP joint. The normal range of opposition of the thumb is from 0 cm to 8 cm. In the case of employees with small hands, compare the loss of opposition with the normal range of opposition in the unaffected hand.

5. Optimal positions of thumb and fingers:

Joint	Optimal Position	Joint	Optimal Position
Thumb IP	20? of flexion	Finger DIP	20? of flexion
Thumb MP	20? of flexion	Finger PIP	40? of flexion
Thumb CMC	30? -35? of radial abduction	Finger MP	30? of flexion

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9.8.2 Sensory Losses in the Thumb and Fingers

Table 9.8.2a, Table 9.8.2b, Table 9.8.2c, and Table 9.8.2d (see following page) assess sensory losses in the thumb and fingers due to digital nerve lesions only.

Sensory losses due to peripheral nerve lesions are assessed under Tables 9.13.1, 9.13.2a and 9.13.2b (tables dealing with neurological impairments affecting the upper extremities).

The two-point discrimination test is used to determine sensory loss:

Total sensory loss = two-point discrimination of greater than 15 mm;
Partial sensory loss = two-point discrimination of 7 to 15 mm.

Two-point discrimination of less than 7 mm is not treated as an impairment.

Transverse sensory loss involves both digital nerves (ulnar and radial). Longitudinal sensory loss involves a single digital nerve (ulnar or radial).

Determine the percentage of digit length involved and consult Table 9.8.2a, Table 9.8.2b, Table 9.8.2c, and Table 9.8.2d, using the corresponding WPI rating for the particular nerve or nerves involved.

WPI ratings for transverse sensory loss must not be combined with WPI ratings for longitudinal sensory loss in the same digit. The conditions of transverse sensory loss and longitudinal sensory loss in an individual digit are mutually exclusive.

WPI ratings for sensory losses in digits are combined with those for abnormal motion or ankylosis in the same digits.

For the thumb and little finger, losses involving the ulnar digital nerve are rated higher than those of the radial digital nerve. For the other fingers, this is reversed.

If the little finger has been amputated, the ring finger is assessed as if it were the little finger.

Table 9.8.2a: Sensory Losses in the Thumb

Percentage of Digit Length	% WPI (thumb)
	Transverse Loss		Longitudinal Loss
	Both Digital Nerves		Ulnar Digital Nerve		Radial Digital Nerve
	Total	Partial	Total	Partial	Total	Partial
10	1	1	1	1	1	0
20	2	1	1	1	1	1
30	3	2	2	1	1	1
40	4	2	3	1	2	1
50	5	3	3	2	2	1
60	7	3	4	2	3	1
70	8	4	4	2	3	2
80	8	4	5	3	3	2
90	10	5	6	3	4	2
100	11	5	7	3	4	2

Table 9.8.2b: Sensory Losses in the Index & Middle Fingers

Percentage of Digit Length	% WPI (index and middle fingers)
	Transverse Loss		Longitudinal Loss
	Both Digital Nerves		Ulnar Digital Nerve		Radial Digital Nerve
	Total	Partial	Total	Partial	Total	Partial
10	1	1	0	0	1	0
20	1	1	1	0	1	1
30	2	1	1	1	1	1
40	2	1	1	1	1	1
50	3	2	1	1	2	1
60	3	2	1	1	2	1
70	4	2	2	1	2	1
80	4	2	2	1	3	1
90	5	3	2	1	3	2
100	5	3	2	1	3	2

Table 9.8.2c: Sensory Losses in the Little Finger

Percentage of Digit Length	% WPI (little finger)
	Transverse Loss		Longitudinal Loss
	Both Digital Nerves		Ulnar Digital Nerve		Radial Digital Nerve
	Total	Partial	Total	Partial	Total	Partial
10	1	0	0	0	0	0
20	1	1	1	0	0	0
30	1	1	1	1	1	0
40	1	1	1	1	1	0
50	2	1	1	1	1	1
60	2	1	1	1	1	1
70	2	1	1	1	1	1
80	2	1	1	1	1	1
90	3	1	2	1	1	1
100	3	2	2	1	1	1

Table 9.8.2d: Sensory Losses in the Ring Finger Finger

Percentage of Digit Length	% WPI (ring finger)
	Transverse Loss		Longitudinal Loss
	Both Digital Nerves		Ulnar Digital Nerve		Radial Digital Nerve
	Total	Partial	Total	Partial	Total	Partial
10	1	0	0	0	0	0
20	1	1	0	0	1	0
30	1	1	1	0	1	1
40	1	1	1	0	1	1
50	2	1	1	1	1	1
60	2	1	1	1	1	1
70	2	1	1	1	1	1
80	2	1	1	1	1	1
90	3	1	1	1	2	1
100	3	2	1	1	2	1

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9.9 Wrists

Table 9.9.1a and Table 9.9.1b assess impairments to range of motion of the wrists, including ankylosis.

