RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00020
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20041127

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Armor Crewman, medically separated for “left fifth finger pain” and “left ring finger pain” rated 20% and 0%, respectively with a combined disability rating of 20%.

CI CONTENTION:  The CI contends his Post-Traumatic Stress Disorder was not addressed by the Medical Board.  The CI’s 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 - 20040916	VARD - 20050125	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Fifth Finger with Metacarpal Resection	5156	20%	Amputation, Little Finger, Left Hand	5156	20%	20041222	
Left Ring Finger proximal interphalangeal (PIP) Fusion and Tenolysis	5230	0%					
			Ankylosis, Ring Finger, Left Hand	5227	0%	20041222	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Left (non-dominant) Fifth Finger with Metacarpal Resection and Left (non-dominant) Ring Finger Status Post PIP Fusion and Tenolysis.  The PEB separated left hand injuries to the fifth finger and fourth finger for diagnostic and rating purposes.  However, both injuries occurred as a result of the same event and procedures.  Examinations and rehabilitation treatments overlapped thereafter.  As a result, details for each injury are combined below.  However, separate rating discussions are presented for each disabling condition.

According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left hand injury conditions began in April 2003 after the CI sustained shrapnel injuries due to an explosion to the left fourth and fifth fingers and metacarpals while deployed.  The CI underwent an emergency partial amputation on 4 April 2003 of the left fifth finger and metacarpal following the injury.  He underwent a revision surgery and pinning of the ring finger fracture of the proximal phalanx on 7 April 2003.  X-rays on 9 April 2003 showed a fifth ray amputation at the level of the base of the fifth metacarpal.  Scattered metallic foreign bodies were present.  Two pins transfixed major fragments of comminuted fourth proximal phalanx fracture in near anatomic alignment/position.  On 16 June 2003, the CI underwent a tenolysis (to release a tendon affected by adhesions) and arthrodesis (fusion) of the proximal interphalangeal (PIP) joint with internal fixation of the left fourth finger.  Despite extensive occupational therapy, grip strength on 18 November 2003 on the left was one fourth of the right.  An electrodiagnostic study of the left wrist was suggestive of a mild chronic proximal median neuropathy.  

The 19 February 2004 MEB NARSUM examination, 9 months prior to separation, noted complaints of hand pain of a “slight to moderate” amount with marked cold intolerance in the left hand as well as marked hypersensitivity to touch.  Physical examination showed a well-healed surgical scar on the left hand laterally.  There was an obvious defect.  He was missing the left fifth finger and metacarpal.  The left fourth finger was fused in a functional position and seemed to have good capillary return.  It was not swollen or tender at the time of the examination.  The CI stated that what he could not do at all was upper body weight training and could not fire a rifle.  During the 12 March 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 8 months prior to separation, the CI reported shrapnel hit his left hand and he lost his “pinkie” and had a fusion of the PIP of the ring finger.  Physical examination showed an absent left pinky and “Harry’s deformity” left ring finger with decreased ROM flexion.”  There were “surgical scars of the left hand/ring finger dorsally-healed.”  At an orthopedic evaluation on 9 July 2004 the examiner noted supple scars of the ring finger with the PIP slightly abducted/pronated with very limited active flexion.  The examiner assessed the left hand ring finger as dysfunctional and the small finger as s/p ray amputation.  Additional surgery was deferred and the CI was referred for an MEB.  An August 2004 orthopedic evaluation indicated the CI had intermittent pain in the left ring finger, which had “painless MP (metacarpophalangeal) motion and minimal DIP pull thru.”

At the 22 December 2004 VA Compensation and Pension (C&P) evaluation, performed 1 month after separation, the CI reported  chronic pain in the left fourth finger into the metacarpal area of the left wrist.  Physical examination showed an amputated left fifth finger.  The left fourth finger had a large scar of the entire left fourth finger to the dorsal surface of the metacarpal area.  The scar was nontender.  The fourth finger was everted outward and the CI could not extend or flex it, and it seemed to be locked in one position only.  The scar was well-healed and nontender, had good adherence and texture without keloid formation, and had no elevation or depression.  
X-rays of the left hand on 22 December 2004 demonstrated all of the fifth digit (little finger) and all of the fifth metacarpal except the proximal-most portion was absent.  The distal end of the remaining fragment of the fifth metacarpal was smooth without evidence of any irregularity to suggest an inflammatory involvement.  The PIP joint of the remaining ring finger (fourth digit) was fused with a metallic plate and transverse screws.  No unusual bone reaction was seen about the metallic elements.  The remaining osseous structures were normal without focal areas of bony erosion or destruction.  No acute or recent fractures or dislocations were detected.  

