Listing 1.23 Non-Healing or Complex Fracture of an Upper Extremity in 2026: The Full Blueprint on Paragraph A Fine and Gross Movement Loss and Paragraph B Documented Medical Need for a One-Handed Assistive Device Under Continuing Surgical Management for Humerus, Radius, and Ulna Non-Union and Malunion

By Anthony Albert, Benefits Research Director at Disability Exchange. Updated for 2026 claims. This is a companion piece to our Listing 1.22 lower extremity non-union deep dive. Read that first if you haven't, because 1.22 and 1.23 share the same 2021 revision language and much of the same evidence structure.

Here is the quick version. Listing 1.23 is SSA's Blue Book pathway for a non-healing or complex fracture of the humerus, radius, or ulna where the person is under continuing surgical management. The 2021 musculoskeletal revision rewrote this listing to make it much more demanding than the pre-2021 version. Two paragraphs. Paragraph A requires functional loss in the fingers and hand. Paragraph B requires documented medical need for a one-handed assistive device. You only need to meet one.

Here's the wrinkle that trips up most claimants. Continuing surgical management is not a suggestion. If your fracture healed uneventfully or if you had one surgery and then were released to home therapy, 1.23 does not fit. You need ongoing operative intervention or a treatment plan that includes anticipated future surgeries. Without that, DDS bumps you out of 1.23 and forces you into Step 5 RFC analysis, which is a harder win.

The other wrinkle is that a one-handed assistive device is not what most people think it is. A cane for balance? Not a 1.23 device. A wrist brace? Not a 1.23 device. A one-handed keyboard? Not a 1.23 device. What SSA counts under 1.00C6d(ii)(B) is a device that takes the place of the affected upper extremity for work-related activities. Very specific. We'll get to it.

What the 2026 listing actually says (verbatim)

Note that 1.23 uses "and" not "or." Both prongs must be met. Contrast this with 1.19 pathologic fractures where Paragraph A (three fractures in 12 months) is joined to Paragraph B (functional loss) by "or." Very different rules. Don't mix them up.

1.00O1: What "continuing surgical management" actually means

1.00O1 defines continuing surgical management as surgical procedures and any other associated treatments related to the efforts directed toward the salvage or restoration of functional use of the affected part. It may include multiple surgical procedures over a period of time. The rule specifically covers grafting for infection or nonunion, revisions, and reconstructions. Post-operative treatment such as prescribed physical therapy is included.

The 12 month duration test in Paragraph B references 1.00O1 to answer the "is expected to last" question. If your surgeon has already scheduled a second procedure, or is planning one, or is treating you with the expectation of future revision, you meet the continuing surgical management prong. If your surgeon closed you out and said "come back if you have problems," you probably don't.

What counts as continuing surgical management in 2026:

• Staged bone grafting (autograft iliac crest, allograft, bone morphogenetic protein 2, RIA graft harvest)
• Exchange nailing of humerus for aseptic non-union
• ORIF revision with locking plate after failed primary construct
• Debridement and antibiotic spacer for infected non-union followed by planned second-stage reconstruction
• Ilizarov external fixation with monthly adjustments
• Bone transport with hexapod fixator
• Free vascularized fibula graft to reconstruct segmental humeral or ulnar loss
• Masquelet induced membrane technique (cement spacer then graft)
• Ulnar or radial osteotomy for malunion correction
• Radial head arthroplasty followed by planned revision
• Elbow arthrodesis or total elbow arthroplasty for post-traumatic destruction

1.00E4: What "fine and gross movement" loss means

1.00E4 gives the operational test for Paragraph B. Inability to independently initiate, sustain, and complete work-related activities involving fine and gross movements. Fine movements are hand-related: pinching a paper clip, buttoning a shirt, using a keyboard, holding a coin. Gross movements are arm-related: reaching overhead, pushing a drawer closed, carrying a file box, lifting a laptop.

Two hands do many jobs. One hand can do fewer. The test in 1.00E4 asks whether the affected extremity by itself can do fine and gross movements to a work-relevant standard. If it cannot, and the impairment has lasted 12 months or is expected to, Paragraph B is met.

Note the word "independently." SSA wants to see whether you can do the movement without adaptive equipment, without one-handed workarounds, and without the other extremity helping. If your right dominant arm has a non-union humeral shaft fracture with a external fixator on for 8 months and counting, and you have to use your left hand to write, eat, dress, drive, and type, then the right arm is functionally out of service. That's the point.

1.00C6d(ii)(B): The one-handed assistive device specifics

The Blue Book language is specific. Documented medical need for a one-handed assistive device that involves the use of the other upper extremity, or being unable to independently initiate, sustain, or complete work-related activities involving both hands.