Loss of range of motion in each functional range is measured from the neutral position. The range of motion is expressed as the two achievable limits of active motion in each direction through the normal range of motion. It is possible that the only motion that can be achieved is between two points on one side of the neutral position.

The WPI rating for restriction of motion in one direction is determined according to the active motion than can be achieved in that direction. It is then added to the WPI rating for the active motion in the reverse direction.

Add the abnormal motion WPI ratings for each direction of motion for both wrist flexion/extension and radial/ulnar deviation. Where there is ankylosis, including after an arthrodesis procedure, the assessment should be made only under the ankylosis scale.

Where an arthroplasty procedure has been undertaken, refer to the edition of the American Medical Association?s Guides to the Evaluation of Permanent Impairment current at the date of the assessment. Combine the total WPI rating for abnormal motion with the relevant WPI rating for arthroplasty, obtained from the American Medical Association?s Guides.

For ankylosis, the optimal position for arthrodesis of the wrist is approximately 15? -20? of dorsiflexion with slight ulnar deviation.

The maximum possible wrist impairment is 35% WPI.

For the same condition, a WPI rating from Table 9.9.1a or Table 9.9.1b may not be combined with a WPI rating from Table 9.14: Upper Extremity Function.

Table 9.9.1a: Wrist Flexion/Extension

Direction	Ankylosis	Loss of Extension	Loss of Flexion	Direction
Extension	%WPI	%WPI	%WPI	Extension
60?	25	0	25	60?
50?	22	1	22	50?
40?	17	2	15	40?
30?	16	3	13	30?
20?	14	4	10	20?
10?	13	5	8	10?
0?	13	7	6	0?
10?	13	8	5	10?
20?	15	11	4	20?
30?	17	14	3	30?
40?	20	18	2	40?
50?	23	22	1	50?
60?	25	25	0	60?
Flexion				Flexion

Table 9.9.1b: Radial and Ulnar Deviation of Wrist Joint

Direction	Ankylosis	Loss of Radial Deviation	Loss of Ulnar Deviation	Direction
Radial Deviation	%WPI	%WPI	%WPI	Radial Deviation
20?	11	0	11	20?
15?	10	1	9	15?
10?	8	1	7	10?
5?	7	2	5	5?
0?	5	2	3	0?
5?	5	3	2	5?
10?	5	3	2	10?
15?	7	5	2	15?
20?	8	7	1	20?
25?	10	9	1	25?
30?	11	11	0	30?
Ulnar Deviation				Ulnar Deviation

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9.10 Elbows

Table 9.10.1 and Table 9.10.1b assess impairments to range of motion of the elbows, including ankylosis.

Add the abnormal motion WPI rating for each direction of motion for both elbow flexion/extension and pronation/supination. Where there is ankylosis, including after an arthrodesis procedure, the assessment should be made only under the ankylosis scale.

For ankylosis, the optimal or functional position is 80? of flexion and 20? of pronation.

The maximum possible elbow impairment is 40% WPI.

For the same condition, a WPI rating from Table 9.10.1a or Table 9.10.1b may not be combined with a WPI rating from Table 9.14: Upper Extremity Function.

