A-3, r. 2 - Regulation respecting the impairment scale

Updated to 1 September 2012

This document has official status.

chapter A-3, r. 2

Regulation respecting the impairment scale

Workers’ Compensation Act

(chapter A-3, s. 124, par. m).

Subject to the following paragraph, chapter A-3 is replaced by the Act respecting industrial accidents and occupational diseases (chapter A-3.001) (1985, c. 6, s. 476).

The Workers’ Compensation Act (chapter A-3), amended by sections 479 to 483 of the Act respecting industrial accidents and occupational diseases (chapter A-3.001) and the regulations made under chapter A-3, remain in force:

(1) for the purposes of the processing of claims made for industrial accidents and deaths that occurred before 19 August 1985 and for claims made before that date for occupational diseases, except in the case of a recurrence, relapse or aggravation contemplated in the first paragraph of section 555 of chapter A-3.001;

(2) for the purposes of every classification of industries and employers’ assessment carried out for a year prior to 1986, subject to sections 580 and 581 of chapter A-3.001;

(3) for the purposes of the application of the Act to promote good citizenship (chapter C-20) and the Crime Victims Compensation Act (chapter I-6).

1. In this Regulation, unless the context indicates otherwise,

“accident victim” means a worker who is the victim of an accident, occupational disease, or aggravation within the meaning of the Workmen’s Compensation Act (chapter A-3);

“impairment” means the medically established sequelae, including disfigurements, of an injury that adversely affect an accident victim’s physical or psychic integrity;

“major deterioration” means a sequela referring to wide, discoloured or hyperpigmented scars caused by lacerations, burns or a considerable loss of tissue;

“disfigurement” means a noticeable sequela, other than functional damage, on the face, neck or other part of the body in the case of major deterioration covering more than 3% of the surface area of the body and constituting a loss of physical integrity. However, linear scars, whether surgical or nonsurgical, on any part of the body, including scars of the face and neck oriented in the direction of the lines of tension of the skin, are excluded.

O.C. 1948-82, s. 1.

2. The impairment percentage of an accident victim whose physical integrity is adversely affected is determined in accordance with Titles I to XI of Schedule A.

However, for an injury not listed in Titles I to X of that Schedule, the evaluation is made by comparing the injury to similar injuries listed in the Scale.

O.C. 1948-82, s. 2.

3. The evaluation of the percentage of an impairment other than a disfigurement is made upon the healing of the wound, taking into account the nature and the functional consequences of the injury, and the effectiveness of the prosthesis or orthesis, but disregarding the socio-occupational consequences that the sequelae of the injury may entail for the accident victim.

O.C. 1948-82, s. 3.

4. The impairment percentage of an accident victim with multiple injuries other than disfigurements is determined by totalling the percentages prescribed for each impairment resulting from those injuries.

However, the sum of those percentages may not exceed the percentage prescribed for a segment, an extremity or the individual as a whole.

O.C. 1948-82, s. 4.

5. The overall impairment percentage granted to an accident victim with nondisfiguring injuries to symmetrical organs is determined by totalling the percentages of the impairments resulting from each injury and by adding the lowest of those percentages thereto.

Where an accident victim is already handicapped because of a previous accident, a congenital disability or a pathological condition, the sequelae of the previous injury are evaluated exclusively for the purpose of the computation referred to in the preceding paragraph.

O.C. 1948-82, s. 5.

6. Disfigurement is evaluated by taking into account the percentages set down in Title XI or the table of body surfaces in the Rule of 9.

O.C. 1948-82, s. 6.

7. The noticeable multiple injuries of an accident victim resulting in disfigurement are globally evaluated for each of the anatomical regions listed in Title XI.

The global percentage granted is obtained by totalling the percentages granted for each of the anatomical regions involved.

O.C. 1948-82, s. 7.

8. Despite section 5, no enhancement factor for the disfigurement percentage is granted for bilateral injuries or where symmetrical body areas are affected.

O.C. 1948-82, s. 8.

9. Disfigurement is evaluated within a 12-month period after the accident victim’s condition has stabilized.

The percentage is set on the basis of:

(1)  the state of the injury at the time of the evaluation, or

(2)  the improvement anticipated, taking into account the possibilities of medicine or surgery.

O.C. 1948-82, s. 9.

10. The percentage granted for impairment, including disfigurement, applies to the whole body of the accident victim and may not exceed 100%.

O.C. 1948-82, s. 10.

11. This Regulation replaces Regulation respecting the impairment table (R.R.Q., 1981, c. A-3, r. 3).

O.C. 1948-82, s. 11.

12. (Omitted).

O.C. 1948-82, s. 12.

SCHEDULE A

IMPAIRMENT SCALE

TITLE I

MUSCULO-SKELETAL SYSTEM, EXCLUDING MAXILLAE AND FACE

(A) UPPER EXTREMITIES AND SHOULDER GIRDLE

(a) interscapulothoracic disarticulation: – 80%

(b) amputations, arm and forearm

(anatomic or physiological loss)

— disarticulation at the shoulder and amputation near the shoulder where fitting of prosthetic device is difficult: – 70 to 80%

— amputation at the middle third of the arm, disarticulation at the elbow or amputation near the elbow: – 60%

— amputation at the middle third of the forearm or disarticulation at the wrist: – 55%

(c) clavicle and scapula

— fracture without sequelae: – 0%

— fracture with deformity: – 1 to 2%

— complete sterno-or acromioclavicular dislocation with or without resection: – 3%

(d) humerus

— consolidated fracture with axial deviation of

i. 5 ° to 15 °: – 3%

ii. more than 15 °: – 5%

— consolidated fracture with shortening of

i. 3 to 4 cm: – 3%

ii. more than 4 cm: – 5%

(e) shoulder (neutral position 0 ° arm along the body)

Articular and para-articular injuries

— ankylosis: permanent limitation of movements following the destruction of scapulohumeral articular surfaces

i. total ankylosis without movement of the scapula: – 35%

ii. glenohumeral fusion, in position of function and with a gliding scapula: – 20%

Ankylosis due to periarthritis or adhesive capsulitis are evaluated according to the maximum recovery or the recovery expected 12 to 18 months following the accident.

— partial ankylosis

i. with movement limited to 90 ° (painful and combined limitation of all movements, including rotations): – 5 to 20%

ii. forward elevation considered separately, limited to 90 °: – 5%

iii. abduction considered separately, limited to 90 °: – 8%

(f) biceps

— musculotendinous rupture: – 2%

(g) elbow (neutral position 0 °; forearm extended over arm)

— fracture

i. fracture of the radial head, resection (without limitation): – 3 to 5%

ii. coronoid intra-articular fracture (without limitation): – 1%

Other fractures will be evaluated according to the degree of functional sequelae.

ankylosis

i. total ankylosis in position of function between 60 ° and 110 °: – 20%

ii. partial ankylosis at the final stage of functional recovery or recovery expected 12 months following the accident:

extension limitation

between 10 ° and 20 °: – 2 to 5%

between 20 ° and 45 °: – 5 to 8%

flexion limitation

between 90 ° and 110 °: –2 to 5%

(h) forearm

— consolidated fracture with considerable axial deviation: – 3 to 5%

— resection of the distal end of the cubitus: – 2%

— Colles’ fracture without stiffness or complications: – 1 to 3%

— complete loss of pronation and supination in position of function: – 10%

— total or partial loss of pronation only: – 1 to 3%

— total or partial loss of supination only: 2 to 5%

Consolidated fractures without deformity are evaluated according to function.

(i) wrist (neutral position 0 °, hand in the axis of the arm, thumb extended upwards)

— total ankylosis of wrist in position of function — 0 ° to 10 ° dorsiflexion: – 12.5%

— fracture of scaphoid or semilunar (pseudarthrosis, aseptic necrosis) according to functional loss of the wrist at the final stage of recovery or of the recovery expected 12 to 18 months after the date of the accident: – 3 to 6%

(j) hand

With the exception of the thumb, where 2 or more fingers are completely or partially amputated, the impairment percentage of those fingers is obtained by adding the impairment percentage of each of the fingers and multiplying by 2.

Furthermore, where there is amputation or equivalent thereof of 4 fingers of the same hand, 0.2% is added for each of the 2 distal phalanges and 0.1% for the proximal phalanx.

Where the thumb is also amputated, its impairment percentage is added to the impairment percentage of the amputated finger together with the enhancement factor of the lesser of the 2 if only one finger is amputated. The percentage for the amputated thumb is added without the enhancement factor if several fingers are amputated.

N.B.: Hand already subjected to a previous amputation or equivalent thereof.

Where a person’s hand was already impaired at the time of the accident, the above rules apply. The sequelae relating to the previous accident are evaluated only in order to establish whether they warrant an enhancement factor and are not included in the addition of the impairment percentages attributed to the recent sequelae.

