RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01630
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20061114

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Infantry, medically separated for “left (non-dominant) forearm”, with a disability rating of 20%.

CI CONTENTION:  The CI requested consideration of all MEB conditions in his application.  His conditions continue to worsen and negatively impact his daily activities.  The CI’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (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 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:  

SERVICE PEB - 20060808	VARD - 20070228	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Forearm Injury	5213	20%	S/P Open Fracture…Left Forearm…	5211	20%	20061205	
Nerve Injury L/Forearm	Not Unfitting	Left Ulnar Dysfunction…	8515	20%	20061205	
TBI		S/P TBI	8045-9304	10%	20061210	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Left Forearm Condition.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the right-hand dominant CI injured his left forearm in a motor vehicle accident (MVA) in Iraq, approximately 17 months prior to referral for MEB.  While serving as the gunner of a Humvee, the vehicle went over the side of a bridge and fell approximately 35 feet.  The CI underwent serial left forearm surgeries by orthopedic surgery.  The final 20 April 2005 procedure revealed 3 separate areas of synostosis (fusion of adjacent bones) with heterotopic (abnormal bone growth in non-skeletal tissues) bone formation that prohibited pronation and supination.  The surgeons performed left ulnar hardware removal with a synostectomy (synostosis dissection) and Sauve-Kapandji procedure (ulnar head to radius arthrodesis [surgical fixation/fusion of a joint], resection of a distal ulna shaft segment, and creation of an ulna pseudoarthrosis [false joint or nonunion]).  This procedure involved fusion of an existing joint and creation of a new articulation (pseudoarthrosis).  A left forearm diagnostic imaging (X-ray) study showed interval left ulna hardware removal, two new screws traversing the distal radioulnar joint (DRUJ), and an osseous defect in the distal ulnar diaphysis (shaft).  The NARSUM, 12 months before separation, recounted the history and interventions.  The distal ulna had been resected, with fixation of the distal radius to the ulna, to stabilize the wrist joint and simultaneously allow some forearm rotation.  Left elbow active range of motion (ROM) values for flexion and extension were normal.  Left forearm ROM values were pronation of 20 (80 normal) and supination of 80 (85) degrees.  Left wrist ROM values were extension of 60 (70) and flexion of 65 (80) degrees.  The diagnoses listed left forearm status post open fractures of both bones, healing of radius, partial resection of distal ulna, with limited forearm rotation (not acceptable) and incomplete median and ulnar nerve injury (acceptable).  The surgeon opined that the CI was unlikely to regain additional forearm rotation, but his sensation and strength were likely to improve.  Occupational therapy (OT) measured repetitive ROM for the MEB with a goniometer.  Left elbow ROM values were within normal limits (WNL).  Left forearm ROM values were pronation of 30/30/35 (80) degrees and supination was WNL.  Left wrist ROM values were WNL.  The updated NARSUM by orthopedic surgery, 6 months before separation, recounted the history and interventions.  The CI complained of mild left forearm discomfort with exercises, but pain did not disturb his sleep.  Left hand and forearm sensation (subjective numbness thumb and index finger tips) and strength had improved since the initial NARSUM evaluation.  The CI reported his left elbow was normal but he was aware of left upper extremity weakness and decreased ROM.  His limited pronation interfered with manual tasks and he was unable to simultaneously extend his left wrist and fingers because of scarring and muscle loss.  The CI stated the sensory loss was "not really that bad" and he denied cold sensitivity.  The left upper extremity examination revealed a healed incision and distal forearm wound incorporating a split thickness skin graft.  The left forearm was visibly smaller, and the muscles less bulky, than the right.  Left elbow ROM values for flexion and extension were normal.  Left forearm ROM values were pronation of 15 (80) degrees and supination was normal.  Left wrist ROM values were extension of 60 (70) and flexion of 70 (80) degrees.  Intrinsic muscles innervated by the ulnar nerve had 3/5 strength.  The CI could actively extend all fingers, but lacked ability to simultaneously extend all index finger joints, or flex thumb tip.  He could oppose tips of thumb to all fingers with near normal strength.  Pin prick sensation was intact at all finger tips.  The surgeon cited the ROM measurements by OT for the MEB.  A left forearm X-ray showed retained hardware, a healed radius, the distal ulna transfixed to radius with 2 screws, and a 2 cm segment removed from the ulna shaft.  The diagnoses listed left forearm status post open fractures of both bones, healing of radius, partial resection of distal ulna, with limited forearm rotation (not acceptable) and incomplete median and ulnar nerve injury (acceptable).  The surgeon opined that the CI was unlikely to regain additional forearm rotation, but his strength may improve.  The 5 December 2006 VA Compensation and Pension (C&P) examination recounted the history and interventions.  The CI complained of 2 years of left forearm pain occurring 6 times per week and lasting 5 hours.  The 3/10 pain was characterized as aching and cramping.  Pain was exacerbated by weather changes and activity and relieved by rest.  At the time of pain, he could function without medication, and was not receiving any treatment for this condition.  The left distal upper extremity examination revealed a healed, hyper-pigmented, and disfiguring surgical incision and skin graft.  There was no skin tenderness, ulceration, adherence, instability, tissue loss, inflammation, edema, keloid formation, or hypopigmentation.  There was a palpable gap between the ends of the surgically created ulnar nonunion with left wrist tenderness.  The left elbow revealed no edema, effusion, tenderness, redness, heat, weakness, abnormal movement, or guarding of movement.  Left elbow ROM values were flexion of 145 (145) and extension of 0 (0) degrees.  Left forearm ROM values were pronation of 80 (80) and supination of 85 (85) degrees.  Left elbow and forearm ROM were not additionally limited following repetitive use by pain, fatigue, weakness, lack of endurance, or incoordination.  Left wrist ROM values were extension of 30 (70) and flexion of 40 (80) degrees.  Left wrist ROM was additionally limited following repetitive use by pain, weakness, and lack of endurance.  Deep tendon reflexes (DTRs) were normal.  Intrinsic hand muscle strength was 4/5 and sensation was decreased over the medial forearm and ulnar nerve innervated fingers.  A left forearm X-ray showed retained hardware and a gap between the fragments of the distal ulna shaft.  The diagnoses listed 1) status post open fracture of the left forearm with surgical repair and skin flap scars, ulnar bone non-union, and decreased left wrist mobility and 2) status post ulnar nerve injury secondary to open forearm fracture with decreased motor strength in the hand intrinsic muscles.