Table 9.10.1a: Elbow Flexion/Extension

Direction	Ankylosis	Loss of Extension	Loss of Flexion	Direction
Flexion	%WPI	%WPI	%WPI	Flexion
140?	25	25	0	140?
130?	23	22	1	130?
120?	20	19	1	120?
110?	19	16	2	110?
100?	16	13	4	100?
90?	15	10	5	90?
80?	13	7	6	80?
70?	14	5	9	70?
60?	15	4	11	60?
50?	17	3	14	50?
40?	19	2	16	40?
30?	20	2	19	30?
20?	22	1	20	20?
10?	23	1	22	10?
0?	25	0	25	0?
Extension				Extension

Table 9.10.1b: Pronation and Supination of Forearm

Direction	Ankylosis	Loss of Pronation	Loss of Supination	Direction
Supination	%WPI	%WPI	%WPI	Supination
80?	17	17	0	80?
70?	16	16	0	70?
60?	16	15	1	60?
50?	15	14	1	50?
40?	14	13	1	40?
30?	14	13	1	30?
20?	13	11	2	20?
10?	11	9	2	10?
0?	9	7	2	0?
10?	7	5	2	10?
20?	5	2	2	20?
30?	5	2	4	30?
40?	7	2	5	40?
50?	9	1	8	50?
60?	11	1	11	60?
70?	14	1	13	70?
80?	17	0	17	80?
Pronation				Pronation

9.11 Shoulders

Table 9.11.1a, Table 9.11.1b and Table 9.11.1c assess impairments to range of motion of the shoulders, including ankylosis.

Add the abnormal motion WPI ratings for each direction of motion for shoulder flexion/extension, abduction/adduction and internal/external rotation. Where there is ankylosis, including after an arthrodesis procedure, the assessment should only be made under the ankylosis scale.

For ankylosis, the optimal or functional position is 20? -40? of flexion, 20? -50? of abduction and 30? -50? of internal rotation. Unless the shoulder has been arthrodesed, an assessment for ankylosis under this table would be rare.

The maximum possible shoulder impairment is 35% WPI.

For the same condition, a WPI rating from Table 9.11.1a, Table 9.11.1b or Table 9.11.1c may not be combined with a WPI rating from Table 9.14: Upper Extremity Function.

Table 9.11.1a: Shoulder Flexion/Extension

Direction	Ankylosis	Loss of Extension	Loss of Flexion	Direction
Flexion	%WPI	%WPI	%WPI	Flexion
180?	18	18	0	180?
170?	18	17	1	170?
160?	17	17	1	160?
150?	17	16	1	150?
140?	17	16	2	140?
130?	17	15	2	130?
120?	17	14	2	120?
110?	17	14	3	110?
100?	16	13	3	100?
90?	16	13	4	90?
80?	15	11	4	80?
70?	13	9	4	70?
60?	12	7	5	60?
50?	10	5	5	50?
40?	9	3	6	40?
30?	9	3	6	30?
20?	9	2	7	20?
10?	11	2	10	10?
0?	14	2	13	0?
10?	15	1	14	10?
20?	16	1	14	20?
30?	16	1	16	30?
40?	17	1	17	40?
50?	18	0	18	50?
Extension				Extension

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Table 9.11.1b: Shoulder ? Internal/External Rotation

Direction	Ankylosis	Loss of External Rotation	Loss of Internal Rotation	Direction
External Rotation	%WPI	%WPI	%WPI	External Rotation
90?	7	0	7	90?
80?	7	0	7	80?
70?	7	0	7	70?
60?	6	0	6	60?
50?	6	1	5	50?
40?	5	1	5	40?
30?	5	1	5	30?
20?	5	1	4	20?
10?	5	1	4	10?
0?	4	1	3	0?
10?	4	1	3	10?
20?	4	1	2	20?
30?	4	1	2	30?
40?	4	2	2	40?
50?	4	2	1	50?
60?	4	3	1	60?
70?	5	5	1	70?
80?	6	6	0	80?
90?	7	7	0	90?
Internal Rotation				Internal Rotation

Table 9.11.1c: Abduction/Adduction of Shoulder

Direction	Ankylosis	Loss of Adduction	Loss of Abduction	Direction
Abduction	%WPI	%WPI	%WPI	Abduction
180?	11	11	0	180?
170?	11	11	0	170?
160?	10	10	1	160?
150?	10	10	1	150?
140?	10	9	1	140?
130?	10	9	1	130?
120?	10	8	2	120?
110?	10	8	2	110?
100?	10	7	2	100?
90?	10	7	2	90?
80?	8	5	3	80?
70?	7	4	3	70?
60?	7	3	3	60?
50?	5	2	3	50?
40?	5	2	3	40?
30?	5	1	4	30?
20?	5	1	7	20?
10?	7	1	6	10?
0?	8	1	7	0?
10?	9	1	8	10?
20?	10	1	9	20?
30?	10	1	10	30?
40?	10	0	10	40?
50?	11	0	11	50?
Adduction				Adduction

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9.12 Upper Extremity Amputations

Total loss of hand function is equivalent to amputation of the whole hand and attracts a WPI rating of 54%.