Practically this means devices that require the good arm to operate a compensatory tool. Examples:

• One-handed can opener requiring the good arm to crank
• Adaptive knife with a rocker blade requiring the good arm to press down
• Dycem non-slip mats to stabilize objects for one-handed use, requiring the good arm to work over the mat
• Button hooks, sock aids, elastic shoelaces
• One-handed keyboards requiring the good arm to type
• Adapted phone cradles or Bluetooth headsets for hands-free phone use

The rule doesn't literally require you to own these devices. It requires medical documentation that you need them, meaning the treating team has documented (in a note, in a home safety evaluation, in an OT assessment) that you cannot do bilateral hand tasks and need adaptive tools that involve the unaffected upper extremity.

Complex fractures of the humerus, radius, and ulna: what we see

Humeral shaft non-union

Adult humeral shaft fractures have a 5 to 15 percent non-union rate. Risk factors: open fracture, comminution, distraction at the fracture site, obesity, smoking, diabetes, NSAID use in early healing, radial nerve injury requiring exploration. Standard treatment for non-union is exchange nailing with reaming or ORIF with a locking compression plate plus autograft. In 2026 the Masquelet technique is popular for segmental defects: first stage cement spacer, second stage graft into the induced membrane 6 to 8 weeks later.

What we see in the file: initial ORIF with plate, screws loose at 4 months, plate exchange with longer construct, still not healed at 8 months, staged bone graft. Now the claimant is 12 months post original injury with a locked non-union, still under active surgical management. Bulletproof continuing surgical management case if properly documented.

Radial shaft and ulnar shaft (both-bone forearm)

Both-bone forearm fractures require ORIF with anatomic reduction. The radius is a curved bone and a straight plate creates a proximal-to-distal radioulnar synostosis nightmare. Complications: synostosis (bony bridge between radius and ulna), loss of pronation-supination, non-union, malunion.

Complex forearm cases involve: Galeazzi fracture (radial shaft plus distal radioulnar joint dislocation), Monteggia fracture (ulnar shaft plus radial head dislocation), Essex-Lopresti injury (radial head plus interosseous membrane plus DRUJ), floating elbow. Each requires staged reconstruction. Each keeps the patient under continuing surgical management for many months.

Distal humerus and elbow destruction

Distal humeral fractures involving both columns (AO C3) are technically demanding. Non-union of the intercondylar segment leads to loss of elbow extension and flexion. Salvage options: revision ORIF with total elbow arthroplasty (TEA) reserved for elderly non-reconstructable cases. Post-traumatic elbow arthritis at 5 years is 60 percent or higher.

Segmental bone loss (open fractures)

Gustilo-Anderson IIIB and IIIC open forearm and humerus fractures with segmental bone loss present a reconstructive challenge. Options: acute shortening, distraction osteogenesis with Ilizarov or hexapod frame, Masquelet, free vascularized fibula graft. These cases stay under continuing surgical management for 18 to 30 months and are strong 1.23 candidates.

The evidence file SSA needs to see for a 1.23 case

• Original injury records: ED note, initial radiographs, surgical consent, operative report from index procedure.
• Serial radiographs at each followup showing lack of callus formation, hardware loosening or breakage, malalignment.
• CT scans of the affected bone documenting non-union (RUST score under 10 out of 16 at 9 months, absence of bridging callus).
• Operative reports from each subsequent surgery. Include description of atrophic versus hypertrophic non-union at time of exposure.
• Cultures if infection is a factor (tissue biopsy at revision, sensitivities, antibiotic regimen).
• Physical therapy notes with dates, frequency, active and passive range of motion measurements, grip strength (Jamar dynamometer), pinch strength.
• Occupational therapy notes with adaptive equipment recommendations and home safety evaluation.
• DASH (Disabilities of the Arm, Shoulder, and Hand) questionnaire scores, QuickDASH, MHQ (Michigan Hand Questionnaire), PRWE (Patient-Rated Wrist Evaluation).
• Treating orthopedic surgeon's medical source statement on HA-1152 or attorney template.

Worked Example 1: Humeral Shaft Non-Union Under Paragraph A (functional loss)

Worked Example 2: Complex Both-Bone Forearm Under Paragraph B (one-handed device)

Common file-building mistakes on 1.23 claims

Mistake 1: Filing before continuing surgical management is clear

If you file at 4 months post-injury and only had one surgery, DDS often sees a fresh fracture and denies for lack of 12-month duration. Better strategy: wait until you have at least one revision or a clear plan for staged reconstruction, then file. Or file at 4 months and be prepared to appeal with new operative reports as they come in.

