RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01918
BRANCH OF SERVICE:  Marine Corps 	SEPARATION DATE:  20040831

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an Reserve E4, Military Police, medically separated for “left distal comminuted extra-articular fracture,” with a disability rating of 20%.

CI CONTENTION:  “Please consider all conditions.”  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 based upon a 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 - 20040708	VARD - 20041012	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Distal Radius Comminuted Extraarticular  Fracture 	5099-5003	20%	Left Radius Fracture…	5299-5215	10%	20040610	
			S/P L Wrist Surgeries & Left Long Finger Trauma with Residual Sensory Deficits	8599-8515	10%	20040610	
			Left Wrist Scars	7805	0%	20040610	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS: 30%	
*Derived from VA Rating Decision (VARD) dated 20041012 (most proximate to date of separation [DOS])

ANALYSIS SUMMARY:  

Left Distal Radius Comminuted Fracture.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI sustained a left distal radius comminuted extraarticular fracture (a break in more than two places and does not extend into the joint) on 10 May 2003 when he jumped off a high speed a four wheeler (ATV).  In the Emergency Room the fracture was reduced under fluoroscopic guidance.  An open reduction and internal fixation (ORIF) was performed on 14 May 2003 and the CI had a second procedure on 16 May 2003 to remove an intraarticular (radial scaphoid joint) penetration of a plate fixation screw.  Thereafter, the CI was placed in a cast, transitioned to a splint, and underwent occupational therapy to regain range of motion and strength.  Following surgery further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “left distal comminuted extraarticular fracture status post open reduction and internal fixation with non-functional range of motion (ROM) and grip strength” for PEB adjudication.  

At the MEB narrative summary (NARSUM) examination, dated 9 January 2004, approximately 7 months before separation, the CI reported limited motion of the left wrist with pain with vigorous use and cold weather.  Examination revealed full extension and flexion of the left elbow, 87 degrees of pronation on the right and 80 degrees of pronation on the left, supination 88 degrees on the right and 72 degrees on the left.  Well-healed scars of the left wrist measured 2.5 cm and 10 cm.  There was no effusion or tenderness to palpation of the left wrist and the distal radial ulnar joint was stable to compression and stress.  There was no carpal joint instability and sensation was normal to light touch and scratch with normal capillary refill in the digits.  ROM measurements of the left wrist are in the chart below.  X-rays of the left wrist revealed a well-healed fracture of the distal radius that was extraarticular with internal fixation plates and screws and a healed fracture of the ulnar styloid.  The ulna was approximately 4 mm ulnar negative and there were some small calcifications near the tip of the ulna.  There was no evidence of articular incongruity or osteoarthrosis.  Mild disuse osteopenia of the distal radius and carpus (carpal bones) was also present.  
  
During the MEB examination (recorded on DD Forms 2807 and 2808) dated 7 April 2004 and 4 May 2004, approximately 4 and 5 months before separation, the CI reported a broken wrist in May 2003 with numbness, tingling, pain and lack of mobility still present.  The examiner noted a decreased ROM of the left wrist and a scar.  The VA Rating Decision (VARD) dated 12 October 2004 provided limited examination details.  There was tenderness over the ulnar aspect and evidence of painful motion.  ROM was recorded as dorsiflexion with pain at 40 degrees, palmar flexion with pain at 40 degrees, radial deviation with pain at 10 degrees, and ulnar deviation with pain at 25 degrees.  There was normal ROM of the hands and fingers with good hand strength.  The ROM examinations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.  

Left Wrist ROM
(Degrees)	MEB
Ortho ~8 Mo. Pre-Sep
	OT ~3 Mo. Pre-Sep	VA C&P ~3 Mo. Pre-Sep	
Dorsiflexion (70 Normal)	52	30	Pain at 40	
Palmar Flexion (80)	50	65	Pain at 40	
Ulnar Deviation (45)	18	20	Pain at 25	
Radial Deviation (20)	18	22	Pain at 10	
Comment	Grip Strength R 168#/L 115 or 68%	Grip Strength R 145#/L 107 or 82%, non-tender	(Final end ROMs noted above unknown)	
§4.71a Rating	PEB 20%	0%	VA 10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 20% rating using code 5099-5003 (degenerative arthritis) for a left distal radius comminuted extraarticular fracture status post open reduction and internal fixation with nonfunctional ROM and grip strength.  The VA assigned a 10% rating using code 5299-5215 (wrist, limitation of motion) for a left radius fracture, status post open reduction and internal fixation.  The VA assigned a 10% rating using code 8599-8515 (mild incomplete paralysis of the median nerve) for status post residual left wrist surgeries and long finger trauma (in 1998 and 1999) with residual sensory deficits.  The VA additionally assigned a 0% rating using code 7805 (scars, other) for left wrist scars.  The Board noted that in the absence of wrist ankylosis (code 5214) there was no route to a higher rating using wrist codes.  Code 5212 (radius impairment) was considered; however, there was neither nonunion nor malunion and there was no flail joint to evoke consideration of code 5210 (radius and ulna nonunion with flail false joint).  By the time of separation the ulna styloid fracture had healed, although there was a 4 mm ulnar negative, which was insufficient to provide a rating using code 5211 (ulna impairment).  Use of an analogous muscle groups VII-IX of the forearm and hands codes (5307-5309) to evaluate wrist function was discussed by Board members.  Although muscles arising from the internal condyle of the humerus were not demonstrated to be impaired, wrist flexion and extension were limited, which gives credence to the use of analogous 5307 (Group VII. Function: Flexion of wrist and fingers) or 5308 (Group VIII. Function: Extension of wrist, fingers, and thumb); however, IAW VASRD §4.56(a) states: An open comminuted fracture with muscle or tendon damage will be rated as a severe injury of the muscle group involved unless, for locations such as in the wrist or over the tibia, evidence establishes that the muscle damage is minimal.  Nevertheless, the CI had some of the cardinal signs and symptoms of muscle disability including loss of power, weakness, lowered threshold of fatigue, and pain, but the record was silent on impairment of coordination and uncertainty of movement, and, in fact, although the fracture was comminuted, it was not open initially, but was opened at the time of surgery.  Board members then discussed to what level of disability the CI had at the time of separation.  Although the VA C&P examination was the most proximate examination to separation, the VARD indicated pain at 40 degrees flexion and 40 degrees extension, but the full ROMs were not indicated.  However, an occupational therapy examination, also approximately 3 months prior to separation, but shortly before the VA C&P examination, revealed dorsiflexion of 30 degrees and palmar flexion of 65 degrees suggestive of  moderate (10%) to moderately severe dorsiflexion (20%) and slight (0%) to moderate (10%) palmar flexion limitations.  Board member’s then discussed whether pyramiding IAW VASRD §4.14, which is to be avoided, would be invoked.  Even if it were not, only the combination of moderately severe dorsiflexion and moderate palmar flexion would exceed the 20% rating assigned by the PEB, which is not consistent with facts in this case.   The VA rated the sensory deficits of the left long finger and scars, neither of which were noted in the record to significantly impair the CI’s functioning.  Therefore, the Board concluded there was no evidence to support a rating higher than the rating adjudicated by the PEB.  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 radius condition.  

BOARD FINDINGS:  In the matter of the left radius condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  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 20140501, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44
       (b) CORB ltr dtd 8 Aug 16

      In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandums, approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USMC

						  XXXXXXXXXXXXXXXXXXX
	     				  Assistant General Counsel
						  (Manpower & Reserve Affairs)