RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXX	 CASE:  PD 13-00373
BRANCH OF SERVICE:  Army	 BOARD DATE:  20130731 DATE OF PLACEMENT ON TDRL:  20060313
Date of Permanent SEPARATION:  20080530		 

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SGT/E-5 (92F/Petroleum Vehicle Operator) medically separated for  left (non-dominant) fifth finger amputation.  The CI was injured while deployed to Iraq while driving his vehicle to get armor put on; an IED exploded in proximity to his vehicle.  CI sustained blast injuries to his right and left hands.  CI immediately had amputation of the left fifth digit, and injuries to both thumbs and shrapnel to right side of scalp.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards.  He was issued a permanent U3 profile and referred for a Medical Evaluation Board (MEB).  The left (non-dominant) fifth finger amputation condition characterized as medically unacceptable and was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded two other conditions see rating chart below for PEB adjudication.  The informal PEB adjudicated left (non-dominant) fifth finger amputation and bilateral thumb pain with scarring as unfitting, rated 10% and 10%, citing criteria of the US Army Physical Disability Agency (USAPDA) pain policy.  However, the PDA changed the rating to bilateral thumb pain due to intramuscular scarring at 20% and left (non-dominant) fifth finger amputation through proximal phalanx at 10% and placed member on the TDRL effective 13 March 2006 citing criteria of the US Army Physical Disability Agency (USAPDA) pain policy and Veteran’s Affairs Schedule for Rating Disabilities (VASRD).  Effective 13 June 2007 the CI was released from TDRL for left fifth finger amputation through the proximal phalanx at 10% and bilateral thumb pain due to intramuscular scarring condition not independently unfitting.  The CI made no appeals, and was medically separated with a 10% Service disability rating.  

CI CONTENTION:  “My current rating with VA is 60%.”  
_____________________________________________________________________________

SCOPE OF REVIEW: SCOPE OF REVIEW: The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e. (2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI.  The Service ratings for the unfitting left fifth digit amputation, left thumb pain due to scarring and right thumb pain due to scaring conditions is are addressed below; and, no additional conditions are within the DoDI 6040.44 defined purview of the Board.  Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the respective Service Board for Correction of Military Records.

RATING COMPARISON: 

Final Service PEB - 20070613	VA (3 Mo. After DOS) - Effective 20060501	
On TDRL - 20060313	Code	Rating	Condition	Code	Rating	Exam	
Condition		TDRL	Sep.					
Left (non-dominant) Fifth Finger Amputation	7804	10%	10%	Amputation, Fifth Finger, Left Hand	5156	10%	20060612	
				Painful Scar, Left Hand	7804	10%	20060612	
				Painful Scar, Fifth Finger, Left Hand Associated with Amputation, Fifth Finger, Left Hand	7804	10%	20060612	
Bilateral Thumb Pain due to Scaring	5309	20%	Not Unfitting	Painful Scar, Right Thumb	7804	10%	20060612	
No Additional MEB/PEB Entries	Other x 6	20060525	
Combined:  30% → 20%	Combined: 50%	

ANALYSIS SUMMARY:  

