RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03422
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20020820

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4 (Radio Communications Security) medically separated by the Informal Physical Evaluation Board for right wrist pain with a disability rating of 10%.  

CI CONTENTION:  The applicant requests the Board consider all conditions.  Her complete submission is at Exhibit A. 

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 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 - 20020521	VARD - 20020822	
Condition	Code	Rating	Condition	Code	Rating	Exam	

Right Wrist Pain Status Post Suave-Kapandji
	5213	0%	Residuals, Right Forearm Injury, Radial FX, Ulna Resection,
Fusion (Dominant Extremity)	5212	40%	20020529	
Ectopic Pregnancy	Not Unfitting	Repair of Right Fallopian Tube 	7614	0%	20020509	
		Adhesions Secondary to Repair of Right Fallopian Tube	7301	0%	20020509	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Right Wrist Condition.  The service treatment record (STR) documents that the CI sustained a right distal radius inter-articular comminuted (multiple fragments or splinters) fracture in a fall on an obstacle course.  She underwent a closed reduction (surgical procedure to restore a fracture to the correct alignment) and percutaneous pinning (K-wires X 4) of a right, dorsally displaced, distal radius fracture.  The CI was immobilized in a cast, with pin fixation in an acceptable alignment, until hardware removal.  Seven weeks later, the orthopedic fixation hardware was removed.  Postoperatively, the CI complained of pain about the ulnar side of the wrist, with loss of supination and pronation.  Through occupational therapy (OT) range-of-motion (ROM) exercises, the CI was able to regain near normal pronation.  She was unable to regain normal supination and continued to have tenderness about the distal ulna and radial ulnar joint.  A right wrist X-ray showed post traumatic deformity of the distal radius, distal radioulnar joint, and small, old fracture fragments distal to the ulna.  The CI underwent a right wrist arthroscopy 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 postoperative right wrist X-ray showed an osteotomy (surgical bone cutting or excision to shorten, lengthen, or realign) through the distal ulnar shaft and screw fixation at the distal radioulnar joint.  At follow-up, it was found that she had healed across her pseudoarthrosis site (15mm gap) with bridging callus.  It was decided to take her back to the operating room to take this down.  The CI underwent recreation of the pseudoarthrosis by surgical takedown of the ulnar pseudoarthrosis site union.  A postoperative right wrist X-ray showed fixation hardware (two screws transfixing distal ulna component to radius) and interval removal of a significant portion of the ulnar osteotomy bridging callus (approximately 9 mm of lucent gap).  The OT active ROM for the right wrist was extension of 65 degrees (70 normal), flexion of 50 degrees (80 normal), forearm pronation of 85 degrees (80 normal) and supination of 35 degrees (85 normal).  

The narrative summary (NARSUM) exam by orthopedic surgery on 30 January 2002 (7 months prior to separation) recounted the history and interventions.  The right-hand dominant CI complained of daily 5/10 right wrist pain and difficulty regaining ROM.  Pain was exacerbated by any accidental tapping or twisting of the right wrist.  She noted an inability to type longer than 10 minutes without having to move her wrist about because of tingling and aching of the right wrist.  The CI was not taking pain medications.  The right upper extremity exam revealed well healed wrist wounds with no erythema (redness), induration (loss of elasticity and pliability), or ulnar wasting.  There were some superficial abrasions from a recently placed cast.  There was tenderness over the distal ulnar resection site and the distal ulna at the wrist.  Active ROM for the right wrist was extension of 65 degrees, flexion of 50 degrees, forearm pronation of 85 degrees and supination of 35 degrees.  There was slight increase in ROM and pain with passive assistance.  Elbow active ROM was extension of 0 degrees (0 normal) and flexion of 135 degrees (145 normal).  The dominant right hand grip strength was 45 pounds versus 90 pounds for the non-dominant left.  Right wrist X-rays showed fixation hardware (two screws in distal radial ulnar joint), surgical bone loss of the distal ulna, and distal ulnar styloid fragmentation.  The diagnosis listed chronic right wrist pain and stiffness status post Sauve-Kapandji procedure. 

Electrodiagnostic studies (EMG/NCV), 14 May 2002, revealed evidence of a mild right carpal tunnel syndrome ([CTS] compression of the median nerve in the wrist carpal tunnel causing numbness and tingling of the palm side of the thumb and fingers [sparing little finger]) without axonal (long nerve cell processes that transmit impulses) loss.  The examiner recommended wearing wrist splints and exercises through OT.  

Radiographic studies on 22 May 2002 showed distal radial-ulnar joint fusion (two cortical screws through distal radius and ulna), resection of portion of the distal ulnar shaft, grossly normal alignment of two ulnar fragments, and no gross evidence of distinct fracture.  The radiologist opined that hardware loosening and a fracture through a fibrous union could not be ruled out and further evaluation with serial radiographs was recommended. 

