RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXX		BRANCH OF SERVICE: ARMY
CASE NUMBER: PD0900275	  BOARD DATE: 20090825
SEPARATION DATE: 20060418
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SUMMARY OF CASE:  This covered individual (CI) was an E5 medically separated from the Army in 2006 after 6 years of service.  The medical basis for the separation was chronic left wrist pain and fusion.  The CI suffered a crush injury to his left (non-dominant) wrist in Jan 2005.  He had multiple left wrist surgeries and a successfully treated bone infection.  His left wrist bone fixations, limited wrist range of motion, and pain resulted in inability to accomplish most Soldier tasks. The CI was referred to the PEB, found unfit and separated at 10% disability.
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CI CONTENTION:  "I have a current rating by the VA of 40% for Loss of Motion of Wrist and also have a claim pending for an increase in service-connection due to surgery on 12/12/08. At that time the wrist was fused using a bone graft from my hip and placement of a metal plate."
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RATING COMPARISON:

Previous Determinations 	
Service	VA Exam 4 months post separation	
PEB Condition	Code	Rating	Date	Condition	Code	Rating	Exam Date	Effective date	
Chronic left wrist pain and loss of motion of the wrist following crush injury between tailgate and tool box Status post IC-wire fixation of a trans scaphoid perilunate fracture dislocation and subsequent hardware removal and debridement for Osteomyelitis that has resolved Has pain with strenuous use of the wrist and very limited wrist motion (dorsiflexion to volar flexion arc of 3 ° to 5°) 	5215	10%	20060224	Residual. S/P Left Wrist
Fracture and Fusion	5214	40%	20070725	20070419	
Intermittent lower back pain		Not unfit	20060224	-					
-				Scar s/p Left wrist
fusion	7804	Deferred
Then 0%		20070419	
TOTAL Combined:  10%	TOTAL Combined (incl non-PEB Dxs):  40% 	

ANALYSIS SUMMARY:

Chronic Left Wrist Pain and Loss of Motion. The CI is right-hand dominant Armament Repairer who injured his left non-dominant wrist on 20050125 via a crushing mechanism.  He had a transscaphoid/perilunate fracture dislocation of his left wrist, with associated fractures of the capitate and lunate and underwent K-wire fixation on 20050124 (the first of 3 surgeries)  The second surgery was performed on 20050307 where fragments of his scaphoid were excised, and a bone graft was inserted radially Allomatrix bone graft inserted an extensor policis longus and extensor digitorum longus tenolysis were performed.  A four corner fusion was performed.  The CI suffered an infection (Osteomyelitis) and had surgical debridement, removal of hardware, and insertion of medicated beads.  The CI's rehabilitation with Occupational therapy did not return him to full function and he cannot do pushups, lift more than 20 pounds, and has decreased range of motion of his left thumb. The CI has occasional nighttime pain and has persistent numbness at the dorsum of the wrist, and the first web space since his injury.  The CI's scar healed well and all muscles distal to the wrist were graded 5/5 including intact and strong adductor of the thumb, as well as flexor.  Modest decreased range of motion to the thumb, with a decreased adduction was noted.  The CI retained full flexion of the fingers with excellent extensor function of the first through fifth fingers.  There was no distinct swelling or tenderness and two-point sensation was 5 mm (normal). X-Rays support the post surgical changes with a pseudoarthrosis of the proximal carpal row, with an appearance consistent with missing bone on the proximal carpus.

Pronation is present to 80 degrees on the left versus 85 degrees on the right.  Supination is present to 60 degrees on the left versus 80 degrees on the right.  Two left wrist range of motion measurements substantially agree with "dorsiflexion to volar flexion are of 3 to 5 degrees at the most" and active range of motion measurements of 20051215 using a goniometer demonstrated left wrist extension 0 to 1 degree, flexion 0 to 2 degrees. All exams showed Ulnar deviation and radial deviation were both 0.

