RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00984
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040924

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Calvary Scout, medically separated for “right wrist injury with ulnar nerve dysfunction” with a disability rating of 10%.  

CI CONTENTION:   “Review all conditions.”  The complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned 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 or non-compensable.  Any conditions outside the panel’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 panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determination 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(s) at the time of separation.  The panel 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 panel 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 – 20040726	VARD - 20050428	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Wrist Injury with Ulnar Nerve Dysfunction	8516	10%	Ulnar Nerve Palsy, Right Hand (Major)	8516	40%	20050324	
			Right Wrist Strain	5215	10%	20050324	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Right Wrist Injury with Ulnar Nerve Dysfunction.  According to the service treatment record and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI was right-hand dominant and his wrist condition began in June 2003 after the wrist was hit with shrapnel from a road-side bomb (IED).  The CI underwent removal of the shrapnel and physical therapy.  The CI reported wrist pain and lost feeling in the 4th and 5th fingers (‘ring’ and ‘little’ fingers) of the right hand.  X-rays thru 23 March 2004 showed findings suggestive of scapholunate ligament injury and several metallic densities in the region of the 3rd and 4th metacarpals (little finger-side of the hand).  No further surgery was recommended.  Despite occupational therapy, the CI continued to have pain at the ulnar side of the right wrist with poor grip and limitations of movement of his 4th and 5th fingers.  

The 12 July 2004 MEB NARSUM examination, 2 months prior to separation, noted complaints of right wrist pain and no feeling in the 4th and 5th digits of the right hand.  Physical examination from the 7 June 2004 occupational therapy evaluation, 3 months prior to separation, showed slight atrophy of the hypothenar eminence on the right hand.  Grip strength on the right was 15 pounds (145 pounds on the left).  There was also decreased right pinch strength (approximately 50% of left side in lateral, tip, and 3-jaw testing).  The range of motion (ROM) of the ring and small finger was decreased without ankylosis (‘being frozen’).  The right wrist ROM was flexion 0/50⁰ (normal 0/70), extension 0/45° (normal 0-80).  Right forearm ROM was to normal VASRD limits.  The examiner stated:  “The (CI) has a moderate decrease in the ability to use the right hand secondary to diminished active range of motion in the right wrist and digits.  He also presents with a moderately severe diminish in the right ring finger and small finger sensation and ability to detect hot, cold, sharp and dull sensation.”  

The 4 August 2004 orthopedic/occupational therapy hand evaluation, 2 months prior to separation, noted complaints of no feeling in the digits, and decreased ROM and strength.  Physical examination documented similar findings to the examination from June 2004 (above) with the addition of a written physician note indicating “significant (3+/5) reduction…finger flexion/extension strength.”  

At the 24 March 2005 VA Compensation and Pension (C&P) evaluation, 6 months after separation, the CI reported pain, weakness, stiffness, swelling, giving way, fatigability, and lack of endurance of the right wrist.  Pain was 5/10 with multiple flares a day to 10/10.  Physical examination showed a well-healed scar.  Wrist ROM was with pain with dorsiflexion of 15 degrees (normal 70) and palmar flexion of 5 degrees (normal 80).  There was tenderness and weakness in the wrist.  The examiner stated that the CI had “a crippling effect from this injury on the intrinsic muscles and range of motion in the right hand. … The (CI) is unable to make a fist.  He can partially bring his index finger and thumb into a fist like position but his other fingers he cannot.”  “He's unable to write with any dexterity.  He cannot do a twisting or a probing motion.  There is weakness of the inter osseous muscles.”  The ROMs of the fingers and joints was decreased without ankylosis.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right wrist condition 10%, coded 8516 (ulnar nerve, incomplete paralysis [mild]), citing pain and sensory loss rated as mild incomplete paralysis.  The VA rated the right wrist ulnar nerve palsy condition 40%, coded 8516 (ulnar nerve, incomplete paralysis [severe]), based on the C&P examination 6 months after separation, citing decreased pain sensation, inability to make a fist and inability to write with any dexterity.  The VA additionally rated the right wrist limited motion condition 10% coded 5215 (wrist, limitation of motion), from the same examination, citing painful limited motion of the wrist.  

The panel considered the NARSUM and occupational therapy evaluations had a higher probative value for rating at separation than the slightly more remote VA examination.  The motor and sensory loss of the right ulnar nerve were considered IAW VASRD §4.120 (evaluations by comparison) and §4.124a (schedule of ratings—neurological conditions and convulsive disorders).  The criteria under code 8516 (ulnar nerve, paralysis) for the “major”/dominant hand are by comparison with the mild (10%), moderate (30%), or severe (40%), incomplete paralysis; or complete paralysis (60%) of the functions of the ulnar nerve.  The examinations showed significantly decreased right hand grip and pinch testing strengths, decreased sensation of the 4th
and 5th digits, and slight atrophy of the hypothenar eminence.  The examiner indicated “moderate decrease in the ability to use the right hand” and “moderately severe diminished sensation” in the 4th and 5th digits.  The panel agreed that the level of disability was greater than the “mild” incomplete level and deliberated between the moderate and severe levels.  The panel considered that neuritis or neuralgia (sensory-only) impairment of the ulnar nerve had a maximum rating up to moderate incomplete paralysis, while the CI had significant objective evidence of weakness.  

The panel agreed that the CI’s disability picture at separation most nearly approximated the moderate incomplete paralysis criteria.  The panel next considered if there was sufficient evidence of wrist joint disability to warrant a separate unfit finding and rating with consideration of VASRD 4.14 (avoidance of pyramiding).  X-rays indicated findings of wrist joint pathology; however, Service examinations did not provide sufficient objective evidence of painful motion, or of limited wrist ROM sufficient to meet the 10% rating criteria under code 5215 (wrist limitation of motion) and pain in the wrist is also considered under code 8516.  The panel adjudged that the CI’s wrist disability was appropriately subsumed under the right ulnar nerve rating above, and therefore no additional rating was justified under this basis.  

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 30% for the right wrist injury with ulnar nerve dysfunction condition, coded 8516.  

BOARD FINDINGS:  In the matter of the right wrist injury with ulnar nerve dysfunction condition, the panel unanimously recommends a disability rating of 30%, coded 8516 IAW VASRD 4.124a.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Right Wrist Injury with Ulnar Nerve Dysfunction	8516	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150609, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170007444, XXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXXXX:

	I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a disability retirement with the combined disability rating of 30% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The re-characterization of your separation as a disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.
 
	The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiry concerning your correction of records should be addressed to the XXXXXXXXXXXXXXXXXXXXX.

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,					      
Enclosure