RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03474
BRANCH OF SERVICE:  ARMY 	SEPARATION DATE:  20060731

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Multichannel Transmission Systems Operator-Maintainer, medically separated for “surgical fusion, left…wrist,” with a disability rating of 20%.

CI CONTENTION:  The CI requests that all conditions be considered.  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 - 20060712	VARD - 20070315	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Surgical Fusion, Left (Non-Dominant) Wrist, Favorable…	5214	20%	DJD, Left Wrist S/P Fusion	5215	10%	20060612	
			Left Wrist Scar	7805	0%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Surgical Fusion, Left (Non-Dominant) Wrist.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI sustained a FOOSH (fell on outstretched hand) injury in 1999 during training and underwent a scaphoid excision and a 4-corner fusion in 2001.  An X-ray series of the left wrist dated 20 September 2005 demonstrated a metallic object in the intercarpal region of the left wrist replacing the carpal lunate with arthrodesis (ankylosis as result of surgery) of the remaining carpal bones and an opaque material overlying the distal left radius.  No acute fracture or dislocation was identified.  Pain in the left wrist began in mid-November 2005.  On examination of the left wrist/hand there was tenderness to pressure on the dorsum of the wrist and hand.  In January 2006 the CI complained of bilateral wrist pain, the left greater than the right, which had surgery in November 2005 to repair a right scapholunate ligament tear.  On examination there was tenderness to palpation of the dorsal aspect of both wrists and throughout the range of motion (ROM).  There was no instability and no weakness.  The etiology of the severe pain of the left wrist was unclear, but reflex sympathetic dystrophy (RSD) was considered and treatment with gabapentin (for nerve pain) and amitriptyline (for nerve pain) was instituted.  At a follow-up visit the CI reported more pain in the left wrist than the right wrist and the dose of gabapentin was increased.  An X-ray series dated 24 January 2006 of the left wrist demonstrated a metallic fixation device at the ulnar side of the carpal bones.  Scaphoid and lunate bones appeared to have been surgically removed.  Sclerosis (thickening) was present of the distal radius, but there was no significant change from prior examination of September 2005.  On examination the CI was unable to flex or extend due to a spider plate in the left wrist and he was unable to lift heavy objects or to perform his normal requirements.  A left wrist arthrodesis (left wrist dorsal fusion with an AO [locking] plate) was performed on 13 February 2006 and X-rays revealed the circular fixation device had been removed and there was placement of a dorsal wrist fusion plate; the instrumentation was intact.   Postoperative occupational therapy was carried out and a note in March 2006 indicated the CI’s wrist pain improved, and he was getting used to position and stiffness.  He had a minor re-injury with a soccer ball.  Examination revealed a maturing wound, mild firm swelling, full digit extension, a full fist, minimal tenderness, and full forearm rotation.  X-rays demonstrated adequate position of implants and progressive union of the radiocarpal joint.  

The NARSUM indicated that although the CI injured his wrist in training and underwent surgery, despite some pain over the ensuing years, he was able to perform his duties.  After deployment in 2004, the pain intensified severely.  By 2006 the pain was constant and severely incapacitating and interfered with his sleep and he was unable to do any of his usual activities.  The surgical fusion healed satisfactorily, but the CI continued to have significant pain and was unable to pick up a great deal of weight with his left hand. Examination of the left wrist revealed significant tenderness on palpation over the surgical area.  There were no neurovascular changes in the left wrist or hand.  Grip strength of the right hand was 80 pounds and 75 pounds and the left hand was 30 pounds and 45 pounds.  The right wrist was not a disabling factor for military service.   

A permanent U3 profile was issued on 6 April 2006 for bilateral wrist pains s/p [status post] surgical repairs with limitations of all military functional activities except wearing a protective mask and all chemical defense equipment.  Additional restrictions included no pushups, no sit-ups, no ruck marching and no field exercises.  The commander’s statement dated 17 April 2006 indicated the CI’s bilateral wrist pain severely limited his capacity to perform all required duties and physical demands.  At the MEB examination (recorded on DD Forms 2807 and 2808) dated 14 April 2006, 3 months prior to separation, the CI reported a left wrist four corner fusion and a total left wrist fusion.  “All is well.”  The medical examiner noted marked/severe decreased ROM of the left wrist and a 10.5 cm surgical scar of the left wrist. 

At the VA Compensation and Pension (C&P) examination in June 2006, performed 1 month before separation, the CI reported weakness and locking in the left wrist.  He reported the condition did not cause any capacitation or any pain, although he reported treatment with hydrocodone, a narcotic, but he was unable to move the left wrist.  On examination there were no signs of edema, effusion, weakness, tenderness, redness, heat, abnormal movement or guarding of movement.  The CI was unable to perform dorsiflexion, palmar flexion, radial deviation, or ulnar deviation of the left wrist.  Joint function was additionally limited by pain, fatigue, weakness, lack of endurance and incoordination after repetitive use and pain was the major functional impact.

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)	Ortho ~4 Mo. Pre-Sep
	MEB ~3 Mo. Pre-Sep
	VA C&P ~1 Mo. Pre-Sep
	
Dorsiflexion (70 Normal)	“full digit extension, full fist”	…”full composite fist with left hand…” Unable to flex or extend “left wrist due to the surgical fusion”	0	
Palmar Flexion (80)			0	
Ulnar Deviation (45)			0	
Radial Deviation (20)			0	
Comment	Maturing operative wound	Grip strength decreased 30 and 45 pounds on the left compared to 80 and 75 pounds on the right	Joint function limited by pain, fatigue, lack of endurance and incoordination after repetitive use	
§4.71a Rating	PEB 20%	PEB 20%	 VA 10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 20% rating using code 5214 (wrist, ankylosis) for a surgical fusion of the left (non-dominant) wrist in a favorable position.  The VA assigned a 10% rating using code 5215 (wrist, limitation of motion) for degenerative joint disease of the left wrist status post fusion.  The VA also assigned a 0% rating using code 7805 for a left wrist scar, which is not in the scope of review.  The Board sought a route to a higher rating; however the record was silent on whether the wrist ankylosis (5214) was any other wrist position, except favorable (30%) or unfavorable, in any degree of palmar flexion, or with ulnar or radial deviation (40%). 
 
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 surgical fusion of the left (non-dominant) wrist condition.  

BOARD FINDINGS:  In the matter of the surgical fusion of the left (non-dominant) wrist 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 20140625, 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 XXXXXXXXXXXXXXXXXX, AR20160011349 (PD201403474)

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