VA exam of 20070728 demonstrated left wrist fixed at 5° of dorsi and volar flexion and 0° radial and ulnar deviation.  (Range of Motion: All measurements are in degrees; first number is start of ROM; second number is when pain begins within the ROM; third number (if used) is the end of AROM; Reference range of normal ROM is in parentheses;  Wrists: the wrist is fixed at 5 degree of dorsi volar flexion, Palmar: (fixed at 5 degree of dorsi flexion 10-10) L with active, passive; R (0-80-80) active, passive some increase in pain up to 7 out of 10 and fatigue of the wrist noted on the left.  Dorsi: (5-10-10) active passive with increased pain noted and fatigue of the left wrist L; R (0-7070) active, passive.  Radial: (0-0-0) active, passive L; R (0.20-20) active, passive.  Ulnar: (0-0-0) active, passive L; R (0-45-45) active passive).  The VA narrative noted: ...examiner recorded your left wrist range of motion as follows: dorsi flexion began at 5 degrees, with pain at 10 degrees, and ended at 10 degrees (normal range of motion begins at 0 degrees and ends at 30 degrees); palmer flexion began at 5 degrees, with pain at 10 degrees, and ended at 10 degrees (normal range of motion begins at 0 degrees and ends at 80 degrees); radial deviation began at 0 degrees, with pain at 0 degrees, and ended at 0 degrees (normal range of motion begins at 0 degrees and ends at 20 degrees); and ulnar deviation began at 0 degrees, with pain at 0 degrees, and ended at 0 degrees (normal range of motion begins at 0 degrees and ends at 45 degrees).  Pain and fatigue were noted throughout the examination.  -- With an evaluation of 40 percent is granted for unfavorable ankylosis of the wrist in any degree, of palmar flexion.

This VA interpretation of exam differs from the military exam in that the VA narrative noted unfavorable ankylosis of the left wrist in palmar flexion of 5° (not able to come to 0° of palmar flexion).  However, I do not interpret the VA exam details in that manner as there was dorsi flexion noted at 5°.  The CI's post separation surgery cannot be considered in the rating determination beyond lending credence to the diagnosis, exams, and disability limitations at the time of separation. Of note, the VA subsequently rated the CI at 40% post his 4th surgery.

Intermittent Lower Back Pain. This condition was found not unfitting and was not contended.  There is no evidence in the record to indicate that it should rise to the unfitting level.
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BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the PDBR to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  There is a major disparity in VASRD code selection between the military and the VA and the Board unanimously agreed that the VA code was predominate.  The PEB coded the left wrist under 5215 Wrist, limitation of motion which has a maximum 10% rating for dorsiflexion less than 15°.  The PEB-noted limitations of "very limited wrist motion (dorsiflexion to volar flexion arc of 3° to 5°)" and two military exams including the NARSUM noted 0° ulnar deviation and 0° radial deviation.  This severe multi-axis limitation depicts left wrist ankylosis, better coded under 5214 Wrist, ankylosis.  As the CI is right handed (left is Minor), and the wrist is ankylosed, but not favorably (20° to 30° dorsiflexion) this would equate to the 30% rating criteria of 5214 using only the Army exam(s).  The VA exam was 4 months post separation and the wrist condition may have worsened.  De-novo rating of the VA exam would also rate at 30%.  The VA rated that exam at 40% due to ankylosis in palmar flexion, but that was not supported by reviewing details of the VA exam.  The Board unanimously voted for a rating of 30% using code 5214.  
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RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows and that the discharge with severance pay be recharacterized to reflect permanent disability retirement, effective as of the date of the CI’s prior medical separation. 

Unfitting Condition	VASRD Code	Rating	
Residual. S/P Left Wrist Fracture and Fusion	5214	30%	
Combined	30%	
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The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20090329, w/atchs.
Exhibit B.  Service Treatment Record.
Exhibit C.  Department of Veterans' Affairs Treatment Record.