— whole hand: – 55%

— last 4 fingers only: – 35%

— thumb only: – 15%

— amputation (anatomic or functional loss)

i. metacarpals: – first: – 10%

– 2nd or 3rd: – 4%

– 4th or 5th: – 3%

ii. thumb – 1 phalanx: – 10%

– 2 phalanges: – 15%

iii. index finger: – 1 phalanx: – 2%

– 2 phalanges: – 4%

– 3 phalanges: – 5%

iv. middle finger: – 1 phalanx: – 1.6%

– 2 phalanges: – 3.2%

– 3 phalanges: – 4%

v. ring finger: – 1 phalanx: – 1.2%

– 2 phalanges: – 2.4%

– 3 phalanges: – 3%

vi. little finger: – 1 phalanx: – 0.8%

– 2 phalanges: – 1.6%

– 3 phalanges: – 2%

vii. 4 fingers: – 35%

viii. 1st, 2nd and 3rd (index, middle and ring): – 24%

ix. 1st, 2nd and 4th (index, middle and auricular): – 22%

x. 1st, 3rd and 4th (index, ring and auricular): – 20%

xi. 2nd, 3rd and 4th (middle, ring and auricular): – 18%

xii. 1st and 2nd (index and middle): – 18%

xiii. 1st and 3rd (index and ring): – 16%

xiv. 1st and 4th (index and auricular): – 14%

xv. 2nd and 3rd (middle and ring): – 14%

xvi. 2nd and 4th (middle and auricular): – 12%

xvii. 3rd and 4th (ring and auricular): – 10%

xviii. 2 or more, at the 2nd articulation: 4/5 of the above values

xvix. 2 or more, at the distal articulation: 2/5 of the above values

— ankylosis

i. thumb

(a) total ankylosis of 2 articulations: – 7.5%

(b) ankylosis of metacarpophalangeal joint: – 3%

(c) ankylosis of interphalangeal joint: – 2.5%

(d) partial ankylosis: according to functional loss

ii. finger

All articulations: the impairment is based on the loss of the functional value of the finger.

Where ankylosis in a faulty position is equivalent to an amputation of one or several phalanges and affects several fingers on the same hand, the table for simple or multiple amputation applies.

(B) PELVIS

(a) simple fracture of the pelvis without diastasis of the pubic symphysis, without sacro-iliac injury and without injury to the acetabulum: – 0%

(b) fracture of the pelvis with deformity, public dislocation or sacro-iliac injury: – 0 to 10%

(c) fracture with acetabular injury (an enhancement factor based on the functional injury to the coxofemoral joint must also be taken into consideration): – 2 to 5%

(d) fracture of the pelvis with osseous dystocia (gynaecological evaluation): – 4%

(e) hemipelvectomy: – 80%

Visceral injuries are evaluated by specialist examinations.

(C) LOWER EXTREMITIES (anatomic or physiological loss)

(a) amputations

— thigh

i. disarticulation at the hip or amputation near the hip within 10 cm from the end of the greater trochanter (fitting of prosthetic device difficult): – 70 to 80%

ii. amputation at the middle third of the thigh: – 55%

— leg

i. disarticulation of the knee, transcondylar and other amputations (e.g. Gritti-Stokes): – 45%

ii. amputation at the middle third of the leg: – 35%

— foot

i. Syme’s amputation: – 30%

ii. across the foot: – 15 to 25%

— toes

i. great toe: – 4%

ii. great toe – one phalanx: – 2%

iii. second toe: – 1%

iv. third or fourth toe: – 1%

v. fifth toe: – 1%

vi. all 5 toes: – 8%

— metatarsal bones

Amputation of the distal end of the 1st and 5th metatarsal bones or consolidated fracture of the 1st and 5th metatarsal bones with faulty angulation of the fragments: – 12%

(b) shortening of the leg by

— 2 cm to 2.5 cm: – 1.5 to 2%

— 2.5 cm to 5 cm: – 2 to 6%

— 5 cm to 6.5 cm: – 6 to 8%

— 6.5 cm to 8 cm: – 8 to 12%

— 8 cm to 10 cm: – 12 to 20%

(c) hip (neutral position 0 °; thigh extended over the pelvis)

In the case of traumatic lesions of the hip, a 2-year wait is necessary to allow for later complications even when the immediate result is satisfactory.

— dislocation without complications: – 5%

— fragmentation fracture of the head or neck of the femur without acetabular injury and without functional disorder: – 5%

— complicated lesions of the hip entailing

i. total ankylosis (0 ° to 20 ° flexion, slight abduction and external rotation of a few degrees) – according to the quality of the ankylosis: – 25 to 35%

ii. partial ankylosis (joint stiffness), according to the loss of movements and inconveniences resulting therefrom: – 5 to 20%

iii. replacement of the hip with a prosthesis (75% movement, without pain) – according to the degree of ankylosis or joint stiffness: – 25% and over

(d) femur

— fracture without sequela: – 0%

— fracture without functional sequela but with intervening sequelae and atrophy: – 0 to 3%

— consolidation with range of angulation from 8 ° to 15 ° and rotation on the axis:– 3 to 10%

— major permanent muscular atrophy: – 3 to 5%

(e) knee the range of knee motion from full extension is from 0 ° to 130 °.

Evaluation is made after recovery (12 to 18 months after the accident)

— fracture of the tibial plateau (without major functional disorder – according to ankylosis, varus or valgus): – 3 to 8%

— meniscectomy

i. good result, one meniscus: – 2%

ii. good result, both menisci: – 5%

— patellectomy

i. partial: – 1 to 5%

ii. total: – 7%

— fracture of the patella

i. without functional disorder: – 0 to 2%

ii. with functional disorder – according to joint stiffness.

— tendinous rupture: – 0 to 3%

— osseous ankylosis in extension or slight flexion of 10 °: – 20%

— partial ankylosis (joint stiffness)

i. limited to 90 ° – according to the resulting inconvenience: – 8%

ii. flexion limited to 35 °: – 10%

iii. 5 ° to 10 ° in recurvatum (extension limitation): – 3%

iv. 10 ° to 15 ° in recurvatum: – 3 to 5%

v. 15 ° to 20 ° in recurvatum: – 5 to 10%

— functional disorders, instability of the knee up to the point of requiring an orthesis: – 3 to 20%

— arthroplasty (according to function): – 25% and over

— fracture of both bones of the leg

i. without sequelae: – 0 to 2%

ii. modification of the adult axis: – 2 to 8%

(f) ankle

— tibiotarsal fracture (without major stiffness)

i. simple sprain or isolated fracture of the external malleolus: – 0 to 2%

ii. isolated fracture of the internal melleolus

(a) without diastasis: – 0 to 2%

(b) with diastasis or pseudarthrosis: – 2 to 5%

iii. fracture of both malleoli

(a) without diastasis: – 2 to 3%

(b) with diastasis: – 3 to 6%

— fracture of the foot

i. astragalus

(a) slight sequelae: – 2%

(b) moderate sequelae: – 4 to 5%

ii. calcaneus

(a) tuberosity or fracture without displacement or joint involvement: – 2%

(b) with joint involvement or displacement: – 3 to 8%

iii. midtarsal region

scaphoid, cuboid, cuneiforms: – 0 to 5%

(g) ankle and foot: arthrodesis and ankylosis

— tibiotarsalar joint – in position of function (maximum plantar-flexion of 0 ° to 5 °): – 12%

— subtalar joint only – in good position: – 5 to 8%

— subtalar and midtarsal joints (triple arthrodesis): – 12 to 18%

— subtalar and tibiotarsal joints: – 15 to 20%

— tarsometatarsal joint: – 3 to 6%

— great toe at metatarsophalangeal joint (along the axis of the 1st metatarsal bone): – 2.5%

— interphalangeal joint – great toe: – 1%

— other toes: – 0.5%

(D) SPINE

(a) the bone structure of the spine: – 70% of the whole person

(b) the cervical spine: – 40% of the whole person

(c) the dorsolumbar spine: – 40% of the whole person

N.B. Vertebral pathology where instability persists, neurological disorders and functional sequelae with major restrictions of the spine with respect to effort are evaluated as follows:

(1) the degree of impairment suggested for bone fusions is calculated with an enhancement factor which must be justified by the evaluating physician.

(2) every complex case with neurological or other disorders is evaluated following a joint examination in the specializations concerned.

Such pathology is due especially to complicated lesions which are not described specifically in this Scale and which usually exceed a 50% sagging of a vertebral body.

