RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04364
BRANCH OF SERVICE:  Marine Corps 	SEPARATION DATE:  20091030

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Nuclear, Biological, and Chemical Defense Specialist, medically separated for “right wrist pain,” with a disability rating of 10%.

CI CONTENTION:  The CI indicates his right forearm still negatively impacts his life.  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 on 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 – 20090817	VARD – 20100709	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Wrist Pain ...
[Surgical Residuals]	5299-5213	10%	De Quervain’s Synovitis, Right Wrist	5299-5213	10%	20100506	
			Surgical Scars, Right Wrist	7805	0%		
Pisotriquetral Arthritis	Cat II	No VA Entry	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  There was a paucity of source clinical notes in the available service treatment record (STR) for this case, and the Board’s recommendation was derived primarily from the Medical Evaluation Board (MEB) narrative summary (NARSUM), other core Disability Evaluation System documents, and VA evidence (that included a thorough summary of STR clinical details in the rating decision) as elaborated below.  Members agreed that further attempt at record retrieval would likely be futile and introduce unnecessary delay in processing the case; since, the available evidence was sufficiently probative and the source clinical records would not materially affect the Board’s ultimate recommendation.

Right Wrist Pain.  The CI suffered an initial injury (fall on outstretched hand) in October 2006 (3 years before separation).  Open fractures of the distal radius and ulna required surgical fixation.  A series of three additional surgeries were necessitated over the clinical course: wrist arthroscopy and debridement in June 2007, repeat arthroscopy and styloid excision in January 2008, and hardware removal with corrective osteotomy and intraosseous membrane release in May 2008 (last procedure, 17 months before separation).  Final X-rays demonstrated adequate hardware alignment and healing of the radial and ulnar fractures without complications and normal carpal (wrist) bones.  Surgical results were still insufficient to allow unrestricted duty and the CI was referred for an MEB, which in turn forwarded “right wrist pain, status-post corrective osteotomy of a radial shaft malunion with persistent radial and ulnar pain and limited supination” and “early pisotriquetral [juncture of two of the carpal bones] arthritis as evidenced by relief of pain with injection” to the PEB.

The NARSUM examination in June 2009 (4 months before separation) documented “unable to make significant gains with his active supination [forearm rotation to palms up position] ... with some radial and ulnar sided wrist pain.” The pain was rated 7-8/10 and prohibited heavy lifting, push-ups, and pull-ups.   The physical examination recorded well healed incisions, a mild sensory deficit distal to the incision (dorsal thumb and index finger), and measured grip strength (75 pounds right and 95 left) that was in the poor range for age and gender.  The range of motion (ROM) findings were “full flexion and extension of the wrist ... supination actively is approximately 70 degrees [normal 85, 30 for minimum 10%] ... [and] ... full pronation.”  

A VA Compensation and Pension (C&P) examination in May 2010 (6 months after separation) documented persistent pain with frequent “severe” flares resulting in a total functional loss of motion due to pain, prohibiting heavy lifting and causing “difficulty opening jars.”  The physical examination recorded a normal elbow exam with tenderness of the distal forearm and wrist.  Measured ROM for the elbow was normal for flexion, extension, and pronation; but, supination was 40 degrees.  Measurements for the wrist were dorsiflexion to 60 degrees (normal 70, 15 for minimum 10%) and palmar flexion to 70 degrees (normal 80, 0 for minimum 10%).

The Board directed attention to its rating recommendation based on the above evidence.  Both the PEB and VA conferred a 10% rating analogous to 5213 (limitation of supination), and the VA decision (based on the C&P examination) cited painful motion for the minimum compensable rating.  The PEB additionally adjudicated the pisotriquetral arthritis as a Category II condition (contributes to the unfitting condition but is not separately ratable).  Members agreed that this condition was intrinsic to the rated condition and not associated with any findings that could be separately rated without violation of VASRD §4.14 (avoidance of pyramiding); thus, it was appropriately subsumed in the same rating recommendation as that for the primary condition.  With regard to the latter there was no ROM limitation or other ratable finding that would support a rating higher than 10% under any other applicable VASRD §4.71a.  Members considered separate ratings for limited supination at the elbow (5213 at 10% as above) and for painful motion at the wrist (5099-5010 [traumatic arthritis] rated 10%).  It was agreed, however, that this would raise a significant question regarding pyramiding; and, at any rate, would be of no overall benefit to the CI.  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 of the right wrist condition.

BOARD FINDINGS:  In the matter of the right 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 20141215, 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 21 Oct 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:

		-, former USMC
		-, former USMC
		- former USMC
		- former USMC
		- former USMC
		- former USMC
		- former USMC