Table 9.14: Upper Extremity Function must not be used for amputations.

Table 9.12.1: Upper Extremity Amputations

% WPI	Criteria
54	Amputation of thumb and all fingers through metacarpals.
56	Amputation at wrist or between wrist and distal to bicipital insertion.
57	Amputation from distal to deltoid insertion to bicipital insertion.
60	Amputation of arm at deltoid insertion and proximally; or Amputation at shoulder.
70	Forequarter amputation.

Table 9.12.2: Amputation of Digits

%WPI	Thumb	Fingers	%WPI
%WPI	Thumb	Fingers	Index & Middle	Ring & Little
2	Tip of thumb excluding bone.	Tip of finger excluding bone.	1	1
7	Through distal phalanx.	Through distal phalanx.	3	2
11	Through IP joint.	Through distal IP joint.	5	3
17	Through proximal phalanx.	Through middle phalanx.	7	4
22	Through MP joint.	Through proximal IP joint.	8	4
22	Through distal third of 1^st metacarpal.	Through proximal phalanx.	10	5
23	At or near the CMC joint.	Through MP joint or metacarpal.	11	5

9.13 Neurological Impairments Affecting the Upper Extremities

Sensory impairments due to digital nerve lesions alone are assessed under Table 9.8.2a, Table 9.8.2b, Table 9.8.2c, and Table 9.8.2d (tables dealing with sensory losses in thumb and fingers).

Care must be taken to avoid duplicating impairment assessments for digital nerve sensory impairment with assessments for peripheral nerve sensory impairment. Assessments for digital nerve sensory impairment are assessed under Tables 9.8.2a, 9.8.2b, 9.8.2c, and 9.8.2d. Assessments for peripheral nerve sensory impairment are assessed under Tables 9.13.1, 9.13.2a, and 9.13.2b.

For sensory impairment in the same digit, WPI ratings obtained from Table 9.13.1, Table 9.13.2a, and Table 9.13.2b, must not be combined with WPI ratings from Tables 9.8.2a, 9.8.2b, 9.8.2c, and 9.8.2d.

The grading system set out in Figure 9-D: Grading System is to be used with Table 9.13.1, Table 9.13.2a, and Table 9.13.2b.

Figure 9-D: Grading System

See note immediately following Figure 9-D.

Grading

Sensory Deficits or Pain

Criteria

Motor Function

Criteria

No sensation;

Severe pain that prevents all activity.

No contraction.

No protective sensibility with abnormal sensations;

Severe pain that prevents most activity.

A flicker.

Decreased protective sensibility with abnormal sensations;

Severe pain that prevents some activity.

Active movement with gravity eliminated.

Diminished light touch AND two-point discrimination with some abnormal sensations;

Slight pain that interferes with some activity.

Active movement against gravity.

Diminished light touch with or without minimal abnormal sensations;

Pain that is forgotten during activity.

Active movement against gravity and resistance.

Normal sensation;

No pain.

Normal power.

Note to Figure 9-D

1. Figure 9-D also appears in Section 9.6 ? Spinal Nerve Root Impairments and Peripheral Nerve Injuries

Affecting the Lower Extremities, page 82, as Figure 9-C. It is repeated here for ease of reference.

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9.13.1 Cervical Nerve Root Impairment

Use the appropriate section of Table 9.13.1, depending on whether there is involvement of a

single spinal nerve, the brachial plexus, or combined nerve root impairment.

WPI ratings for sensory impairment should be combined with those for motor impairment, using the Combined Values Chart (see Appendix 1). Table 9.13.1 must not be used in conjunction with Table 9.15: Cervical Spine (see page 114) where the SAME nerve is assessed under that table.

The maximum WPI rating for one upper extremity is 60%. A WPI of 60% may be awarded either:

for complete brachial plexus sensory loss; or

brachial plexus motor loss;

but these cannot be combined to give a WPI rating greater than 60% for the one upper extremity.