(E) CERVICAL SPINE

(a) cervical sprain without radiologically visible lesions but with painful sequelae that are objectively verifiable: – 2%

(b) stable fragmental fracture without major disorder: – 3%

(c) fracture of one or 2 vertebrae with luxation or subluxation, without neurological disorder, with or without injury to the posterior arch and lateral masses: – 8 to 15%

(d) open reduction and fusion of 2 vertebral bodies

— anterior approach: – 5 to 10%

— posterior approach: – 15 to 20%

— C-1, C-2 – ankylosis or grafting with loss of rotation: – 20%

(e) open reduction and fusion of 3 vertebral bodies

— anterior approach: – 12 to 20%

— posterior approach: – 15 to 25%

(f) operated herniated cervical disc, with or without fusion (Cloward)

— cervical discoidectomy – 1 level: – 5 to 10%

— cervical discoidectomy – 2 levels: – 8 to 12%

(F) DORSAL SPINE

(a) severe thoracodorsal trauma (including the sternum and ribs)

— without immediate radiologically visible traumatic lesions but followed by osteoarthritic phenomena or aggravation of a prior pathological condition: – 2 to 5%

— with radiologically visible lesions and intercostal neuralgia: – 5 to 10%

(b) stable fracture of one vertebral body, without neurological disorder

— less than 25% of the vertebral body: – 2 to 5%

— more than 25% but less than 50% of the vertebral body: – 5 to 8%

(c) fracture of 2 vertebral bodies without neurological disorder

— less than 25% of the vertebral body: – 5 to 8%

— more than 25% but less than 50% of the vertebral body: – 8 to 12%

(G) DORSOLUMBAR SPINE

(a) stable fracture of D-12 or L-1, without neurological disorder

— less than 25% of the vertebral body: – 5 to 10%

— more than 25% but less than 50% of the vertebral body: – 10 to 15%

(b) stable fracture of D-12 and L-1, without neurological disorder

— less than 25% of the vertebral body: – 8 to 18%

— more than 25% but less than 50% of the vertebral body: – 15 to 25%

(H) LUMBAR SPINE

(a) fracture of one vertebra

— less than 25% of the vertebral body: – 2 to 5%

— more than 25% but less than 50% of the vertebral body: – 5 to 10%

(b) more than one vertebra

— less than 25% of the vertebral body: – 4 to 8%

— more than 25% but less than 50% of the vertebral body: – 8 to 15%

(c) lumbar discoidectomy

— 1 level: – 5 to 8%

— 2 levels: – 10 to 15%

(d) lumbar fusion (with or without discoidectomy)

— 1 space (with or without discoidectomy): – 8 to 12%

— 2 spaces (with or without discoidectomy): – 12 to 20%

— more than 2 spaces (with or without discoidectomy): – 15 to 25%

(e) fracture of a spinous process, transverse process, fragmental fractures due to avulsion, pseudarthrosis: – 0 to 2%

(f) sprain without radiologically visible lesions but with objectively verifiable painful sequelae: – 2%

(g) chronic coccygodynia with or without coccygectomy: – 1%

(h) chemonucleolysis

— 1 space: – 2%

— more than one space: – 1% per extra space

i. laminectomy or exploration without discoidectomy

— per level: – 3%

TITLE II

CENTRAL AND PERIPHERAL NERVOUS SYSTEM

(A) CRANIOCEREBRAL TRAUMA

(a) cerebral concussion or contusion

— no identifiable or measurable residuals; subjective symptoms only: – 0 to 5%

— where, in spite of a particularly prolonged coma with brain stem injury, no signs of organic neurological impairment exist, psychological or psychiatric evaluation is used in establishing permanent impairment

— residuals, where they exist, are evaluated in accordance with the pertinent scale (see B and C under this Title)

(b) skull fractures

— linear without displacement: – 1 to 2%

— with recess, with or without a depressed fracture of the skull, without duramatral teartion

i. requiring elevation by trepanation: – 1 to 3%

ii. in case of craniectomy and plastic surgery – according to localization and extent: – 2 to 7%

— with recess and cortico-duramatral lacerations, whether or not complicated by sinus lacerations and extrusion of brain matter

Objective neurological sequelae are compensated in accordance with the fixed percentages. Following such trauma, the possibility of epilepsy occurring is taken into account. The Evaluation Scale is the same as that used following closed cranial trauma.

Fracture of the base with duramatral tear leading to a subarachnoidal fistula via one of the paranasal sinuses or via the external auditory duct. The evaluation is final after 2 years only.

At the end of that period

i. where meningitis without sequelae occurred or where the fracture line continues to appear on tomographies, to the percentage already granted, add: – 5%

— hydrocephalus justifying a derivation of cerebrospinal fluid: – 20%

(c) cerebral concussions or contusions complicated by a closed linear cranial fracture, without neurological sequelae discernable or measurable by usual clinical procedures: – 2 to 6%

(d) posttraumatic epilepsy

— occurrence of epileptic fits: if delayed clinical signs of epilepsy have appeared, use the following scale according to whether or not the fits are controlled by anticonvulsants

i. the fits slightly disturb the activities of daily living: – 5 to 15%

ii. the fits moderately disturb the activities of daily living: – 20 to 45%

iii. the fits require constant supervision or confinement: – 100%

— no epileptic fits: the evaluation may not be final until 2 years after the trauma.

After that lapse of time

i. if the electroencephalogram is normal

— permanent partial impairment: – none

ii. if the electroencephalogramme is abnormal

— multifocal or localized epileptic anomalies definitely increase the risk of possible occurrence of symptomatic epilepsy. To the impairment percentage already determined, add: – 5%

(B) CRANIAL NERVES

(a) olfactory nerve

— total unilateral loss: – 0%

— total bilateral loss: – 3%

(b) optic nerve

— total unilateral loss: – 16%

— total bilateral loss: – 100%

(c) oculomotor, trochlear and abducens nerves (total loss)

— injured singly or in combination, causing double vision which may be corrected by covering one eye: – 16%

(d) trigeminal nerve

— total unilateral sensory loss (according to neuritic dysaesthesia): – 1 to 10%

— supraorbital anaesthesia: – 1 to 3%

— upper maxillary branch

i. affecting the hard palate, dental arch and lip: – 2 to 6%

ii. affecting the anterior dental arch and the lip: – 2 to 4%

iii. affecting the upper lip: – 1 to 3%

— inferior maxillary branch affecting anterior dental arch and lip: – 1 to 4%

(e) facial nerve

— total unilateral paralysis: – 10 to 15%

— paralysis of the ophtalmic branch: – 1 to 10%

— paralysis of the buccal and mandibular branches: – 1 to 6%

— total bilateral paralysis: – 30 to 45%

(f) auditory nerve

— cochlear branch, total traumatic unilateral deafness: – 8%

— total posttraumatic bilateral deafness, definitely sudden and more or less complete: – 30 to 60%

— disturbance of vestibular functions

i. without disturbing the activities of daily living: – 0 to 5%

ii. certain restrictions in the ability to perform the activities of daily living, but without need of assistance: – 5 to 20%

iii. unable to perform the activities of daily living: – 20 to 60%

(g) glossopharyngeal nerve, pneumogastric nerve (isolated or combined injury to such nerves)

— dysphagia

i. as determined by diet: – 10 to 30%

ii. feeding by stomach tube: – 40%

— dysphonia

i. minimal: able to express most needs: – 0 to 12%

ii. moderate: serious restrictions, person limited to expressing essential needs only: – 12 to 20%

iii. marked: no articulated language: – 20 to 35%

(h) hypoglossal nerve

— unilateral paralysis: – 0%

— bilateral paralysis causing

i. dysphagia

(a) as determined by diet: – 10 to 30%

(b) feeding by stomach tube: – 40%

ii. dysphonia

(a) minimal – able to express most needs: – 0 to 12%

(b) moderate – serious restrictions, person limited to expressing essential needs only: – 12 to 20%

(c) marked – no articulated language: – 20 to 35%

(C) CEREBROSPINAL INJURY

(a) spinal cord or brain

— posture and ability to walk

i. able to stand, but has difficulty walking: – 5 to 20%

ii. able to stand, but able to walk on a plane surface only or not at all: – 25 to 60%

iii. unable to stand or walk: – 100%

— use of upper extremities (unilateral loss)

i. mildly impaired digital dexterity: – 5 to 10%

ii. lack of digital dexterity: – 15 to 25%

iii. self-care difficult: – 30 to 35%

iv. self-care impossible: – 40 to 70%

— respiration

i. respiration difficult only when additional exertion is required: – 5 to 20%

ii. walking severely limited: – 25 to 50%

iii. victim confined to bed or lack of spontaneous breathing: – 100%

— urinary bladder functions (neurogenic bladder)

i. dysfunction in the form of urgent miction: – 5 to 10%

ii. satisfactory reflex function but without volontary control: – 15 to 30%

iii. poor reflex activity and lack of volontary control of reflex activity, up to total lack of control: – 30 to 60%

— anorectal function

i. limited volontary control: – 0 to 5%

ii. presence of automatic reflex but lack of volontary control, up to lack of automatic reflex: – 10 to 25%

(b) brain

— communication disturbances (dysphasia, aphasia, alexia, agraphia, acalculia)

i. minor difficulty: – 0 to 15%

ii. able to understand linguistic symbols but unable to emit sufficient or appropriate language (depending on language capacity): – 25 to 80%

iii. unable to understand language or speak: – 100%

— disturbances of higher cognitive functions constituting the well-known organic cerebral syndrome and affecting orientation, understanding, memory, judgment, introspection and social behavior

i. disturbances which do not prevent victim from performing the tasks of daily living: – 5 to 15%

ii. some supervision required: – 20 to 45%

iii. almost constant supervision required: – 45 to 80%

iv. need for seclusion or confinement in a protective milieu, domestic or otherwise; the victim cannot care for himself: – 100%

v. ocular disturbances

— homonymous hemianopia: – 50%

— emotional disturbances, which may also be caused by organic cerebral injury and include irritability, euphoria, depression, involontary laughter and crying, and akinetic mutism. Psychiatric or psychological evaluation is required.