Mistake 2: Not distinguishing atrophic from hypertrophic non-union

Atrophic non-union has poor blood supply, no callus, and is a hard treatment problem. Hypertrophic non-union has good biology, callus present but not bridging, and often heals with better mechanical stability. The pathology matters because DDS reviewers sometimes assume non-union is non-union. Documenting atrophic pattern strengthens the continuing surgical management argument because it predicts more procedures.

Mistake 3: Forgetting the "shaft" limitation in the listing

Listing 1.23 specifies shaft of the humerus, radius, or ulna. Metaphyseal fractures (proximal humerus, distal radius Colles) are technically not shaft. If your Colles fracture is non-united, you don't literally meet 1.23. You'd argue medical equivalence, or route through 1.18 abnormality of a major joint (wrist), or 1.20 amputation if a partial hand amputation occurred, or 1.17 reconstructive surgery of a major weight-bearing joint (doesn't fit for wrist).

Mistake 4: Missing the fine and gross movement documentation

You need actual measurements. Grip strength in pounds. Pinch strength. DASH scores. Range of motion in degrees. Without objective data, the "inability to independently initiate, sustain, and complete work-related activities involving fine and gross movements" is a subjective statement and DDS will discount it.

Mistake 5: Assuming a wrist brace equals a one-handed assistive device

A wrist brace is an orthotic that supports the affected extremity. It's not a one-handed assistive device under 1.00C6d(ii)(B). The rule requires a device that involves the OTHER upper extremity or that is needed because you cannot do bilateral tasks. Wrist brace: no. Rocker knife: yes.

Mistake 6: Filing without OT documentation

Occupational therapy notes are the anchor for Paragraph B. If your surgeon sees you every 6 weeks and gives you 15 minute visits, you probably don't have the ADL and adaptive equipment documentation you need. Ask for an OT referral. Ask for a home safety evaluation. Ask for adaptive equipment prescriptions.

Grid rules if 1.23 doesn't quite fit

If your case falls short of 1.23 but has significant upper extremity limitations, Step 5 RFC analysis kicks in. Grid Rule 202.06 applies to a 55+ year old with limited education and skilled or semi-skilled work with non-transferable skills. Grid Rule 201.14 applies to 50 to 54 year olds with high school and skilled non-transferable skills at sedentary. Add manipulative limitations (occasional versus frequent handling and fingering) to the RFC and you often erode all light and sedentary work, leaving no jobs at Step 5.

2026 SGA and payment picture for 1.23 claims

Substantial Gainful Activity in 2026 is $1,620 per month non-blind, $2,700 per month statutorily blind. SSDI benefit amounts range from $1,000 to $4,018 per month depending on lifetime earnings. Maximum SSDI in 2026 is $4,018.

Medicare eligibility after 24 months of SSDI entitlement (5 month waiting period plus 24 month qualifying period = 29 months from onset). Impairment-related work expenses for 1.23 claimants might include: adaptive tools, ergonomic work station, OT copays, extra transportation because driving is impaired, hand therapy sessions above insurance coverage.

How to Build a Winning 1.23 File in 7 Steps

1. Confirm your fracture location is covered. Shaft of the humerus, radius, or ulna. Colles and distal radius metaphyseal fractures do not literally meet 1.23.
2. Document continuing surgical management. Collect operative reports from every procedure. Ask your surgeon for a note stating anticipated future surgeries or ongoing operative treatment.
3. Get objective functional data. Grip strength (Jamar), pinch strength, DASH, QuickDASH, MHQ, PRWE, active and passive range of motion. Have PT and OT document these regularly.
4. Get OT adaptive equipment documentation. Prescribed one-handed devices, home safety evaluation, ADL scoring (Barthel, FIM).
5. Get the medical source statement. HA-1152 from your orthopedic surgeon documenting continuing surgical management, expected duration, and functional limitations.
6. File the application. Include all operative reports, imaging, and treating physician records. Reference 1.00O1 and 1.00E4 in your allegation.
7. Appeal denials with fresh records. Non-union cases mature over time. What looks borderline at 8 months often looks clear at 14 months. Keep records flowing to DDS and appeal within 60 days if denied.

Frequently asked questions about Listing 1.23

Related deep dives on this site

• Listing 1.15 Spinal Nerve Root Compromise
• Listing 1.17 Reconstructive Surgery Major Joint
• Listing 1.18 Abnormality of a Major Joint
• Listing 1.19 Pathologic Fractures
• Listing 1.20 Amputation
• Listing 1.22 Non-Healing Lower Extremity Fracture