Table 9.13.1: Cervical Nerve Root Impairment

	Single Nerve Involvement						Single Nerve Involvement
	Sensory Impairment						Motor Impairment
	Grading						Grading
	5	4	3	2	1	0	5	4	3	2	1	0
Nerve Root	% WPI						% WPI						Nerve Root
C5	0	1	1	2	3	3	0	2	7	11	15	18	C5
C6	0	1	2	4	5	5	0	4	8	13	18	21	C6
C7	0	1	1	2	3	3	0	4	8	13	18	21	C7
C8	0	1	1	2	3	3	0	5	11	16	23	27	C8
T1	0	1	1	2	3	3	0	2	5	7	10	12	T1

	Brachial plexus involvement or combined nerve root impairment						Brachial plexus involvement or combined nerve root impairment
	Sensory Impairment						Motor Impairment
	Grading						Grading
	5	4	3	2	1	0	5	4	3	2	1	0
Nerves or Nerve Roots	% WPI						% WPI						Nerves or Nerve Roots
Complete Brachial Plexus (C5 to T1 Inclusive)	0	12	24	42	54	60	0	12	24	36	51	60	Complete Brachial Plexus (C5 to T1 Inclusive)
Upper Trunk of Brachial Plexus (C5, C6, Erb-Duchenne)	0	3	6	11	14	15	0	9	18	27	38	45	Upper Trunk of Brachial Plexus (C5, C6, Erb-Duchenne)
Middle Trunk of Brachial Plexus (C7)	0	1	1	2	3	3	0	4	8	13	18	21	Middle Trunk of Brachial Plexus (C7)
Lower Trunk of Brachial Plexus (C8, T1, D?jerine-Klumpke)	0	2	5	8	11	12	0	8	17	25	36	42	Lower Trunk of Brachial Plexus (C8, T1, D?jerine-Klumpke)

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9.13.2 Specific Nerve Lesions Affecting the Upper Extremities

Only employees with an objectively verifiable diagnosis qualify for a WPI rating under Table 9.13.2a and Table 9.13.2b (both on following page). The diagnosis is made not only on credible and clinically logical symptoms but, more importantly, on the presence of positive clinical findings and loss of function. The diagnosis should be documented by electromyography as well as sensory and motor nerve conduction studies. As noted under the Principles of Assessment, the assessing medical practitioner should not order additional investigations solely for assessment purposes.

It is critical to understand that there is no correlation between the severity of conduction delay on nerve conduction velocity testing, and the severity of either symptoms or the WPI rating.

If available, surgical findings of evidence of nerve compression and reactive hyperaemia upon nerve release can be used to confirm the diagnosis.

Using the Combined Values Chart (see Appendix 1), WPI ratings obtained for sensory impairment should be combined with WPI ratings for motor impairment.

A WPI rating under Tables 9.13.2a and 9.13.2b may be combined (except where the SAME nerve is assessed) with WPI ratings from Table 9.15: Cervical Spine.

Table 9.13.2a: Specific Nerve Lesions Affecting the Upper Extremities ? Sensory Impairment

	Grading
	5	4	3	2	1	0
Nerve	% WPI
Axillary	0	1	1	2	3	3
Medial antebrachial cutaneous	0	1	1	2	3	3
Medial brachial cutaneous	0	1	1	2	3	3
Median nerve (above mid forearm)	0	5	9	16	21	23
Median nerve (below mid forearm)	0	5	9	16	21	23
Radial palmar digital of thumb	0	1	2	3	4	4
Ulnar palmar digital of thumb	0	1	3	5	6	7
Radial palmar digital of index finger	0	1	1	2	3	3
Ulnar palmar digital of index finger	0	0	1	1	2	2
Radial palmar digital of middle finger	0	1	1	2	3	3
Ulnar palmar digital of middle finger	0	0	1	1	2	2
Radial Palmar digital of ring finger	0	0	1	1	2	2
Musculocutaneous	0	1	1	2	3	3
Radial (including loss of triceps function)	0	1	1	2	3	3
Radial (at elbow with sparing of triceps)	0	1	1	2	3	3
Suprascapular	0	1	1	2	3	3
Ulnar (above mid forearm)	0	1	2	3	4	4
Ulnar (below mid forearm)	0	1	2	3	4	4
Ulnar palmar digital of ring finger	0	0	0	1	1	1
Radial palmar digital of little finger	0	0	0	1	1	1
Ulnar palmar digital of little finger	0	0	1	1	2	2