— disturbances of consciousness including confusion, semiconsciousness or stupor (uncontrolled reactions to pain stimuli and coma)

i. minor deterioration: – 5 to 20%

ii. moderate deterioration: – 25 to 70%

iii. stupor, semiconsciousness or coma: – 100%

— neurological disorders or other disturbances of consciousness such as syncope, epilepsy, cataplexy or narcolepsy

i. where slightly impairing the ability to perform the activities of daily living: – 5 to 15%

ii. where moderately disturbing the ability to perform the activities of daily living: – 20 to 45%

iii. where greatly disturbing the ability to perform the activities of daily living: – 45 to 80%

iv. where entailing constant supervision, confinement or suspension of the activities of daily living: – 100%

(D) PERIPHERAL NERVOUS SYSTEM

(a) Impairment caused by injury to a root

Injured                 Loss of function    Loss of function     Loss of function 
spinal                  through sensory      through motor      through sensory and 
nerve root                impairment           impairment        motor impairment  

C-5                        0 to 4%             0 to 20%            0 to 20%     
 
C-6                        0 to 6%             0 to 25%            0 to 25%

C-7                        0 to 4%             0 to 25%            0 to 25%

C-8                        0 to 4%             0 to 30%            0 to 30%
 
T-1                        0 to 4%             0 to 15%            0 to 15%

L-3                        0 to 4%             0 to 15%            0 to 15%

L-4                        0 to 4%             0 to 15%            0 to 15%

L-5                        0 to 4%             0 to 25%            0 to 25%

S-1                        0 to 4%             0 to 15%            0 to 15%
        

(b) Impairment resulting from injury to the brachial plexus

— Total impairment (sensory and motor): – 0 to 70%

                        Loss of function    Loss of function     Loss of function
                        through sensory      through motor      through sensory and
                          impairment          impairment         motor impairment
                                  

Superior trunk	
(C-5 C-6 Erb-Duchenne
paralysis)                 0 to 20%           0 to 50%             0 to 50%    

Middle trunk (C-7)          0 to 4%           0 to 25%             0 to 30%

Inferior trunk
(C-8 T-1 Klumpke-
Déjerine syndrome)         0 to 15%           0 to 50%             0 to 50%
                

(c) Impairment caused by injury to a spinal nerve and affecting the head and neck

Injured nerve          Loss of function    Loss of function     Loss of function
                        through sensory      through motor    through sensory and
                          impairment          impairment         motor impairment
  
                                
Greater occipital          0 to 5%               0%                  0 to 5%     

Lesser occipital           0 to 3%               0%                  0 to 3%

Great auricular 
C-2, C-3                   0 to 3%               0%                  0 to 3%

Spinal accessory              0%              0 to 10%              0 to 10%
        

(d) Impairment of peripheral spinal nerves affecting an upper extremity

Injured nerve           Loss of function    Loss of function     Loss of function
                        through sensory      through motor      through sensory and
                          impairment          impairment         motor impairment
 
                                 
– Anterior thoracic           0%                0 to 4%               0 to 4%

– Circumflex (axillaris)    0 to 4%            0 to 25%              0 to 25%

– Dorsal nerve of scapula     0%                0 to 4%               0 to 4%

– Long thoracic               0%               0 to 10%              0 to 10%

– Medial cutaneous nerve 
  of arm  (cutaneus 
  brachii medialis)         0 to 3%               0%                  0 to 3%

– Medial cutaneous nerve
  of forearm (cutaneus 
  antebrachii medialis)     0 to 3%               0%                  0 to 3%

– Median, above middle 
  forearm                  0 to 30%            0 to 40%              0 to 45%

– Median, below middle 
  forearm                  0 to 30%            0 to 25%              0 to 30%

– Musculocutaneous          0 to 4%            0 to 15%              0 to 15%

– Radial (triceps lost)     0 to 4%            0 to 35%              0 to 35%

– Radial 
  (triceps not lost)        0 to 4%            0 to 25%              0 to 25%  

– Upper and lower nerves 
  of the subscapularis
  and teres major 
  (subscapularis)             0%                0 to 4%               0 to 4%

– Suprascapularis           0 to 4%            0 to 10%              0 to 12%

– Thoracodorsal               0%                0 to 7%               0 to 7%

– Ulnar, above middle 
  forearm                   0 to 7%            0 to 25%              0 to 25%  

– Ulnar, below middle 
  forearm                   0 to 7%            0 to 15%              0 to 20%
        

(e) Impairment of a unilateral nerve affecting the inguinal region

   Injured nerve                        Loss of function through sensory impairment	

— Iliohypograstric                                       0 to 3%                 

— Ilioinguinal                                           0 to 5%
        

(f) Impairment caused by spinal nerve injury affecting lower extremities

  

  Injured nerve         Loss of function    Loss of function     Loss of function
                        through sensory      through motor      through sensory and
                          impairment          impairment         motor impairment 

– Femoral                   0 to 3%             0 to 20%            0 to 20%

– Genitofemoral             0 to 3%                0%                0 to 3%

– Inferior gluteal             0%               0 to 10%            0 to 10%

– Lateral cutaneous 
  nerve of thigh 
  (cutaneus femoris 
  lateralis)                0 to 4%                0%                0 to 4%

– Obturator nerve, 
  nerve of the internal
  obturator muscle, of 
  the pyramidal muscle,
  of the quadrate muscle 
  of the thigh and of the 
  superior gemellus muscle     0%                0 to 7%             0 to 7%

– Posterior cutaneous nerve 
  of the thigh              0 to 2%                0%                0 to 2%

– Superior gluteal             0%               0 to 10%            0 to 10%

– Large sciatic, above 
  branches to ischiotibial
  muscles                  0 to 20%             0 to 45%            0 to 50%

– Common peroneal           0 to 2%             0 to 18%            0 to 20%

  i. deep peroneal
(peroneus profondus),
above mid-leg                  0%               0 to 12%            0 to 12%

below mid-leg                  0%                0 to 3%             0 to 3%

  ii. superficial peroneal
(peroneus superficialis)    0 to 3%              0 to 5%             0 to 7%

– Internal popliteal nerve    

  i. above knee             0 to 7%             0 to 18%            0 to 20%

  ii. tibial, posterior   

  (a) in the upper third 
of leg                      0 to 7%             0 to 12%            0 to 12%

  (b) at mid-calf level     0 to 7%              0 to 7%            0 to 10%

  iii. medial plantar
(medial plantaris)          0 to 2%              0 to 3%             0 to 4%

  iv. lateral plantar
(lateral plantaris)         0 to 2%              0 to 3%             0 to 4%

  v. external sapheneous
(cutaneus sural)            0 to 2%                 0%               0 to 2%
        

TITLE III

I – MAXILLO-FACIAL TRAUMA

(concerning the fields of dental, neurological, otorhinolarynological, ophthalmological and plastic surgery)

(A) LESIONS OF THE JAWS AND HARD PALATE

(a) mutilations

— loss of both upper maxillae, with loss of dental arch, hard palate and nasal bone structure: – 30 to 80%

— loss of mandible, including the entirety of its dental portion: – 50 to 80%

— loss of one upper maxilla with bucconasal fistula and more or less extensive loss of mandibular arch tissue: – 40 to 75%

— loss of a single upper maxilla, with retention of the other one and of the mandibular arch: – 20 to 40%

(b) loss of tissue, pseudarthrosis, malunion

— maxilla

i. pseudarthrosis

— great mobility of the entire maxilla (transverse facial fracture), masticatory problems (including impairment percentage for teeth): – 10 to 40%

— malunion with mobility of a more or less extensive part of the maxilla, the remainder remaining fixed; according to the size of the mobile part and the possibility of mastication or of a prosthesis (including impairment percentage for teeth): – 5 to 25%

— loss of tissue from the hard and soft palate, or from the hard palate only with large bucconasal or buccosinusal fistula, both mutilations being the cause of similar problems (disorders of speech and deglutition): – 10 to 30%

— loss of tissue from the hard palate, involving the dental arch, possibility of prothesis: – 3 to 7%

— partial loss of tissue from the dental arch, no possibility of a functional and adequate prosthesis (increases impairment percentage for teeth: – 0 to 5%

ii. malunion

— any deviation that causes serious difficulty in dental articulation (false retrognathia, laterodeviation); no possibility of a prosthesis (including impairment percentage for teeth): – 10 to 20%

— malunion resulting in slight difficulty in dental articulation, comparable to problems related to prosthesis or peridontal problems: – 3 to 10%

— mandible

i. loss of tissue

(a) extensible loss of tissue, with loose pseudarthrosis, allowing neither mastication nor fitting of a prosthesis (including impairment percentage for teeth): – 15 to 20%

(b) partial loss of tissue from dental arch with the possibility of a well-functioning prosthesis (this does not include impairment percentage for teeth): – 0 to 5%

ii. pseudarthrosis

(a) tight pseudarthrosis of the ramus: – 0 to 5%

(b) loose pseudarthrosis of the ramus: – 5 to 10%

(c) tight pseudarthrosis of the body of the mandible: – 5 to 10%

(d) loose pseudarthrosis of the body of the mandible: – 10 to 20%

(e) tight pseudarthrosis of the symphysis: – 5 to 10%

(f) loose pseudarthrosis of the symphysis: – 10 to 20%

iii. malunion

as described for the maxilla

(c) temporomandibular articulations and other lesions that interfere with the function thereof

— ankylosis

i. total ankylosis allowing the passage of liquids only: – 15 to 50%

ii. lesser restriction in opening mouth, making eating more or less difficult and dental treatment almost impossible; according to the size of the opening measured from the edge of the incisors

(a) opening less than 10 mm: – 10 to 40%

(b) opening from 10 to 30 mm: – 5 to 20%

— intra and para-articular fractures of the temporomandibular joint

i. fracture of the neck of the condylar process, with no appreciable displacement or serious functional problems: – 0 to 3%

ii. fracture of the neck of the condylar process with internal displacement. without angulation or dislocation, with retention of propulsive movements: – 2 to 5%

iii. fracture with 45 ° internal angulation and dislocation of the head of the condyle and with loss of propulsive movements: – 4 to 10%

iv. fracture with antero-internal angulation, loss of propulsive movements and rotation: – 5 to 15%

v. intra-articular fracture with no displacement causing lessening of propulsive movements or rotation, lesion of the meniscus that may degenerate into posttraumatic arthritis: – 0 to 6%

(d) damage to or loss of teeth (during an accident or restoration)

                                                           Maxilla or mandible

– central incisor:                                                 1% 

– lateral incisor:                                                 0.75%

– canine:                                                          1.5%

– first premolar:                                                  1%

– second premolar:                                                 1%

– first molar:                                                     1.25%

– second molar:                                                    1%
          

The impairment percentages for teeth are cumulative.