Left (non-dominant) Fifth Finger Amputation Condition and bilateral thumb.  The TDRL entry narrative summary (NARSUM) of 3 February 2006 stated the right hand dominate CI while in Iraq (April 2005) and driving his vehicle was involved in an IED explosion.  He sustained blast injuries to both hands.  The CI’s left fifth digit was immediately amputated before the first knuckle; both thumbs received soft tissue injury.  He was medevaced CONUS for further treatment and care.  Radiographs of bilateral thumbs, 31 May 2005, were normal; no radiopaque foreign body seen.  The CI reported pain in bilateral thumb pads and left amputation site.  Clinical examination recorded the presence of shrapnel in both thumbs and a stable partial amputation of the fifth digit.  Physical examination of the hands 7 October 2005 recorded good ability to make fist and no evidence of neuropathy.  Repeat x-rays of the hands, May 2006, were normal.  Occupational therapy (OT) examination, 6 February 2006, recorded range of motion (ROM) right thumb MCPJ to be normal.  The examiner assessed significantly decreased left hand gross grip strength and sensitivity in bilateral thumb pads.  Radiographs of bilateral hands, 12 June 2006 recorded the presence of a few small metallic foreign bodies in the soft tissue adjacent to the distal phalanx of the left third finger.  Mild flexion deformity at the proximal interphalangeal joint (IPJ) of the right fifth finger was noted.  The CI was given a trial of duty to see if he would be able to fire his weapon.  He was unsuccessful and was referred to the MEB.  At the entry TDRL NARSUM MEB exam 3 February 2006, physical examination documented well healed stump of the left fifth amputated digit;  mild right fifth digit contracture and small scar wounds at the right and left  thumb pads each less than 1.5 cm in length.  The examiner referenced ROM performed by OT and referenced above.  The CI reported pain in both thumbs and amputated digit and stated the loss of strength was mainly on the left hand.  He reported decreased ability to lift any kind of weights.  The CI’s profile allowed weights up to 20 pounds.  The PEB placed the CI on TDRL for the unfitting conditions as charted above.  At the VA Compensation and Pension (C&P) examination on 12 June 2006, approximately four months after being placed on TDRL and 11 months before separation, the CI reported moderate to severe hand pain with weather changes and with the use of vibrating type equipment such as lawn mowers.  He denied constant pain.  Examination of the bilateral thumbs, recorded normal palmar flexion without pain and small scars on the each thumb pad, with some pain on examination.  There was no evidence of tissue adherence, instability,   elevation or depression of the scars on palpation and no evidence of inflammation, edema, or keloid formation.  There was no inflexibility or limitation of motion caused by the scar.  Examination of the left fifth digit showed no evidence of inflammation, deformity or tenderness of the amputation site.  There was no evidence of neurovascular compromise and muscle strength was normal.  On OT examination 13 April 2007, approximately six weeks before separation, the CI The examiner reported occasional phantom pain at the amputation site.  On examination normal movement of fifth finger metacarpophalangeal joint bilaterally, normal neurological examination of both hands, and, decreased grip strength of left hand with sensitivity to pressure and temperature in the left thumb were noted.  At the TDRL exit NARSUM of 14 May 2007, less than a month before separation, the CI reported improvement in the motion in his thumbs but continued to have pain when ‘using his hands a lot’.  The CI was working as a local truck driver.  He noted main occupational areas affected by the conditions to be mowing grass, activities with vibration, and working with high impact tools.  Physical examination of the both hands and, thumbs, recorded normal ROM of the thumb and full opposition.  Pain with motion was elicited during ROM testing on this exam but was not present on OT examination the same day.  Muscle strength was normal and there was no evidence of neurological or vascular compromise.  Grip strengths, and neurovascular exams were normal bilaterally.  Mild tenderness was noted at the amputation site.  The examiner recommended removal from TDRL status citing the improved and stable condition.  The Board directs attention to its rating recommendation based on the above evidence.  At TDRL entry, the PEB adjudicated the left fifth finger amputation coded 5156 (amputation) at 10%.  The PEB initially adjudicated the bilateral thumb condition as unfitting, coded analogously 5003 for bilateral pain, created an amended adjudication under code 5309 and rated the condition at 10% each thumb.  The higher 20 % rating under 5156 requires a greater than 50% bone loss, necessitating metacarpal resection, not supported by evidence.  The Board deliberated whether the CI’s bilateral thumb condition met the 10%, or the 20% 5309 rating at the time of TDRL entry.  The 20% evaluation requires severity involving debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring.  The Board opined that the evidence in the record did not support a higher than 10% rating for each thumb based on criteria.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the left fifth digit and bilateral thumb conditions at TDRL entry.  At the conclusion of TDRL, the PEB, 13 June 2007, adjudicated the left amputated fifth digit condition as unfitting rated as 7804 at 10% for painful scar.  The PEB noted the bilateral thumb pain due to scarring was not found to be separately unfitting and therefore this condition was not rated.  The Board undertook a careful review of the treatment records and noted at the time of the exit NARSUM the CI was fully employed, had no limitation on range of motion in either thumbs and no evidence of functional loss in the use of his thumbs.  There was no evidence of ratable neuropathy or vascular compromise.  The Board agreed the record in evidence supports neither thumb condition was unfitting at the time of TDRL exit and, thus, not ratable.  There were no other applicable VARSD codes to consider in the rating of the left fifth digit condition.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the left fifth finger and bilateral thumb conditions.  

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 Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the left fifth digit condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the bilateral thumb condition, the Board unanimously recommends no change from the PEB determination as not unfitting.  There were no other conditions within the Board’s scope of review for consideration. 

RECOMMENDATION:  The Board, therefore, recommends that there be no recharacterization of the CI’s disability and separation determination, as follows:  

UNFITTING CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
Left Fifth Finger Amputation	7804	10%	10%	
Bilateral Thumb Pain Due To Scarring	5309	20%	Not Unfitting	
COMBINED	30%	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130511, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

			

SFMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXXXXXXXXX, AR20140000083 (PD201300373)

I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual.  Under the authority of Title 10, United States Code, section 1554a,   I accept the Board’s recommendation and hereby deny the individual’s application.  
This decision is final.  The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Encl