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Table 9.13.2b: Specific Nerve Lesions Affecting the Upper Extremities ? Motor Impairment

	Grading
	5	4	3	2	1	0
Nerve	% WPI
Medial and lateral pectoral	0	1	1	2	3	3
Axillary	0	4	8	13	18	21
Dorsal scapular	0	1	1	2	3	3
Long thoracic	0	2	4	5	8	9
Median nerve (above mid forearm)	0	5	10	16	22	26
Median nerve (anterior interosseous branch)	0	2	4	5	8	9
Median nerve (below mid forearm)	0	1	2	4	5	6
Musculocutaneous	0	3	6	9	13	15
Radial (including loss of triceps function)	0	5	10	15	21	25
Radial (at elbow with sparing of triceps)	0	4	8	13	18	21
Subscapulars (upper and lower)	0	1	1	2	3	3
Suprascapular (upper and lower)	0	2	4	6	9	10
Thoracodorsal	0	1	2	4	5	6
Ulnar (above mid forearm)	0	6	11	17	24	28
Ulnar (below mid forearm)	0	4	8	13	18	21

9.13.3 Complex Regional Pain Syndromes (CRPS)

Complex Regional Pain Syndromes (CRPS) include Reflex Sympathetic Dystrophy (CRPS I), and Causalgia (CRPS II). The hallmark of these syndromes is a characteristic burning pain that is present without stimulation or movement, that occurs beyond the territory of a single peripheral nerve, and that is disproportionate to the inciting event. The pain is associated with specific clinical findings, including signs of vasomotor and sudomotor dysfunction and, later, trophic changes of all tissues from skin to bone.

Sympathetic nervous system dysfunction was thought to be involved in the generation of the symptoms and signs; hence, the term reflex sympathetic dystrophy (RSD). Causalgia was considered similar to RSD except, unlike RSD, it followed a lesion of a peripheral nerve, either of a major mixed nerve in the proximal extremity (major causalgia) or of a purely sensory branch more distally (minor causalgia). A recent reconsideration of these syndromes has generated new terminology and ideas concerning the underlying pathophysiology. The International Association for the Study of Pain has proposed the term complex regional pain syndromes, which has replaced the term RSD with CRPS I and causalgia with CRPS II. The most important difference from earlier opinions is that sympathetic dysfunction is not assumed to be the underlying basis for the symptoms and signs of CRPS. It is felt that sympathetically maintained pain is not an essential component of CRPS, as it may be present in a variety of painful conditions, including or independent of CRPS.

Contrary to previous suggestions, regional sympathetic blockade has no role in the diagnosis of CRPS.

Since a subjective complaint of pain is the hallmark of these conditions, and many of the associated physical signs and radiographic findings can be the result of disuse, the differential diagnosis is extensive; it includes somatoform pain disorder, somatoform conversion disorder, factitious disorder, and malingering. Consequently, the approach to the diagnosis of these syndromes should be conservative and based on objective findings.

The criteria listed in Figure 9-E predicate a diagnosis of CRPS upon a preponderance of objective findings that can be identified during a standard physical examination and demonstrated by radiographic techniques. At least eight of these findings must be present concurrently for a diagnosis of CRPS. Signs are objective evidence of disease perceptible to the examiner, as opposed to symptoms, which are subjective sensations of the individual.

Use the methodology to determine impairment. Use either Steps in CRPS I (RSD) Impairment Determination or Steps in CRPS II (Causalgia) Impairment Determination as appropriate. Only one of the methodologies may be used and the impairment rating from one of the two methodologies may not be combined with one from the other methodology.

The impairment rating method described for sensory deficits due to lesions of digital nerves is not applied in CRPS.