The percentage thus obtained is reduced by two-thirds if the victim is fitted with a permanent prosthesis.

It is reduced by one-third if the injured person is correctly fitted with a well supported, removable prosthesis, such apparatus not constituting restitutio in integrum but contributing appreciably to the improvement of the person’s functional condition.

(B) FRONTO-ORBITONASAL AREA

(a) transverse facial fracture

— fracture of the cribiform plate of the ethmoid bone with rhinorrhea: – 3 to 5%

— depression of the frontal sinus: – 0 to 5%

— posttraumatic hypertelorism, with or without blockage of the lacrimal duct

i. unilateral: – 0 to 5%

ii. bilateral: – 5 to 8%

(b) fracture of the floor of the orbit

— displacement causing descent of the eyeball and enophthalmos with diplopia: – 1 to 25%

— malposition of canthus, change in palpebral fissure (according to functional difficulty): – 0 to 5%

(c) fracture of the malar bone and the zygoma

— deformation with no obstruction of the mandible: – 0 to 3%

— with obstruction of the mandible: – 5 to 20%

(d) fracture of the nose

— obstructions

i. unilateral mechanical obstruction: – 0 to 2%

ii. bilateral mechanical obstruction: – 2 to 5%

iii. functional obstruction: – 0 to 5%

iv. total obstruction with dyspnea after moderate effort: – according to evaluation of rhinologist

— rhinitis and perforation of the septum

i. asymptomatic: – 0 to 1%

ii. symptomatic (epistaxis, rhinorrhea, nasal obstruction, loss of taste and smell); according to extent of symptoms: – 2 to 5%

— post traumatic trophic conditions: – 0 to 5%

(C) SALIVARY GLANDS

Permanent fistulae following surgical failure, according to the importance of the gland: – 5 to 15%

(D) TONGUE (total or partial anatomic loss)

evaluation according to functional difficulty (dysphagia – dysphonia)

(a) minimal: – 0 to 5%

(b) moderate: – 5 to 20%

(c) marked: – 20 to 80%

II – VISION

Impairment resulting from loss of sight is determined according to Table No. 1, entitled “VISION”, included below.

Impairment must always be determined after optical correction with glasses.

Where possible, indicate the visual acuity (after correction) that the victim possessed before the accident and proceed as outlined in the 6 examples given at the end of this Division.

Where a victim previously having sight in only one eye loses his other eye, the resulting impairment is 100%.

(a) loss of vision in one eye, with or without enucleation: – 24%

(b) cataract or aphakia

— unilateral: – 12%

— bilateral: – 25%

(c) pseudophakia: – 7%

Snellen        20/20 20/25 20/30 20/40 20/50 20/60 20/70 20/80 20/100 20/200 20/400
scale


         Metric
         scale   6/6 6/7.5   6/9  6/12  6/15  6/18  6/21  6/24   6/30   6/60  6/120

20/20    6/6     0.0   1.0   2.0   4.0   6.0   8.0   9.0  10.0   13.0   20.0   24.0

20/25    6/7.5   1.0   2.0   2.0   7.0   9.0  11.0  12.0  14.0   16.0   23.0   28.0

20/30    6/9     2.0   2.0   8.0  11.0  12.0  14.0  15.0  17.0   19.0   26.0   31.0

20/40    6/12    4.0   7.0  11.0  16.0  18.0  20.0  21.0  23.0   25.0   32.0   37.0

20/50    6/15    6.0   9.0  12.0  18.0  24.0  25.0  27.0  28.0   30.0   38.0   43.0

20/60    6/18    8.0  11.0  14.0  20.0  25.0  30.0  32.0  33.0   35.0   43.0   48.0

20/70    6/21    9.0  12.0  15.0  21.0  27.0  32.0  36.0  38.0   40.0   47.0   52.0

20/80    6/24   10.0  14.0  17.0  23.0  28.0  33.0  38.0  42.0   44.0   51.0   57.0

20/100   6/30   13.0  16.0  19.0  25.0  30.0  35.0  40.0  44.0   51.0   58.0   63.0

20/200   6/60   20.0  23.0  26.0  32.0  38.0  43.0  47.0  51.0   58.0   80.0   85.0

20/400   6/120  24.0  28.0  31.0  37.0  43.0  48.0  52.0  57.0   63.0   85.0  100.0

                

The following 6 examples are included in order to assist the evaluating physician in applying the above Table:

EXAMPLE 1

Injury to 2 previously normal eyes

(a) before the accident: (R) 20/20 (L) 20/20

(b) after the accident, after correction: (R) 20/70 (L) 20/50

(c) impairment percentage granted: 27%

EXAMPLE 2

Injury to 2 previously abnormal eyes

(a) before the accident, after correction: (R) 20/50 (L) 20/40

(b) after the accident, after correction: (R) 20/70 (L) 20/100

(c) impairment percentage after the accident: 40%

(d) impairment percentage before the accident: 18%

(e) impairment percentage granted: 40% – 18%: 22%

EXAMPLE 3

Injury to one eye, both eyes being previously abnormal

(a) before the accident, after correction: (R) 20/200 (L) 20/30

(b) after the accident, after correction: (R) 20/200 (L) 20/70

(c) impairment percentage after the accident: 47%

(d) impairment percentage before the accident: 26%

(e) impairment percentage granted: 47% – 26%: 21%

EXAMPLE 4

Injury to 2 previously normal eyes

(a) before the accident: (R) 20/20 (L) 20/20

(b) after the accident, after correction: (R) Enucleated (L) 20/100

(c) impairment percentage granted: 63%

EXAMPLE 5

Injury to one eye, the other being previously abnormal

(a) before the accident, after correction: (R) 20/200 (L) 20/20

(b) after the accident, after correction: (R) 20/200 (L) 20/40

(c) impairment percentage after the accident: 32%

(d) impairment percentage before the accident: 20%

(e) impairment percentage granted: 32% – 20%: 12%

(f) if the right eye was normal before the accident,

the impairment percentage would be: 4%

EXAMPLE 6

Injury to one eye, the other being previously abnormal

(a) before the accident, after correction: (R) 20/70 (L) 20/20

(b) after the accident, after correction: (R) 20/70 (L) 0.0

(c) impairment percentage after the accident: 52%

(d) impairment percentage before the accident: 9%

(e) impairment percentage granted: 52% – 9%: 43%

(f) the right eye was normal before the accident, the impairment would be: 24%

TITLE IV

GENITOURINARY SYSTEM

(A) NEPHRECTOMY

(a) with normal results of basic tests: – 10%

(b) impairment of renal function (according to the changes in basic tests): – 20 to 40%

(B) URINARY BYPASS (urinary shunt) – 20%

(C) BLADDER DAMAGE (anatomical or functional, but not neurogenic)

(a) cured, with no complications or residual infection: – 0%

(b) infection or incontinence, according to seriousness (evaluation made after optimum recovery, or recovery expected 12 to 18 months after the accident): – 5 to 15%

(D) URETHRA DAMAGE

(a) constriction requiring occasional dilation (every 3 or 4 months): – 5%

(b) constriction requiring treatment (every 3 or 4 weeks): – 10%

(c) surgically incurable fistulae: – 15%

(E) MALE GENITAL ORGANS

(a) penis (total or partial emasculation): – 20%

(b) loss of one testicle, the other remaining functional: – 5%

(c) loss of both testicles

— up to 17 years of age, inclusive: – 30%

— from 18 to 60 years of age, inclusive: – 10 to 25%

— over 60 years of age: – 5%

(F) FEMALE GENITAL ORGANS

(a) internal genital organs

— loss of one ovary, with or without connecting fallopian tube (the corresponding organs remaining intact): – 5%

— loss of both adnexa

i. up to 16 years of age, inclusive: – 30%

ii. from 17 to 60 years of age, inclusive: – 10 to 25%

iii. over 60 years of age: – 5%

— loss of uterus: – 5%

(b) external genital organs (the percentages given below are not cumulative)

— loss of vagina – complete removal: – 20%

— destruction of upper half of vagina: – 14%

— loss of vulva or clitoris: – 15%

dystocia due to bone structure making a cesarean section likely is evaluated taking into account the residual bone lesion and the cesarean section anticipated. The latter justifies an additional impairment percentage of: – 5%

TITLE V

RESPIRATORY SYSTEM

(A) INCONSPICUOUS IMPAIRMENT OF VENTILATORY FUNCTION

A basic impairment percentage (5%) is granted to any accident victim with radiological pathognomonic signs of amianthosis or silicosis recognized by the Commission de la santé et de la sécurité du travail but not showing up in any significant way in ventilatory function tests.

