RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00095
BRANCH OF SERVICE:  Army	BOARD DATE:  20150407
SEPARATION DATE:  20060323

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Infantryman) medically separated for loss of some function of left hand resulting from a gunshot wound.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty.  He was issued a permanent U3 profile and referred for a Medical Evaluation Board (MEB).  The “loss of function left hand secondary to gunshot wound (GSW)” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded one other condition (intermittent cervical/lumbar pain) for PEB adjudication.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “history of gunshot wound during combat in Iraq with some loss of left (non-dominant) hand function,” as unfitting, rated 10%, citing application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining condition was determined to be not unfitting.  The CI made no appeals and was medically separated.

CI CONTENTION:  “I believe the rating I received did not reflect the severity of my gunshot wounds or the permanent damage retained after recovery.”

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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military/Naval Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.

RATING COMPARISON:

IPEB – Dated 20060103	VA* - (~4 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Some Loss of (Non-Dominant) Left Hand Function	5399-5309	10%	Status Post Extensor Tendon Surgery, Residuals, Gunshot Wound Left Hand with Amputation Distal Phalanx Index Finger	5310-5221	30%	20060707	
Other x 1 (Not In Scope)	Other x 5	
RATING:  10%	RATING:  60%	
*Derived from VA Rating Decision (VARD) dated 20060807 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Left Hand Condition.  While deployed on 16 February 2004, the CI received a high velocity GSW to his left (non-dominant) hand with superficial shrapnel wounds to his left shoulder.  The case file did not comment on the presence of any exit wound.  He was evacuated from theater and underwent multiple surgeries for wound debridement, irrigation, reduction of multiple fractures, tendon transplantation, bone grafting and reconstruction.  Post-operatively, he underwent extensive physical therapy and occupational therapy for muscle strengthening as well as, range of motion (ROM) and grip control.  He was permanently profiled in August 2004 and an MEB was initiated.

At the MEB narrative summary on 17 November 2005; 4 months prior to separation the CI reported pain upon use of his left hand.  Additionally, he endorsed, “…the inability to perform aggressive use with his left hand such as push-ups, pull-ups, pulling, prolonged griping, prolonged strength use and fine manipulation.”  The examiner described the CI’s functionality of his left hand condition as the following:

He does have problems with typing; he has to use his index finger in a "hunt and peck" method.  He cannot play the guitar which he could do previously.  He has trouble with holding and tightening screws or anything that requires significant resistance against the use of the left hand.  The functional use of the hand, as far as holding screws at certain angles, he is not able to do.  He has trouble getting change out of his left pocket.  He has significant difficulty with grip of the left hand, primarily because of no flexion at the metacarpal-phalangeal joint of the little finger over the ulnar aspect of the left hand.

The physical examination (PE) revealed healed scars over all four fingers, wrist, and left forearm.  The tip of the left index finger was amputated and the little finger was shortened in comparison.  He was unable to form a fist of the left hand.  Atrophy was present about the thumb and index finger.  Intrinsic motion (abduction and adduction) of the left hand fingers were absent.  ROM was decreased in the first three fingers; excluding the thumb and little finger.  Light touch sensation was decreased by approximately 50% about the back of the left hand.  His list of diagnoses was numerous and secondary to the initial gunshot injury and included bone, muscle, tendon, and neuro-sensory components.

At the VA Compensation and Pension examination on 7 July 2006; 4 months after separation, the CI reported continuous left hand pain associated with weakness, stiffness, diffuse swelling and the inability to freely get a grip with his left hand.  Additionally, he endorsed daily painful flare-ups lasting 2-3 hours.  The examiner noted, “the range of motion (ROM) is not easily monitored because there are so many impacted areas with loss of tendon space, tendon sheaths, attachments, and loss of joints as well as reconstructive involvements.  The destruction and then the reconstruction have markedly limited his joint function; however, pain seems to be the over-riding limiting factor.”  The VA PE revealed a significantly damaged and distorted hand.  There was decreased wrist and finger ROM.  The complete back of the hand revealed a loss of sensation.  The diagnosis remained left hand GSW with residuals.

The Board directed attention to its rating recommendation based on the above evidence.  The service analogously coded the condition under the VASRD Group IX muscle code which specifically noted the rarity of injured hand muscles and therefore, rate on limitation of motion; minimum of 10%.  The VA dual coded the condition under VASRD §4.73 and §4.71a noting muscle Group X (5310) as well as favorable ankylosis of four digits (5221) (excluding the thumb) at 30%.  Board members first agreed that the VA’s code 5310 was listed in error for that code specifies muscles of the foot.  All members acknowledged that individual ROM of the left fingers, hand, or wrist was non-compensable under VASRD ROM criteria.  In this case, the extensive amount of anatomic destruction paved the way to consider rating options under a variety of separate body systems to include joint, muscles, and or nerves.  Under specific joint codes, there was no option available that would benefit the CI from the current PEB’s 10% rating.  In considering a muscle code, the Board agreed that the PEB’s choice of Group IX was appropriate and further agreed in a maximum of a 10% rating.  Clearly, neurologic impairment was present having a significant loss of sensation to the back of his left hand.  The action officer explained that the dorsum of the human hand is provided sensation by a combination of both the radial and ulnar nerves.  Board members considered and agreed that the level of neurologic impairment was below the level of “severe” and more appropriately described as “moderate.”  The maximum rating is 20% for any level below severe.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the left hand condition.

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 hand condition, the Board unanimously recommends a disability rating of 20%, coded 8516 IAW VASRD §4.124a.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:

CONDITION	VASRD CODE	RATING	
Gunshot Wound; Left Hand 	8516	20%	
COMBINED	20%	

The following documentary evidence was considered:
Exhibit A.  DD Form 294, dated 20131226, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-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 XXXXXXXXXXXXXXXXXXXX, AR20150012766 (PD201400095)

1.  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 to modify the individual’s disability rating 20% without recharacterization of the individual’s separation.  This decision is final.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.   

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Encl						

CF: 
(  ) DoD PDBR
(  ) DVA