Figure 9-E: Objective Diagnostic Criteria for CRPS (RSD and causalgia)

Local clinical signs

Vasomotor changes:

Skin colour: mottled or cyanotic

Skin temperature: cool

Oedema

Sudomotor changes:

Skin dry or overly moist

Trophic changes:

Skin texture: smooth, nonelastic

Soft tissue atrophy: especially in fingertips

Joint stiffness and decreased passive motion

Nail changes: blemished, curved, talonlike

Hair growth changes: fall out, longer, finer

Radiographic signs

Radiographs: trophic bone changes, osteoporosis

Bone scan: findings consistent with CRPS

Interpretation:

e 8 Probable CRPS

< 8 No CRPS

Notes to Figure 9-E

1. Modified and adapted from Ensalada LH, ?Complex regional pain syndrome?, in Brigham CR, ed, The Guides Casebook, Chicago, Ill: American Medical Association, 1999, 14.

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Figure 9-F: Impairment Grading for CRPS

CRPS I & II	Sensory deficits and pain	CRPS II	Motor deficits and loss of power
Grade (see Fig 9-C)	% of upper extremity impairment	Grade (see Fig 9-D)	% of upper extremity impairment
5	0	5	0
4	1-25	4	1-25
3	26-60	3	26-50
2	61-80	2	51-75
1	81-99	1	76-99
0	100	0	100

Steps in CRPS I (RSD) Impairment Determination

In CRPS I, neither the initiating causative factor nor the symptoms involve a specific peripheral nerve structure or territory. If the diagnostic test in Figure 9-E is satisfied, the impairment assessment is derived as follows

Step 1	Assess the WPI for the affected upper extremity using Tables 9.8 to 9.11 as appropriate.
Step 2	Convert the WPI rating from Step 1 to an upper extremity impairment rating (divide by 0.6).
Step 3	Assess the appropriate percentage impairment of the affected extremity resulting from sensory deficits and pain according to the grade that best describes the severity of interference with activities as described in Figure 9-D (page 101). Use clinical judgment to select the appropriate severity grade from Figure 9-D and the appropriate percentage from within the range for each grade shown in Figure 9-F and explain the reasons for that selection. The maximum value is not automatically applied.
Step 4	Combine the impairment rating for sensory deficits and pain obtained from Step 3 with the rating obtained from Steps 1 and 2.
Step 5	Convert the combined rating to a WPI rating (multiply by 0.6).

In contrast to CRPS II, impairment values for sensory and motor deficits of a specific nerve structure cannot be applied.

Steps in CRPS II (Causalgia) Impairment Determination

In CRPS II, a specific sensory or mixed nerve structure is involved. If the diagnostic test in Figure 9-E is satisfied, the impairment assessment is derived as follows.

Step 1	Assess the WPI for the affected upper extremity using Tables 9.8 to 9.11 as appropriate.
Step 2	Convert the WPI rating from Step 1 to an upper extremity impairment rating (divide by 0.6)
Step 3	Assess the appropriate percentage impairment of the affected extremity resulting from sensory deficits and pain of the injured nerve(s) according to the grade that best describes the severity of interference with activities as described in Figure 9-D. Use clinical judgment to select the appropriate severity grade from Figure 9-D and the appropriate percentage from within the range for each grade shown in Figure 9-F and explain the reasons for that selection. The maximum value is not automatically applied.
Step 4	Assess the appropriate percentage impairment of the affected extremity resulting from motor deficits and loss of power of the injured nerve(s) according to the grade that best describes the severity of interference with as described in Figure 9-D. Use clinical judgment to select the appropriate severity grade from Figure 9-D and the appropriate percentage from within the range for each grade shown in Figure 9-F and explain the reasons for that selection. The maximum value is not automatically applied.
Step 5	Combine the impairment ratings for sensory deficits and pain (Step 3), and for motor deficits and loss of power (Step 4), with the rating obtained from Steps 1 and 2.
Step 6	Convert the combined rating to a WPI rating (multiply by 0.6). Severe CRPS II may result in complete loss of function and in impairment of the extremity as great as 100%.

9.14 Upper Extremity Function

Before using Table 9.14 the medical assessor should read the instructions (see Part II ? Introduction) preceding the specific joint impairment tables (Tables 9.8?9.11). Table 9.14 is used strictly in accordance with those instructions.

Table 9.14 is an alternative table, which may be used instead of the specific orthopaedic or neurological table or tables. It is important to note that Table 9.14 assesses the function of the entire upper extremity. Consequently, for the purposes of ascertaining the most beneficial WPI rating for the same upper extremity, any assessment under Table 9.14 for a single upper extremity may be compared only with the total or combined impairment obtained after using other tables in Chapter 9, Part II ? The Upper Extremities.