N.B.:

— The relationship is recognized between pulmonary neoplasia and asbestos fribrosis.

— A cause-and-effect relationship is recognized between death caused by mesothelioma and previous exposure to asbestos fibre.

— A relationship is recognized where an accident victim with asbestosis fribosis develops cancer of the digestive tract, pharynx or larynx.

(B) IMPAIRMENT OF VENTILATORY FUNCTION

Impairment of ventilatory function may occur as a result of an impairment of any kind of the pulmonary function. Posttraumatic impairment of ventilatory function is never isolated in the case of an accident. The neurological aspect is evaluated according to Title II of this Scale. The traumatic aspect must be evaluated by a pneumologist, in view of daily activities and according to the following criteria:

(a) clinical criteria, objective and subjective

— dyspnea I to V (international classification)

— cough

— sputum

— orthopnea

— bronchial and parenchymatous rales

— general physical examination

— chest pain

— hemoptysis

— pulmonary history

— occupation

(b) objective criteria

i. roentgenography

oblique, lateral and posteroanterior high-voltage X-rays are taken for the examination of the

— pulmonary parenchyma

— condition of the heart

— pleura

ii. respiratory physiology

— basic

— pulmonary volumes

— expiratory flow rates

— maximal respiratory flow rates

— diffusing capacity at rest

— gas exchange at rest

— optional and according to each specific case

— gas exchange studies after exertion; Jone’s stages I and III for cases of pneumoconiosis

— measure of pulmonary elasticity (lung compliance) used in all cases of a first claim for asbestosis

— bronchial provocation challenges in cases of occupational asthma

(c) principal criteria for diagnosing

i. asbestosis

— history of sufficient exposure to asbestos

— evidence of restricted pulmonary function in tests of ventilatory function

— progressive exertional dyspnea

— inspiratory crackling rales at lung bases

— clubbing of the fingers

— small, irregular category I opacities on pulmonary radiograph consistent with asbestos fibrosis, according to the 1971 ILO/UC classification

— signs of interstitial fibrosis with a sufficient number of fibres or ferruginous bodies appearing upon histological examination

ii. silicosis

— history of sufficient exposure to silica dust

— progressive exertional dyspnea

— small rounded opacities on the chest radiograph of at least category 1 according to the ILO/UC 1971 classification

— histological findings consistent with silicosis upon microscopic examination of lung tissues.

N.B. All the criteria described above respecting asbestosis and silicosis are not needed to diagnose the 2 diseases.

It should be noted that the values computed as standard according to international norms are valid within a range of 20% of the standard values established herein. These standard values vary according to age and weight, and become less and less valid with advanced age, especially with respect to carbon dioxide tests.

Test of ventilatory function may be supplemented with a Jones type progressive effort test.

As it is impossible to evaluate respiratory impairment to within 1%, the impairment will be nil or 5% and over.

Classes of respiratory impairment

i. Class I

Roentgenograms of the chest are usually normal, but there may be evidence of healed or inactive disease of the chest, such as minimal nodular silicosis or pleural scars. Dyspnea, where it occurs, is consistent with the circumstances of activity. Values obtained from tests of ventilatory function are not less than 85% of predicted normal values for the patient’s age, sex, and height: – 0%

ii. Class II

Roentgenograms of the chest may be normal or abnormal. Dyspnea does not occur at rest and seldom occurs during the performance of the activities of daily living. The patient can keep pace with persons of the same age and body build on a level surface without breathlessness but not on hills or stairs. Values obtained from tests of ventilatory function are in the range of 70% to 85% of the predicted normal values for the patient’s age, sex, and height: – 10 to 20%

iii. Class III

Roentgenograms of the chest may be normal but usually are not. Dyspnea does not occur at rest but does occur during the performance of the activities of daily living. However, the patient can walk 2 kilometres (1 mile) at his own pace without experiencing dyspnea, although he cannot keep pace on a level surface with others of the same age and body build. Values obtained from tests of ventilatory function are in the range of 55% to 70% of the predicted normal values for the patient’s age, sex, and height. The test of arterial oxygen saturation when performed at rest and after exercise, is usually 88% or greater: – 25 to 35%

iv. Class IV

Roentgenograms of the chest are usually abnormal. Dyspnea occurs during such activities as climbing one flight of stairs or walking 100 m over a level surface, with a minimum of exertion, or even at rest. Values obtained from tests of ventilatory function are less than 55% of predicted normal values for the patient’s age, sex and height. The test of arterial oxygen saturation, when performed at rest or after exercise, is usually less than 88%: – 50% and over

A ventilatory impairment of 60% and more is equal to an impairment of: – 100%

(C) TRAUMATIC BRONCHOPULMONARY INJURY

This traumatic injury entails anatomic changes with objective sequelae, without impairment of ventilatory function. Thoracic impairment due to trauma or surgery is taken into account.

(a) tracheobronchial rupture

(chronic irritation, etc...)

i. minimal: – 2 to 5%

ii. moderate: – 5 to 10%

iii. marked: – 10 to 15%

(b) pleuropulmonary scars

A perforating wound, contusion, etc. that does not impair ventilatory function.

There may be loss of tissue

i. minimal: – 0 to 3%

ii. moderate: – 3 to 5%

iii. marked: – 5 to 10%

TITLE VI

DIGESTIVE SYSTEM

(A) SUPRADIAPHRAGMATIC

(a) tongue: impairment is evaluated in accordance with Title III of this Scale

(b) oesophagus (thoracic trauma): damage accompanied by stenosis persists, requiring medication; diet remains more or less normal: – 5 to 10%

(B) SUBDIAPHRAGMATIC

(a) laparotomy – 3 to 5%

(b) stomach and duodenum

i. traumatic rupture: – 3 to 5%

ii. stress ulcer, study of case history, posttraumatic changes in a preexisting condition

— followed by a complete recovery: – 0%

— followed by progression toward a chronic condition: – 5%

— followed by deterioration toward stenosis: – 15 to 20%

(c) small intestine

According to lesion and size of resection: – 0 to 15%

(d) liver

— uncomplicated laceration without considerable tissue loss: – 0 to 5%

— serious laceration with loss of tissue: – 5 to 15%

— fistula(e), with impairment of hepatic function: – 5 to 25%

(e) pancreas

— no digestive disorders, tests normal: – 3 to 5% –

— digestive disorders, changes in functional tests for exocrine and endocrine secretions: – 10 to 30%

(f) spleen

Although not part of the digestive system, the spleen, as an intra-abdominal organ, has been placed under this Title.

— in adults, the removal of the spleen may sometimes result in immunological deficiency. The impairment percentage provided for a laparotomy is applied. To this is added: – 3%

— in children, loss of the spleen may disturb the haematopoietic system. Childhood terminates with the beginning of puberty, which occurs at about 11 years for girls and at 12 to 13 years for boys. The evaluation must be referred to a haematologist. Special consideration.

(g) hernia of the abdominal wall

i. inguinale (direct, indirect) or femoral

— unilateral: – 1%

— bilateral: – 2%

ii. recurrent uni – or bilateral hernia: – 2%

iii. hernia in the location of a previous laparotomy: – 5%

TITLE VII

CARDIOVASCULAR SYSTEM

Vascular impairment is usually caused by multiple lesions and does not require special evaluation. However, complications resulting from a vascular lesion must be distinguished from symptoms originating in the nervous or musculoskeletal system. The vascular diagnosis must be based on objective clinical findings or specific recognized vascular tests.

In order to establish a relationship between an accident and a cardiovascular abnormality

(a) the vascular lesion must not have been present before the accident and the presence of the following must be looked for:

i. symptoms suggesting a certain degree of vascular insufficiency or other disorder having occurred before the trauma;

ii. signs of a disease already recorded in previous examination reports;

iii. chronic vascular insufficiency or other disease in an untraumatized extremity.

However, it must be borne in mind that the trauma may have worsened a preexisting disease which probably would have remained asymptomatic for a long period of time.

(b) the lesion must have developed within a reasonable period of time after the trauma, that is, in less than 15 days in particular instances and with justification, that period may be extended to 90 days.

(c) the trauma must show sufficient signs of localization and severity.

(A) MAJOR CARDIOVASCULAR LESIONS

Major cardiovascular lesions must be evaluated individually taking into account the severity of the lesion and possible future consequences in cases where there are no immediate sequelae.

