Social Security Disability & SSI Benefits: Fractures

Benefits Depends On Meeting Two Criteria

Social Security Will Review Your Medical Evidence

Important Issues. Broken bones and fractures are common, and Social Security sees a lot these types of cases. You need certain medical evidence to prove disability. You also need to be aware of three particular issues relevant to a Social Security disability and SSI fracture case. First, your fracture will need to be very severe and this nearly always means you have fracture complications. Second, your fracture will need to meet the Duration Requirement. Third, braces and ambulation devices are common.

Fractures can occur anywhere in the body. The most common parts of the body wherein a person suffers a disabling fracture is -

1. Neck vertebrae,
2. Back vertebrae,
3. Legs (foot, ankle, tibia, fibia, femur),
4. Hip,
5. Arms (wrist, ulna, radius, humerus).

Fracture Complications. Let's start with complications. If you have a fracture, it is usually set by a doctor, and it heals. Some fractures, commonly spinal fractures, are left to heal on their own. These types of fractures typically cause some short-term limitations, heal within a couple months, and rarely result in a disability. Nearly all successful Social Security disability and SSI fracture cases are ones wherein the bone has not healed (a nonunion) or the trauma causing the fracture has also caused tissue or nerve damage, excessive scar tissue, bone or tissue infections, necrosis (death of body tissue), or another medical condition like complex regional pain syndrome/reflex sympathetic dystrophy.

Diagnosis. Social Security will obtain your medical records. You will need to have evidence of the unhealed bone/fracture. This is the one of the few situations when a x-ray is sufficient to establish a diagnosis. However, fractures normally heal quickly (couple months) and are not disabling. Fractures with complications are often disabling. In this case, addition testing will be done to 1) determine why the fracture is not healing correctly, 2) diagnose any additional medical condition that may be causing the nonunion, or 3) diagnose any new medical condition caused by the fracture. This may include a CT scan, MRI, or bloodwork (infections). If you have nerve damage, an EMG will be performed.

Symptoms. Upon review of your records, Social Security focus on your symptoms which are generally -

1. Pain,
2. Numbness,
3. Weakness,
4. Reduced range of motion, and
5. Wound symptoms (tenderness, redness, swelling, drainage, and fever).

Treatment. Your ongoing medical treatment is important. Again, you will need to show fracture complications to win your case, and how you doctors address these complications with treatment will demonstrate how severe your complications are -

1. Medications (pain, inflammation, antibiotics);
2. Vitamins;
3. Wound care;
4. Physical therapy;
5. Cessation of smoking (if you are a smoker),
6. Casts and braces;
7. Canes, walkers, shower chair, and wheelchairs; and
8. Surgeries (usually fusions of the bone with hardware or debridement of tissue).

Duration Requirement. The Duration Requirement is part of Step One of both the adult and child disability criteria. To receive Social Security and SSI disability benefits, you must meet the Duration Requirement which requires your medical condition -

1. Results in death,
2. Is expected to last 12 months, or
3. Has lasted 12 months.

If your fracture has not resulted in complications, you will nearly always not meet the Duration Requirement, and your case will be denied.

Assistive Devices. Assistive devices are extremely common in facture cases: cast, brace, cane, shower chair, walker, or wheelchair. If you use an assistive device, you must document 1) your need for a device, and 2) your use of the device which is discussed on our next page - Functional Limitations.

Social Security & SSI Fracture Listings

The listing for a femur, tibia, pelvis, or tarsal bones fracture is Adult Listing 1.06. You will need to show 1) a nonunion of your fracture, 2) an inability to ambulate (walk) effectively, and 3) your functioning has not and is not expected to be restored for at least 12 months.

The listing for an upper extremity fracture is Adult Listing 1.07. You will need to show 1) a nonunion of your fracture, 2) ongoing surgeries, and 3) your functioning has not and is not expected to be restored for at least 12 months.