An X-ray series on 13 May 2005 of the left hand demonstrated an amputation of the fifth digit through the base of the fifth metacarpal and there was a poster plate fusion of the fourth finer middle and proximal phalanges in flexion.  At the 13 May 2005 VA C&P examination for the hand, thumb and fingers, 6 months after separation, the CI reported occasional dull pain in the ring finger along with sharp pain in cold weather, some stiffness in the mornings, and some discomfort on the ulnar side of wrist, which he treated with Aleve (naproxen, a nonsteroidal anti-inflammatory drug (NSAID)).  He did not have any flare-ups of pain in the finger and he was able to do activities of daily living without assistance.  Physical examination showed along the ulnar side of the left hand, the small finger and the fifth metacarpal were absent down to near the base of the fifth metacarpal, a small part of which was palpable.  There was tenderness over the ulnar collateral ligament.  The ring finger had full motion of the metacarpophalangeal (MCP) joint.  The PIP joint was fused at 30 degrees and the distal interphalangeal (DIP) joint had passive motion of 0-60 degrees.   There was no active extension of the DIP joint and the extensor tendon was absent.  There was weak active flexion of the DIP joint.  The DIP joint had a resting position of 60 degrees of flexion due to tendon imbalance.  There was a long dorsal scar and there was a skin graft on the ulnar side of the finger with slight tenderness to touch over the scar in the skin graft.  The grip strength of the left hand was greatly reduced and there was ulnar rotation of the ring finger. There was no fatigability or incoordination.  X-rays of the left hand demonstrated amputation of the small finger and 5th metacarpal with a metacarpal base remaining.  There was a fusion of the ring finger PIP joint with a dorsal plate and six screws.  Other joints were normal.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left (non-dominant) fifth finger with metacarpal resection condition 20%, coded 5156 (little finger, amputation of).  The PEB also rated the left (non-dominant) ring finger status post PIP fusion and tenolysis 0%, coded 5230 (ring or little finger, limitation of motion).  The VA also rated the amputation, little finger, left hand (non-dominant) condition 20% coded 5156, based on the VA C&P examination 1 month after separation, citing metacarpal resection involving loss of more than one-half the bone.  The VA rated the ankylosis, right finger, left hand (non-dominant) 0%, coded 5227 (ring for little finger, ankylosis of (unfavorable or favorable), based on the VA examination 1 month after separation, citing a noncompensable evaluation for ankylosis of the ring or little finger is the maximum disability evaluation for ankylosis of the ring finger.

Members first discussed the left fifth (little) finger amputation and noted that code 5156 offers a maximum of a 20% rating for a metacarpal resection (more than one-half the bone lost).  Therefore, there was no route to a higher rating for the fifth finger disability.  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 for the left (non-dominant) fifth finger with metacarpal resection condition.  

Members then discussed the left ring status post PIP fusion and tenolysis and noted that code 5227 offers only a 0% rating for unfavorable or favorable ankylosis.  However, a note for code 5227 states “Also consider whether evaluation as amputation is warranted and whether an additional evaluation is warranted for resulting limitation of motion of other digits or interference with overall function of the hand.”  Amputation was not warranted; therefore, code 5155 (ring finger, amputation of) is not applicable, while code 5230 (ring or little finger, limitation of motion) offers only a 0% rating for any limitation of motion, which provides no benefit to the CI.  Use of code 5099-5003 (arthritis, degenerative) was considered.  However, it was the PIP joint that was ankylosed, and the use of the code required there were need be a group of minor joints affected by limitation of motion, although the DIP did not have active extension since the extensor tendon was absent.  There was weak active flexion of the DIP joint.  The DIP joint had a resting position of 60 degrees of flexion due to tendon imbalance.  VASRD §4.45 indicates “multiple involvement of the interphalangeal, metacarpal and carpal joints of the upper extremities…are considered groups of minor joints.”  However, the finger was not swollen or tender at the NARSUM examination nor was painful motion recorded in any of the examinations proximate to separation.  Although there was no muscle injury per se, as a result of injuries sustained and tenolysis, the extensor tendon to the ring finger was absent.  Therefore, use of code 5308 (Group VIII. Function: Extension of wrist, fingers, and thumb; abduction of thumb. Muscles arising mainly from external condyle of humerus: Extensors of carpus, fingers, and thumb; supinator) offers a rating option, but since only extension of the DIP of the left ring finger was impaired, only a slight disability could assessed with a 0% rating.  However, the note following code 5309 (Group IX Function:  The forearm muscles act in strong grasping movements and are supplemented by the intrinsic muscles in delicate manipulative movements. Intrinsic muscles of hand: Thenar eminence; short flexor, opponens, abductor and adductor of thumb; hypothenar eminence; short flexor, opponens and abductor of little finger; 4 lumbricales; 4 dorsal and 3 palmar interossei)  states “The hand is so compact a structure that isolated muscle injuries are rare, being nearly always complicated with injuries of bones, joints, tendons, etc. Rate on limitation of motion, minimum 10 percent.”  Therefore, since the ring finger had a joint injury that was fused, no extension of the DIP due to the absence of an extensor tendon, and weak active flexion of the DIP joint as well as the DIP joint having a resting position of 60 degrees of flexion due to tendon imbalance, a 10% rating is appropriate especially since the CI did have decreased grip strength thereby limiting his capability of performing the heavy labor duties of an armor crewmember especially, but not limited to, loading ammunition and fixing and/or replacing broken tank tracks.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the left (non-dominant) ring finger status post PIP fusion and tenolysis condition, coded 5230-5309.  

BOARD FINDINGS:  In the matter of the left (non-dominant) fifth finger with metacarpal resection condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the left (non-dominant) ring finger status post PIP fusion and tenolysis condition, the panel unanimously recommends a disability rating of 10%, coded 5230-5309 IAW VASRD §4.73, §4.55, §4.56 and §4.71a.  There were 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	
Left Fifth Finger with Metacarpal Resection	5156	20%	
Left (Non-Dominant) Ring Finger Status Post PIP Fusion and Tenolysis	5230-5309	10%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160109, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170015120, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	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 U.S. Army Physical Disability Agency, (AHRC-DO) XXXXXXXXXXXXXXXXXXX.

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

Sincerely,					      
Enclosure