RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04359
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20090818

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E5, Navigation Equipment Operator, medically separated for “chronic right wrist pain,” with a disability rating of 10%.  

CI CONTENTION:  “Right wrist also has nerve damage that should be separately evaluated.” 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 - 20090508	VARD - 200900916	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Wrist Pain	5099-5003	10%	Right Wrist, Degenerative Joint Disease, S/P Surgery with Scar	5215-5024	10%	20090813	
S/P Right Radial Styloid Fracture and ORIF	Category II	No VA Placement	
S/P Right DeQuervain Release 1st Dorsal Wrist Compartment		No VA Placement	
S/P Radial Styloid Screws removal		No VA Placement	
S/P Right 5th Metacarpal Fracture	Category III	History of Right 5th Metacarpophalangeal Joint (MCP) Fracture with Residual of Pain and Decreased ROM	5230	0%	20090813	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS: 10%	
______________________________________________________________________________

ANALYSIS SUMMARY:  

Chronic Right Wrist Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s chronic right wrist pain condition began on 23 January 2008 after a motorcycle accident where he sustained a closed fracture to the 5th metacarpal neck (see below) and a right radial styloid fracture for which he underwent an open reduction and internal fixation (ORIF) on 25 January 2008.  He was placed in short–arm cast to allow interphalangeal motion of all digits, which after the cast removal, he was noted to have a secondary De Quervain’s tendonitis (painful tendons on the thumb side of the wrist).  Occupational therapy was instituted for thumb spica splinting and range of motion (ROM) exercises.  Despite surgery, extensive occupation therapy, and steroid injections in the first dorsal compartment tendon sheath, he still had significant stiffness of his right wrist and diminished ROM and experienced pain when lifting 10 to 15 pounds.  In July 2008, forearm supination and pronation were normal; wrist extension and flexion were 52 and 36 degrees respectively with slight loss of motion; and wrist radial and ulnar deviation were 10 and 35 degrees respectively.  Magnetic resonance imaging (MRI) demonstrated a pattern associated with a torn scapholunate ligament in October 2008.  On 5 December 2008, he underwent radial styloid screws removal and a right De Quervain’s release of the first dorsal wrist compartment.  An arthrogram of the right wrist in February 2009 revealed no evidence of a TFCC (triangular fibrocartilage complex) or scapholunate ligament injury.  Hand surgery evaluation on 19 February 2009, noted a healed radial styloid fracture with no significant intrinsic ligament tears.  At the NARSUM examination dated 23 March 2009, examination revealed a well healed scar of the radial aspect of the wrist. ROM measurements were extension 50 degrees and flexion 35 degrees.  Grip strength was decreased.  At the MEB examination, recorded on DD Forms 2807 and 2808, dated 30 March 2009 and 13 April 2009 respectively, approximately 4 months prior to separation, the CI reported use of a wrist brace and pain in the right wrist with limited right hand and wrist movement and numbness of the right thumb.  Physical examination revealed decreased ROM of the right wrist in flexion and extension with tenderness on the radial distal forearm.  Decreased sensation of the right thumb and decreased strength of the right wrist and hand were also present.    

At the VA Compensation and Pension (C&P) examination on 13 August 2009, performed 5 days before separation, the CI complained of constant 2/10 pain of the wrist and with flares to 7/10 that occurred monthly and lasted for 2 days in duration.  Any use of the wrist aggravated the pain, which was responsive to ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID) and Roxicet (oxycodone, a narcotic and acetaminophen, a pain reliever).  He also complained of 3/10 pain in his right 5th metacarpal that occurred weekly. The ROM measurements are in the chart below.  Physical examination revealed tenderness, but no swelling, effusion, muscle spasm, joint laxity, muscle atrophy, fibrous or bony residual of fracture or ankylosis.  X-rays of the right hand on 13 August 2009 showed no significant joint or bony abnormality, while X-rays of the right wrist demonstrated osteoarthritic changes of the radiocarpal joint.  

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.  

Right Wrist ROM
(Degrees)	MEB ~5 Mos. Pre-Sep
	
MEB H&P Form 2808
~4 Mos. Pre-Sep
	VA C&P 5 Days Pre-Sep
	
Dorsiflexion (70 Normal)	50	
Decreased ROM; in flexion, extension; 	51	
Palmar Flexion (80)	35		14	
Ulnar Deviation (45)	-		38	
Radial Deviation (20)	-		25	
Comment	Scar well healed; grip strength decreased;	Decreased sensation to thumb; tender radial distal thumb; decreased strength right wrist and hand	Pain at the end of the ROMS; no loss of motion with repetition but pain present; tenderness of the wrist	
§4.71a Rating	10%	10%	10%	
The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under an analogous 5099-5003 code (degenerative arthritis), citing chronic right wrist pain as the Category I unfitting condition.  Additionally, the PEB determined status post right radial styloid fracture and ORIF, status post right De Quervain release 1st dorsal wrist compartment, and status post radial styloid screws removal were Category II conditions that contributed or were related to the Category I condition.  The VA assigned a 10% rating using an analogous 5215-5024 code (wrist limitation of motion-tenosynovitis) based on the VA C&P examination 5 days before separation for right wrist, degenerative joint disease, status post-surgery with scar (major).  In the absence of wrist ankylosis (code 5214), dorsiflexion less than 15 degrees or palmar flexion limited in line with forearm (code 5215), radius and ulna, nonunion of, with flail false joint (code 5210), ulna impairment (code 5211), radius impairment (code 5212) or supination and pronation impairment (5213), the Board was unable to find a route to a higher rating.  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 chronic right wrist pain condition.  

Contended PEB Category III Condition-Status Post Right 5th Metacarpal Fracture.  The Board’s main charge is to assess the fairness of the PEB’s determination that the Category III status post right 5th metacarpal fracture condition was not unfitting.  The CI sustained a fracture of the 5th metacarpal at the time of the motorcycle accident on 23 January 2008.  X-rays demonstrated a 5th metacarpal fracture at the metadiaphysis (growth plate/bone shaft junction) without displacement or distraction.  A short arm cast was applied and the CI subsequently underwent surgery for the right radial styloid fracture on 25 July 2008 after which a Burkhalter cast was applied.  Occupational therapy was carried out for the right wrist and hand.  A second Limited Duty (LIMDU) document only addressed the right radial styloid fracture s/p ORIF and the non-medical assessment did not explicitly mention the 5th metacarpal fracture, but did note the CI was not worldwide assignable because of his physical condition.  At the VA examination the CI complained of 3/10 pain in his right 5th metacarpal that occurred weekly, but there was no tenderness, swelling, effusion, joint laxity, or bony residual of the fracture or ankylosis.  The ROM of the right little finger at the metacarpal phalangeal joint was 49 degrees without pain and X-rays of the right hand demonstrated no significant joint or bony deformity.  The VA assigned a 0% rating using code 5230 (ring or little finger, limitation of motion) for a history of right 5th metacarpophalangeal joint (MCP) fracture with residual of pain and decreased ROM (major).  

There was no performance-based evidence from the record that the right 5th metacarpal fracture significantly interfered with satisfactory duty performance at separation.  After due deliberation, and 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 right 5th metacarpal fracture condition; and so, no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the chronic right wrist pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended status post right 5th metacarpal fracture 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, 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 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 11 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:

		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN