RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01131
BRANCH OF SERVICE:  Marine Corps 	SEPARATION DATE:  20050831

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Machine Gunner, medically separated for “left hand injury status post (S/P) combat related blast injury with complex combined soft tissue loss S/P reconstruction” with a disability rating of 20%.  

CI CONTENTION:  “I have been diagnosed with new service connected disabilities since my discharge.” 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 - 20050627	VARD - 20051011	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Hand Injury 	5219	20%	Left Hand Segmental Loss of Small and Ring Finger Metacarpal, S/P ORIF with Bone Grafting
	8516	30%	20050506	
Segmental Loss of Small and Ring Finger Metacarpals 	Category II					
S/P Interosseous Artery Flap and Radial Forearm Flap	Category II	Multiple Scars and Skin Grafts, Left Forearm and Left Arm	7805-7800	10%	20050503	
Ulnar Nerve Neuropraxia 	Category II	No VA Placement	
MCP Joint Contractures 	Category II	No VA Placement	
Extensor Tendon Reconstruction 	Category II	No VA Placement	
Left Hand Injury	Category II	No VA Placement	
Combat Blast Injury with Soft Tissue Loss S/P Reconstruction	Category II	No VA Placement	
Post-Traumatic Stress Disorder	Category III
Not Unfitting	No Original Claim 
(9411 at 30% from exam of 20081027, 3+ years after separation.)	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY: 

Left Hand Injury (Subsuming Category II Diagnoses).  According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI sustained a blast (shrapnel) injury to his non-dominant left hand in Iraq in July 2004.  This entailed complex injuries (open 4th and 5th metacarpal fractures, extensor tendon injuries to small and ring fingers, and distal ulnar nerve contusion); and, required sequential reconstructive surgeries (open reduction and internal fixation, skin and muscle flap grafts, vascular grafts [interosseous arteries], and tendon relocations [small and ring finger extensors]).  Clinical entries in the STR reflected an uncomplicated course with optimal surgical results given the severity of injury; and, the evidence probative to functional impairment, range of motion (ROM), and other VASRD rating criteria was consistent with that from the NARSUM and VA examinations which follow.  There was no evidence for associated injury or unfitting impairment at the wrist, elbow, or other digits.  

The 8 October 2004 NARSUM examination by a hand surgeon, 11 months before separation, documented that, while the CI was “functionally restored,” he still suffered significant impairments.  These included a “moderately bulky dorsal flap,” extensor tendon contractures of the small and ring fingers limiting ROM of those digits, a fingertip amputation of the small finger “diminishing the ability to grasp objects or perform effective opposition [pincer function]),” and the sensory deficits described below.  The physical examination additionally recorded moderately severe ROM limitation (measured) of all small and ring finger joints, sensory loss of the graft tissue over the dorsal hand and harvest site on the ulnar forearm, and “decreased sensation over the ulnar aspect of his small and ring fingers which has improved since original injury but still is diminished lacking some self-discrimination of the small finger.”

The NARSUM listed the following diagnoses that were specifically incorporated in the PEB adjudication as charted above: “left hand injury status post combat-related blast injury with complex combined soft tissue loss status post reconstruction,” “segmental loss of small and ring finger metacarpals status post open reduction and internal fixation with bone grafting,” “extensor tendon loss status post extensor tendon reconstruction and side-by-side repair,” “ulnar nerve sensory neuropraxia secondary to blast injury,” “residual metacarpophalangeal joint contractures of small and ring finger,” and “status post interosseous artery flap and radial forearm flap.”

A 3 May 2005 VA neurological Compensation and Pension (C&P) examination, 4 months before separation, documented complaints of numbness, weakness and difficulty with grip; but, noted that “he still can perform most of the activities of daily living with the hand.”  The examiner recorded physical findings of “slight loss of sensation” of the ulnar forearm and ulnar hand, and “weakness” of extension and flexion of the small and ring fingers.   The neurologist opined that the weakness was due to tendon and muscle damage, and that nerve involvement was most likely confined to the “palmar sensory branch” of the ulnar nerve.

A 6 May 2005 VA orthopedic C&P examination, stated that “virtually all activities involving the use of the hand” and “fine movements of dexterity” were affected by the injury; but, the examiner opined that the CI had “regained excellent use of the hand and fingers considering the extent of the injuries.”  The physical examination recorded “somewhat limited” grip strength, significant flexor and opposition deficits of the small and ring fingers, “good” finger extension, and “just about normal” fingertip sensation.  A general C&P examination was conducted the same day but was not probative to rating of the hand condition other than corroborating right hand dominance.

The panel directed attention to its recommendation based on the above evidence.  Members first considered whether any of the additional NARSUM diagnoses, e.g., those adjudicated by the PEB as Category II (conditions that contribute to the unfitting condition but are not separately ratable), were reasonably subject to separate service rating.  It was noted that some of these represented distinctly different injuries with attendant disability; but, members agreed that none of them could be isolated from the overall impairment as unfitting in themselves, or justified for separate rating without violation of VASRD §4.14 (avoidance of pyramiding) that explicitly acknowledges “injuries to the muscles, nerves, and joints of an extremity may overlap to a great extent.”  It was thus concluded that all were appropriately subsumed in the same rating recommendation as a single unfitting condition.  It was likewise agreed that none of the scars rated by the VA could be justified for service rating, since it was the tendon injuries that produced the contractures and there was no evidence of functional consequences attributable to the scars that would establish the requisite link to fitness.

The panel agreed that no additional service ratings were supported, members turned to deliberation of the appropriate rating recommendation for the unfitting hand condition.  The PEB’s 20% rating under code 5219 (two digits of one hand, unfavorable ankylosis of) was consistent with the “ring and little fingers” criterion (major and minor) of that code, and conceded unfavorable ankylosis although there was still preservation of some ROM (an analogous prefix would have been more precise).  No higher rating was possible under code 5219 given the facts in evidence.  The VA‘s 30% rating under the 8516 ulnar nerve code was based on the C&P examination evidence and was consistent with the criterion for “severe” impairment (minor).  A higher rating under code 5219 would require complete paralysis, clearly not applicable, and no alternate nerve code rating was justified that would yield a rating higher than the PEB’s 20%.

Members considered alternate rating under the applicable muscle disability code 5308 (Group VIII hand extensors), but the maximum rating for “severe” disability is 20% (minor).  There was no evidence for ROM limitation or any other ratable criterion that would justify a rating higher than 20% under any other applicable code in the VASRD.  Members next deliberated whether a 30% rating under the 5219 nerve code (as per the VA) could be fairly recommended in lieu of the PEB code and rating.  

The VA neurologist’s assessment before separation, however, indicated that the peripheral nerve impairment was not the dominant factor in the CI’s functional disability.  There was likely no motor deficit, and even the finger sensory deficits (arguably the only functionally significant nerve impairment) were characterized in the NARSUM as improving and appeared to have resolved by the time of the VA orthopedic and neurology C&P examinations.  Members agreed, therefore, that leveraging the less consequential nerve injury in order to justify more favorable rating criteria was not reasonably consistent with  VASRD §4.7 (higher of two evaluations).  Furthermore, it was agreed that the rating for “severe” impairment under code 8516 (recalling that the nerve injury was confined to a distal branch of the ulnar nerve) was equivocal given the functional evidence (practical function intact, finer tasks impaired), and “moderate” impairment under code 8516 supports the same 20% rating conferred by the PEB.  The PEB’s code was a more precise fit with the clinical evidence and, in fairness, conceded the unfavorable ankylosis criterion to maximize the rating.  

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication of the left hand injury condition.

Contended Conditions:  Post-Traumatic Stress Disorder (PTSD).  Although the STR clinical records are not in evidence, the CI first presented with mental health (MH) complaints in October 2004 (12 months before separation).  He was diagnosed with PTSD and responded favorably to treatment (Lexapro); but, symptoms reemerged during the MEB period and his medication was changed to Remeron (a mood stabilizer).   A psychiatric addendum to the NARSUM (7 June 2005, 3 months before separation) documented a “robust response” to Remeron, and stated that the CI “did not desire” individual or group therapy for PTSD.  The mental status examination was normal except for a “somewhat depressed ... but full ranging” affect (mood described as “euthymic”), and the examiner specified “adequate memory and concentration.”  The MEB psychiatrist characterized the Axis I diagnosis of PTSD as “mild,” although opined that it might worsen with the stress of continued military service.  

The commander’s statement did not note any MH diagnosis or impairment, and there were no STR clinical entries that indicated any functional impairment related to MH issues.  There was no VA evidence during the early post-separation period that documented any MH complaints or treatment, and VA records indicated that the CI was a successful full-time student (nursing) until about 2 years after separation.  

The panel directed attention to its recommendation based on the above evidence; and, its main charge was an assessment of the fairness of the PEB’s determination that the PTSD was not unfitting.  The panel’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  Although the CI may have manifested some MH symptoms at separation, there was no performance-based evidence that indicated there was MH impairment severe enough to preclude retention.  The commander’s statement, the lack of any evidence from the STR for significant MH functional impairment, and the post-separation VA evidence (especially the occupational history) all supported a conclusion that the MH condition was not unfitting at the time of separation.  After due deliberation in consideration of the preponderance of the evidence, members agreed that there was insufficient cause to recommend a change in the PEB fitness determination for PTSD.

BOARD FINDINGS:  In the matter of the left hand injury condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended post-traumatic stress disorder, the panel unanimously recommends no change from the PEB determination as not unfitting.  There were no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends that there be no modification and no re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150602, w/attachments
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

      In accordance with reference (a), I have reviewed the cases listed below and 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:

		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
	 	- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC

		
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