The following lesions are type cases which must be evaluated by a specialist in cardiovascular and thoracic surgery

(a) cardiac and pericardial lesions

(b) major lesions of arterial and veinous trunks: thoracic and abdominal aorta, pulmonary artery, arteries off the aortic arch, superior and inferior vena cava

(c) carotid lesions

(d) arterial or venous anomalies of the thoracic outlet

(e) aneurisms, true or false

(f) arteriovenous fistulae

(g) high blood pressure secondary to a renal lesion

(B) VASCULAR LESIONS AFFECTING THE EXTREMITIES

The severity of an impairment is determined by using the following classification

(a) asymptomatic extremity, whether or not there is a loss of arterial pulse or hardening of arteries: – 0 to 3%

(b) extremity afflicted with slight, moderate or severe intermittent claudification with disability: – 5 to 25%

(c) extremity showing severe ischaemia

i. with constant pain at rest: – 15 to 35%

ii. with gangrene

in accordance with the value of the segment of the lost extremity, already determined in the musculoskeletal section.

Vasomotor phenomena must be subjected to an objective physiological study.

(C) VENOUS AND LYMPHATIC LESIONS

(a) varicose veins

(according to the extent, localization and system affected): – 0 to 3%

(b) recurring superficial thrombophlebitis: – 0 to 8%

(c) deep thrombophlebitis and lymphangitis

the disability resulting from this lesion is determined in accordance with the severity of the residual syndrome.

i. asymptomatic: – 0%

ii. minor postphlebitic syndrome, well controlled by standard medical treatment: – 0 to 3%

iii. moderate postphlebitic syndrome, not completely controlled by standard medical treatment: – 3 to 10%

iv. marked postphlebitic syndrome, not controlled by standard medical treatment and with an ulcerous episode: – 10 to 15%

v. marked postphlebitic syndrome, not controlled by standard medical treatment and with recurring ulcerous episodes: – 15 to 30%

The evaluation of related pulmonary embolisms is made in accordance with the criteria established in the respiratory section.

TITLE VIII

GLANDULAR SYSTEM

Lesions of the endocrine glands are rarer traumatic lesions that are always caused by either

— cranial trauma (hypothalamo-hypophyseal)

— laceration of the neck (thyroid)

— an abdominal lesion (laceration of the pancreas, an adrenal gland, etc.)

Sequelae are evaluated according to the impairment and especially to the remaining function and the response to hormonal treatment.

(A) INJURY TO THE HYPOTHALAMUS AND HYPOPHYSIS LEADING TOHYPOPITUITARISM

(a) overall

i. hormone replacement remains simple and effective; diagnosis usually premature according to the number of functions impaired: – 30 to 40%

(b) selective

i. according to the hormonal function impaired (see other glands)

ii. diabetes insipidus: – 10%

iii. dwarfism: special consideration is required based upon age and the seriousness of the syndrome: – 30 to 80%

(B) INJURY TO THE THYROID GLAND

(a) where hormone replacement is adequate: – 5 to 10%

(b) where cardiac or other complications are anticipated if the development is protracted, the evaluation is carried out by referring to similar lesions described in Title VII: – special consideration

(C) INJURY TO THE PARATHYROIDS (extensive lesion causing hypoparathyroidism)

(a) appropriate, uncomplicated therapy: – 5 to 10%

(b) difficult therapy entailing problems daily: – 10 to 20%

(D) IMPAIRMENT OF THE PANCREAS (diabetes)

(a) where it is controlled by diet: – 0 to 5%

(b) where it is controlled by diet and oral medication: – 5 to 10%

(c) where insulin therapy is necessary: – 15 to 20%

(E) INJURY TO THE ADRENAL GLANDS

(a) unilateral loss: – 5%

(b) bilateral loss with adequate hormone therapy: – 10 to 20%

(F) INJURY TO THE GONADS (testicles and ovaries)

(a) unilateral loss: – 5%

(b) bilateral loss

i. up to 17 years of age inclusive for a boy up to 16 years of age inclusive for a girl: – 30%

ii. reproductive years – adult: – 10 to 25%

iii. over 60 years of age – 5%

TITLE IX

PSYCHIC SYSTEM

INTRODUCTION

The psychic functions (mental, affective, adaptive, behavioural) of certain accident victims may be permanently damaged

(a) General Impairment Producing Mechanisms

Such impairments are sometimes the direct consequence of a lesion in the central nervous system and therefore entail a psychiatric or psychological evaluation which goes beyond the sole assessment of a neurological impairment. In other cases, the impairment reflects a permanent affective dysfunction revealing chronic psychological maladaptation to trauma having temporarily or permanently damaged another part of the body. Impairments of this nature may sometimes result from the interaction of the 2 impairment producing mechanisms.

(b) General Evaluation Criteria

Impairment is assessed by means of a clinical psychiatric or psychological examination. Adequate knowledge of the accident victim’s personality prior to the accident, his complete background and his usual mode of adaptation is necessary for the conducting of a clinical evaluation. The victim’s premorbid level of personal adaptation must be considered in order to determine the degree of functional damage stemming from mental illness caused by an accident.

A detailed objective mental examination is essential. The symptomatology must establish an entirely credible, total and coherent syndrome. Impairment of psychic functions must be manifested by changes in the patient’s daily activities and interpersonal relationships and in certain cases must be accompanied by physiopathological signs. Symptoms must be present during a sufficiently long period and, as a rule, must persist despite constant, standard therapy Additional objective information on the patient’s abnormal mental condition is usually provided by his family and friends and those treating him. A purely subjective syndrome that is difficult to verify rarely indicates severe permanent partial impairment.

The clinical evaluation may sometimes be supplemented with a social or psychometric evaluation. Unfavourable social circumstances may influence that accident victim’s rehabilitation and overall prognosis but do not in themselves constitute an impairment of psychic functions. The evaluation must take his motivational aspect into account. Lastly, an impairment assessed by such psychiatric or psychological evaluation is different in its very nature from an impairment caused by the loss of enjoyment of life or of a mutilated organ.

(c) Groups and Classes of Impairment

Permanent impairment of the accident victim’s psychic functions may result from

— chronic brain syndromes

— psychoses

— neuroses

— personality disorders

The history of psychiatric or psychological sequelae, the specific results of the mental examination and supplementary examinations usually allow only one nosologic category to be determined. However, organic brain syndromes may, in particular, be accompanied by and thus include in their clinical picture and evaluation psychotic or neurotic signs or deterioration of the personality.

Symptomatic severity is accompanied by repercussions going beyond the accident victim’s mere experience to change his usual activities of daily living and his personal or social efficiency. The accident victim requires constant supervision or therapy, assistance or a particular milieu, and in certain cases even needs to be looked after on a full-time basis for the fulfillment of his basic needs.

The diagnosis as to the degree of severity of the impairment affecting the whole person must be specified by applying the general evaluation criteria, by taking the objective effects of the assessed syndrome into consideration, and by referring to the following classes

— Class I: minor impairment: – 0 to 15%

— Class II: serious impairment: – 15 to 45%

— Class III: extremely serious impairment: – 45% and over

Precise quantification in one class may be difficult to achieve, thus the necessity for a comparison with similar cases whose development was followed by the evaluating physician. It may be necessary to wait some time before the final evaluation of the impairment can be carried out.

A standard clinical psychiatric or psychological evaluation may not necessarily determine an additional impairment and may be useful only for evaluating the motivation of a patient with an impairment in another system or for establishing that the patient’s potential for a more complete rehabilitation requires further scrutiny before the degree of impairment in the other system is established.

(A) CHRONIC BRAIN SYNDROMES

The syndrome is directly associated with organic brain injury resulting from trauma. Above all, it consists of disturbances of the higher cognitive functions. It is essentially characterized by impairment of orientation, comprehension, memory and of the abilities to learn, anticipate, make decisions and exercise judgment. A supplementary psychometric evaluation may be useful in this case. In addition to these essential signs, the subject may show signs of instability, puerilism, erosion of the importance of moral values, or character disorders.

The syndrome is sometimes complicated by psychotic or neurotic reactions in which case they are included in the evaluation. Psychoses or neuroses without organic brain injury will be evaluated separately in their own class.

(a) Class I

The patient has impairment of the higher cognitive functions but is able to perform most of the activities of daily living, as prior to the accident: – 0 to 15%

(b) Class II

The patient has impairment of the higher cognitive functions and in some cases exhibits constant or intermittent but recurring psychotic or neurotic symptoms, to such an extent that he requires supervision and direction for several or most of his daily activities: – 15 to 45%

(c) Class III

The impairment of the higher cognitive functions and the psychological adaptation to the impairment itself are such that the performance of daily activities requires more or less constant care in a protective milieu (home or similar establishment).

Patients with extremely severe impairments require help even in meeting their most elementary needs: – 45% and over

(B) PSYCHOSES

Psychosis is a severe disturbance of mental function likely to cause more or less considerable impairment, depending on its nature, severity, duration, repercussions, the patient’s history and his reaction to therapeutic measures. It is often advisable to wait 2 or 3 years before making the final evaluation of the impairment. The clinical picture may then stabilize and show evidence of permanent impairment. In certain cases basic impairment may be only the more or less strong possibility of relapses.

The syndrome is essentially manifested by disturbances in perception, thinking (process, form, content) and behaviour and by abnormalities in emotional control. It is usually accompanied by a lack of self-criticism and often involves abnormal behaviour discernible by those around him.