The VA Compensation and Pension (C&P) examination on 29 May 2002, performed 3 months before separation, recounted the history and interventions.  The CI complained of constant 6/10 right wrist pain with associated arm numbness, tingling, pain, and fatigability.  Pain could be exacerbated to 10/10 with activity or pressure against the distal forearm.  The CI reported little improvement in ROM or strength after months of therapy.  She complained of hand weakness with prolonged use and could not lift greater than 5 pounds.  A combination analgesic/opioid (Tylenol #3) was prescribed to be taken as needed for pain.  The CI was wearing a wrist splint since she had re-injured the wrist in a fall a week and a half prior.  The physical exam revealed a surgical scar on the right forearm and a concave indentation along the distal ulna.  There was tenderness over the surgical scar.  Right wrist active ROM was extension of 55 degrees, flexion of 50 degrees, ulnar deviation of 20 degrees and radial deviation of 10 degrees.  Forearm active ROM was pronation of 85 degrees and supination of 30 degrees.  Supination caused significant (10/10) pain.  Elbow and finger ROM were within normal limits.  Right hand grasp was considerably weaker than the left.  The Tinel (percussing nerve elicits tingling over distribution of the nerve) and Phalen (compresses median nerve at wrist and elicits pain, tingling, and numbness in the hand and fingers) tests were positive and the Allen (assesses patency of radial or ulnar artery) test was negative.  Except for hand grasp, strength was otherwise normal.  Sensation, pulses, and deep tendon reflexes (DTRs) were normal and pathologic reflexes were absent.  The diagnoses listed distal right forearm fracture status-post surgical interventions and right carpal tunnel syndrome.

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating under the 5213 code (supination and pronation, impairment of), citing right wrist pain and limitation of supination.  The VA assigned a 40% rating using the 5212 code (radius, impairment of) based on the VA C&P examination 3 months before separation, citing (nonunion in the lower half of the radius with loss of bone substance 1 inch or more and marked deformity.  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).  When a bridging callus healed across the pseudoarthrosis, the CI underwent a surgical takedown of the osteotomy site union to recreate the pseudoarthrosis.  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 the 5210 code.  The radiographic imaging showed an ulnar osteotomy (approximately 9mm of lucent gap); this was an integral and functional component of the procedure performed.  While this surgically created osteotomy/pseudoarthrosis was present, it does not represent significant loss of bone substance, marked deformity, or evidence of nonunion for consideration under the 5211 code.  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 the 5211 code.  There was no radius loss of bone substance, marked deformity, nonunion, malunion, or bad alignment for consideration under the 5212 code.  There was no impairment of pronation for consideration under the 5213 code.  While the limitation of supination in the OT and NARSUM exams of 35 degrees did not attain a minimum rating, the C&P ROM of 30 degrees was consistent with a 10% rating (to 30 degrees or less) under the 5213 code.  Physical exams and radiographic imaging did not demonstrate the characteristic anatomical deformities of wrist ankylosis, unfavorable palmar flexion, ulnar deviation, or radial deviation for consideration under the 5214 code.  The limitation of motion in the proximate OT, NARSUM and C&P exams did not attain a minimum rating under the 5215 code, however, the Board agreed a 10% rating was supported with application of VASRD §4.40 (functional loss) or §4.59 (painful motion). 

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the right wrist condition, coded 5215.  
Contended PEB Conditions.  

Ectopic Pregnancy.  The Board’s main charge is to assess the fairness of the PEB’s determination that the ectopic pregnancy (pregnancy outside of uterine cavity where 98% occur in fallopian tubes) was 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.  The STR documented that the CI reported to a clinic following 3 weeks of vaginal bleeding.  She had a positive pregnancy test and intrauterine device (IUD) strings were noted to be in place.  The CI was advised by obstetrics/gynecology (OB/GYN) to have the IUD removed and was counseled on the risk of pregnancy loss; the IUD was removed.  Serial hormone values (HCG) associated with pregnancy continued to rise concerning for a blighted ovum (anembryonic pregnancy where a gestational sac develops without an embryo) versus ectopic pregnancy.  The CI underwent a dilation and curettage ([D&C] procedure to remove tissue from inside uterus) and the pathology did not identify products of conception.  Serial HCG labs were concerning for an ectopic pregnancy so the CI was treated medically with Methotrexate ([MTX] a folic acid antagonist which inhibits DNA synthesis and cell reproduction in actively proliferating cells such as fetal cells).  Two week later, the CI presented to the emergency room complaining of acute, severe, left lower quadrant abdominal pain.  Physical exam and labs suggested a blood loss anemia.  A diagnosis of ruptured ectopic was made, blood was ordered for transfusion, and the CI was taken emergently to the operating room.  She received two units of blood and underwent evacuation of a hemoperitoneum (blood in the peritoneal cavity) and a laparoscopic right salpingostomy (fallopian tube surgical incision to repair a damaged tube or remove an ectopic pregnancy). The right tube showed evidence of a recent tubal abortion and the uterus, both ovaries and the left tube were grossly normal.  The examiner in the OB/GYN NARSUM addendum opined that the CI was at increased risk of having another ectopic pregnancy, but had an 85% chance of having a normal intrauterine pregnancy.  The ectopic pregnancy was not profiled or implicated in the commander’s statement and was not judged to fail retention standards.  There was no performance based evidence from the record that the surgically treated ectopic pregnancy 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 ectopic pregnancy condition and so no additional disability rating is recommended.

BOARD FINDINGS:  In the matter of the right wrist condition, the Board recommends a disability rating of 10%, coded 5215 IAW VASRD §4.71a.  In the matter of the contended ectopic pregnancy 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.  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of the prior to medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Right Wrist Pain	5215	10%	
RATING	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140709, 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 XXXXXXXXXX, AR20160003774 (PD201403422)

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, accept the Board’s recommendation to modify the individual’s disability rating to 10% without re-characterization 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:

CF: 
(  ) DoD PDBR
(  ) DVA