For the purposes of ascertaining the most beneficial WPI rating, Table 9.14 may not be compared with single impairments under the other tables, unless there are no other impairments affecting the upper extremities.

At least one major criterion, and at least two minor criteria (where listed), must be satisfied for a WPI rating to be assigned under Table 9.14. Where possible, the major criteria should be assessed on the basis of neurological examination of motor strength, co-ordination and dexterity. Where possible, functional activities should be assessed by observation of the specified activities.

Table 9.14 should be used only to assess impairment from objectively identified orthopaedic or neurological conditions arising in, and affecting, the upper extremities.

While it is true that disuse secondary to pain may produce secondary dysfunction of the upper extremities, this must not be assessed using Table 9.14 unless this dysfunction is permanent (that is, not likely to improve as a result of surgery, medication or other rehabilitative treatment) and there are objective clinical findings that can be validly assessed using other tables in Chapter 9, Part II ? The Upper Extremities..

Table 9.14 must not be used for amputations.

Where one limb only is affected, regardless of the number of impairments found in that limb, the limb should be assessed using the relevant Tables other than 9(14) and all impairments combined using the Combined Values Table. The combined impairment rating should then be compared to the rating taken from the relevant (Non dominant or dominant) column in 9(14) and the higher rating obtained from the two methods chosen.

Where both limbs are affected, each limb should be assessed using the Tables other than 9(14) and all impairments in both limbs combined using the Combined Values Table. The combined impairment rating should then be compared to the rating taken from the ?Both extremities? column in Table 9(14) and the higher rating obtained from the two methods chosen.

Table 9.14 may be used to assess upper extremity impairment arising as a result of spinal cord damage. Observe the special procedure set out in the introduction to Part III of this Chapter. However, Table 9.14 is not to be used to assess upper extremity impairment arising as a result of nerve root compression, or other neurological sequelae of cervical spinal conditions. These should be assessed under Table 9.13.1, Table 9.13.2a and Table 9.13.2b (tables dealing with neurological impairments affecting the upper extremities).

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Table 9.14 Upper Extremity Function

% WPI	% WPI	% WPI	MAJOR CRITERIA (at least one required)	MINOR CRITERIA (at least two required where listed)
Non-Dominant Extremity	Dominant Extremity	Both Extremities	MAJOR CRITERIA (at least one required)	MINOR CRITERIA (at least two required where listed)
0	0	0	Normal digital dexterity. No limitations in use of extremity for personal care.	Writes 2 A4 pages or more at one time. Can lift more than 30 kilograms (males). Can lift more than 20 kilograms (females). Able to lace shoes easily. Joins paper clips without difficulty.
3	5	10	Minor loss of digital dexterity. Minor limitations in use of extremity for personal care.	Rests after writing an A4 page. Cannot lift more than 30 kilograms (males). Cannot lift more than 20 kilograms (females). Finds it difficult to do up shoelaces. Fumbles when joining paper clips.
8	10	20	Moderate loss of digital dexterity. Moderate limitations in use of extremity for personal care.	Rests after writing half an A4 page. Cannot lift more than 10 kilograms. Cannot do up shoelaces. Cannot join paperclips. Dresses slowly unassisted.
15	20	35	Major loss of digital dexterity. Major restrictions in personal care.	Rests after writing 50 words or less. Cannot lift more than 3 kilograms. Cannot put on a tie or belt. Needs assistance to cut up food. Needs some assistance to dress.
25	30	50	Little useful digital co-ordination. Severely limited use of extremity for personal care.	Rests after writing 10 words or less. Cannot lift more than 0.5 kilograms. Constantly drops light objects (eg, cups). Unable to cut up food. Needs extensive assistance to dress.
30	40	60	No co-ordination of digits. Severely limited use of extremity for personal care.	Unable to sign name. Constantly needs a splint to write or eat. Unable to lift light objects. Needs food placed in mouth to eat. Unable to dress without assistance.
40	50	70	Minimal extremity movement against gravity. Cannot use extremity for personal care.	Cannot use extremity to eat. Cannot bring a pen to paper. Cannot raise extremity to assist dressing.
60	60	84	Unable to use upper extremity at all.