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 20% rating under the 5213 code (supination and pronation, impairment of) citing history of accident with multiple injuries, only medically unacceptable residual were limitations of left (non-dominant) forearm and thumb movement (unable to actively flex the thumb tip, not ratable), normal forearm supination, and “Pronation is actively limited to a maximum of 35 degrees while passively (the ratable criteria) to 71 degrees.”  The VA assigned a 20% rating under the 5211 code (ulna, impairment of) based on the VA C&P examination a month after separation, citing history of accident with multiple injuries, right hand dominant, status post left forearm open fracture and surgical repair, residual scars, non-union with wide gap between fragments of distal ulna shaft, and left forearm pain.  There was no elbow ankylosis, deformity, fracture, flail joint, limitation of flexion, or limitation of extension for consideration under 5205, 5206, 5207, 5208, or 5209.  The intended consequence of the Sauve-Kapandji procedure was to fuse the ulnar head to the radius and to resect a portion of the distal ulna shaft to create a pseudoarthrosis (false joint or nonunion).  Radiographic images of the distal ulna and radius revealed the expected postoperative appearance following the Sauve-Kapandji procedure.  As the ulnar head and radius were fused, there was no nonunion for consideration under 5210.  While radiographic imaging showed an ulnar osteotomy, this was an integral and functional component of the corrective procedure performed.  The surgically created osteotomy/pseudoarthrosis does represent ulna nonunion in lower half consistent with a 20% rating (minor) under 5211.  Recognizing the surgical sequelae of the ulnar head and radius being fused, and the two ulnar fragments having grossly normal alignment, these do not represent malunion or bad alignment for consideration under 5211.  There was no radius loss of bone substance, marked deformity, nonunion, malunion, or bad alignment for consideration under 5212.  There was no impairment of supination for consideration under 5213.  While the limitation of pronation in the C&P examination (80 degrees) exams did not attain a minimum rating, the limitations in the NARSUM (20 degrees), OT (30/30/35 degrees), and updated NARSUM (15 degrees) exams were consistent with a 20% rating under 5213.  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 forearm condition. 

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the left forearm incomplete median and ulnar nerve injury and traumatic brain injury (TBI) conditions were not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  While the nerve injury was profiled, TBI was not.  The contended conditions were not implicated in the commander’s statement and were not judged to fail retention standards.  All were reviewed and considered by the Board.  There was no performance based evidence from the record that any of these conditions significantly interfered with satisfactory duty performance.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the any of the contended conditions and so no additional disability ratings are recommended.
 
BOARD FINDINGS:  In the matter of the left forearm condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended left forearm incomplete median and ulnar nerve injury and traumatic brain injury (TBI) conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.    

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140414, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 XXXXXXXXXXXXXXXXXXXXXXX AR2016001 0521 (PD201401630)

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:

Enclosure

CF:
( ) DoD PDBR
( ) DVA