(a) Class I

An impairment in this Class is manifested by minor and discrete disturbances in perception, thinking, emotional control or behaviour, but it has little effect on how the patient functions in comparison to his adaptation prior to the accident. Patients who are well controlled by constant psychotropic medication, which alleviates the necessity for rehospitalization, are placed in this Class: – 0 to 15%

(b) Class II

A psychosis in this Class is evident upon mental examination, easily discernible by those around the patient and is reflected in difficulty in social behaviour, odd behaviour and a fairly noticeable reduction in social and personal efficiency. Nevertheless, disorders are not too serious, so the patient can be tolerated in his milieu. The patient’s collaboration is inconstant, the possibility of intermittent hospitalization is likely and the syndrome is poorly controlled by medication. The patient may require occasional supervision and direction in leading his daily life: – 15 to 45%

(c) Class III

A psychosis in this Class is so severe that the patient manifests disturbances in perception and thinking, and an inability to control his emotions that leads him to behave in a way that is socially intolerable or dangerous to his own well-being. The patient always requires at least part-time supervision and direction so that he can lead his daily life. In more serious cases, he may require a protective milieu or constant care in an establishment, with recurrent hospitalization: – 45% and over

(C) NEUROSES

Individuals react differently to life’s problems. Some accident victim’s are prone to adapt neurotically to trauma and its sequelae. Neuroses have no known organic cause. The patient remains lucid and is able to distinguish between external reality and his own subjective experiences. He does not show personality disorganization, but his behaviour may be disturbed within the limits of what is generally socially acceptable. Neuroses may entail excessive anxiety and phobic, hysterical, obsessive-compulsive, depressive and sometimes even psychosomatic symptoms.

Given the strictly subjective nature of a neurosis, its great variability, its natural tendency to subside and the motivational context (secondary gains), it is necessary to wait long enough to ensure a strict application of the following general clinical evaluation criteria: previous manner of adaptation, objective repercussions on daily life and relationships, the psychosomatic element, regular continuation of treatment, and social context.

(a) Class I

i. The neurosis is above all subjective but credible, complete and coherent. It is attended with minor changes and does not render the victim incapable of adaptive behaviour. There is no reduction in daily activities or in social or personal efficiency: – 0 to 15%

ii. As these impairments do not result from a severe disability, they usually should be placed in the lowest third of this percentage, specifically, from: – 0 to 5%

(b) Class II

The symptomatic severity of the neurosis, although usually variable, requires the patient to constantly rely on alleviating therapeutic measures and to modify his daily activities, therefore substantially reducing his social and personal efficiency. The neurosis may also entail functional psychophysiological disorders requiring symptomatic treatment and causing intermittent stoppage of regular activities: – 15 to 45%

(c) Class III

i. The neurosis is overpowering and leads to a definite deterioration of personal and social efficiency. Interpersonal relationships undergo considerable and constant changes – isolation or the need of being encouraged and comforted. Daily activities are upset, and the patient needs to be supervised and guided by those around him. Pathological tissular lesions which are more or less reversible may be present with the psychosomatic component: – 45% and over

ii. It is uncommon for a neurotic condition alone to be attended with regression, deterioration and dependence justifying a percentage higher than the lowest third of this percentage; the impairment should be between: – 45 to 65%

(D) PERSONALITY DISORDERS

This class mainly concerns character disorders attended with a lack of emotional maturity and expressed as difficulty in interpersonal relationships, poor control of inhibitions, a reduction of tolerance to frustration, excessive egocentricity, inconstancy of efficiency, and fairly serious social maladaptation. In most cases, manifestations of personality disorders existed prior to the accident, and impairment, if any, only increases the preexisting social maladaptation. The motivational context with respect to temporary demonstrative reactions that are likely to subside after the financially advantageous settlement of the impairment granted must be assessed carefully. A social evaluation in addition to the clinical evaluation may prove useful.

Personality changes caused by organic brain syndrome must be evaluated in accordance with the Scale provided therefor.

(a) Class I

i. The level of character adjustment usually existing prior to the accident is consistently worsened and leads to a more pronounced deficiency in social judgment, deterioration of interpersonal relationships, increasing variability inconsistency in efficiency, behavioural deviations and the inability to avoid coming into conflict with society or harming oneself. The patient is not capable of adapting to the difficulties of daily life: – 0 to 15%

ii. In general, the impairment should not exceed the lowest third of this percentage: – 0 to 5%

(b) Class II

The maladaptation is such that the individual shows considerable loss of self-control, is not able to learn from experience and seriously harms himself and those around him in a repeated manner. The lack of social control may have resulted in legal supervision of various kinds. Such psychiatric or psychological impairment, when considered separately, is rarely granted. It must be determined whether or not such objective behavioural deterioration belongs to another impairment class: – 15 to 45%

(c) Class III

Does not apply in this category: – 45% and over

TITLE X

HEARING

(Cf.: neurological system and maxillofacial trauma)

(A) – hearing loss, one ear: – 5%

— hearing loss, 2 ears: – 30%

(B) – absolutely sudden and more or less complete post traumatic bilateral hearing loss associated with other injuries (skull fracture, fracture of the temporal bone, complete destruction of the peripheral apparatus – both vestibular and cochlear): – 30 to 60%

        Hearing loss                   Worse                    Better      
        in decibels                    ear                       ear              
		       

            DB                          %                         % 

          25ISO                        0.5                       2.5

          30IS0                        1.0                       5.0

          35ISO                        1.5                       7.5

          40ISO                        2.0                      10.0

          45IS0                        2.5                      12.5

          50ISO                        3.0                      15.0

          55ISO                        3.5                      17.5

          60ISO                        4.0                      20.0

          65ISO                        5.0                      25.0
                

NOTES:

(1) The examination must be carried out without a corrective hearing device and at frequencies of 500, 1,000 and 2,000 Hz by aerial and bone conduction.

(2) If hearing loss in decibels falls between 2 figures indicated in the Table, the higher figure is taken.

— Example: if hearing loss is 31 dB, a hearing loss of 35 dB is granted.

(3) The examiner must deduct 0.5 dB for each ear for each year of age over the age of 60.

(4) Where possible, he must give the rate of hearing loss prior to the accident and proceed in accordance with the following examples.

AT FREQUENCIES OF 500, 1,000 AND 2,000 Hz BY AERIAL AND BONE CONDUCTION

(A) Hearing loss of a 42-year-old accident victim Impairment percentage

Right ear Left ear

20 + 40 + 60 = 120 15 + 30 + 55 = 100

120 ÷ 3 = 40 dB – 2%

100 ÷ 3 = therefore 35 dB: – 7.5%

____________________

9.5%

Impairment percentage accorded: 9.5%

____________________

____________________

(B) Hearing loss of a 35-year-old accident victim

(a) before the accident: complete deafness in right ear

(b) after the accident: complete deafness in both ears

(c) after the accident: impairment is: – 30%

(d) before the accident: impairment was: – 5%

(e) impairment percentage accorded: 30% – 5%: – 25%

(C) Hearing loss of a 66-year-old accident victim

Right ear Left ear

20 + 45 + 65 = 130 25 + 40 + 70 = 135

(a) at age 66, the deduction for presbycusis is:

(66-60 x 1/2 = 3 dB)

(b) 130 ÷ 3 = 43.3 dB - 3 dB = 40.3 dB

(c) 135 ÷ 3 = 45 dB - 3 dB = 42 dB

(d) for 40.3 dB takes 45 dB: – 2.5%

(e) for 42 dB takes 45 dB: – 12.5%

____________________

15%

Impairment percentage granted: 15%

____________________

(a) before the accident

i. right ear: 40 dB therefore impairment of: – 2%

ii. left ear: 35 dB, therefore impairment of – 7.5%

____________________

(b) after the accident

i. right ear: 70 dB, therefore impairment of: – 5%

ii. left ear: 55 dB, therefore impairment of: – 17.5%

____________________

22.5%

(c) impairment percentage after the accident: 22.5%

(d) impairment percentage before the accident: 9.5%

(e) impairment percentage accorded: 22.5% – 9.5%: 13%

____________________

____________________

TITLE XI

DISFIGUREMENTS

(A) FACE

(a) faulty scar, from 2 to 8 cm, no healing possible: – 0.5% to 2%

(b) numerous faulty scars, no healing possible, no injury to physiognomy: – 2% to 5%

(c) extensive faulty scar, no healing possible, change in physiognomy: – 5% to 15%

(d) deformation, with or without bone injury and loss of tissue: – 15% to 30%

(B) NECK

(a) tracheostomy scar: – 1%

(b) faulty retractile scar affecting less than half the surface area of the neck, no healing possible: – 1% to 3%

(c) keloid scar affecting more than half the surface area of the neck: – 3% to 5%

(C) MAJOR DETERIORATION ON ANY OTHER PART OF THE BODY

(a) major deterioration covering 3% to 9% of the surface area of the body: – 1% to 5%

(b) major deterioration covering 9% to 18% of the surface area of the body – 5% to 8%

(c) major deterioration covering 18% to 36% of the surface area of the body: – 8% to 15%

(d) major deterioration covering 36% and more of the surface area of the body: – 15% to 100%

(D) CUTANEOUS TELANGIECTASIA OF OCCUPATIONAL ORIGIN

Compensated on the basis of number, extent and location of the lesions: – 0.5% to 3%

O.C. 1948-82, Sch. A.

REFERENCES

O.C. 1948-82, 1982 G.O. 2, 3099