RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00563
BRANCH OF SERVICE:  nAVY	SEPARATION DATE:  20050202

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Global Command & Control System Operator, medically separated for “right wrist chronic triangular fibrocartilage complex tear, with continued ulnar-sided wrist pain” with a disability rating of 10%.   

CI CONTENTION:  Condition continues to negatively affect his life and work.  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 – 20041029	VARD - 20040621	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Wrist Pain	5099-5003	10%	Right Wrist Fracture…	5212	10%	20040528	
Status Post ORIF, Right Distal Radius Fracture	Cat II					
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY: 

Right Wrist Pain.  According to the service treatment record and Medical Evaluation Board (MEB) narrative summary (NARSUM), the right-hand dominant CI’s right wrist pain condition began in March 2003 after sustaining a comminuted distal radius fracture in a motorcycle accident.  On 13 March 2003, he underwent an open reduction internal fixation (ORIF), and a month postoperatively, the fracture site was healing well with slight widening of the distal radial ulnar joint; however, the range of motion (ROM) was supination to 20 degrees (normal 85) and  pronation to 20 degrees (normal 80), with pain along the distal ulna.  
On 16 May 2003, X-rays demonstrated normal anatomic alignment with a surgical plate and screws at the distal radius and a bony fragment of the ulnar styloid s noted.  At an orthopedic visit the same day, there was tenderness at the dorsum of the wrist and 5/5 grip strength with pain.  Supination was 70%, pronation 60%, flexion 40% and extension 50%.  

At a 21 July 2003 occupational therapy visit, ROM (in degrees) was: supination to 72, pronation within functional limits, flexion to 50 (normal 80), extension to 50 (normal 70), ulnar deviation to 14 (normal 45), and radial deviation to 24 (normal 20).  Right hand grip strength was 65/70/70 pounds compared with left hand strength of 75/75/75 pounds (taken 5 weeks earlier)   

During a 26 September 2003 orthopedic appointment, the CI complained of decreased wrist ROM and continued ulnar/radial-sided pain despite occupational therapy.  Extension was to 70 degrees and palmar flexion to 65 degrees with good radial/ulnar deviation.  Pronation was full and supination was to 75 degrees.  There was first dorsal compartment tenderness with a positive Finkelstein’s test (indicative of tenosynovitis) and increased excursion of the right distal radius ulnar joint compared to the left.  Right wrist X-rays on 26 September 2003 demonstrated an old, healed distal radial fracture with metallic plate and screws in place and an old avulsion ulnar styloid.  There was no acute fracture or dislocation.  At a 3 November 2003 orthopedic visit, the results of a right wrist arthrogram demonstrated a large tear of the triangular fibrocartilage complex (TFCC).  On examination there was distal radial ulnar joint instability, crepitus, and pain with a full wrist ROM.  Repair was recommended and a 3 May 2004 orthopedic note indicated a hand surgeon recommended elective surgery; however the CI declined.  The 3 May 2004 MEB NARSUM examination, 8 months prior to separation, noted complaints of continued right ulnar-side wrist pain and decrease ROM. Physical examination showed increased excursion of the distal radioulnar joint as compared to the opposite wrist.  There was crepitus to motion and tenderness at the TFCC but full wrist ROM. 

At the 28 May VA Compensation and Pension (C&P) evaluation, 8 months before separation, the CI reported daily pain and significant right wrist weakness.  Physical examination showed he could “pronate and supinate the hand well” with “good extension of the hand” and a “mild degree of pain with making a fist.” 

During the 23 June 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 7 months prior to separation, the CI reported he suffered from a broken wrist and had a TFCC tear.  He knew surgery could be performed but stated he “would still have some degree of pain with certain motions,” and opted not to have surgical treatment.  Physical examination showed decreased sensation over the right vertical incision (6-7 cm long).
  
The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right wrist pain condition 10%, coded 5099-5003 (arthritis, degenerative).  The PEB also listed “s/p ORIF, right distal radius fracture” as a related Category II condition (contributes to the primary unfitting condition but not separately ratable).  The impairment from the fracture ORIF was properly subsumed under the overall rating for the right wrist IAW §4.14 (avoidance of pyramiding; more than one rating based on the same impairment is prohibited).  The VA also rated the right wrist fracture and TFCC tear at 10%, but coded 5212 (radius, impairment of), based on the C&P examination 8 months before separation, citing residual pain and functional impairment.  Panel members noted there was no wrist ankylosis (code 5214), wrist limitation of motion (code 5215), nonunion with flail false joint of the radius (code 5210), impairment of the radius (code 5212), or impairment of supination and pronation (code 5213) sufficient to warrant a higher rating than the 10% assigned by the PEB.  However, there was X-ray evidence of an ulnar styloid fragment from an avulsion fracture, which warrants a 20% rating using code 5211 (ulna, impairment of) for nonunion in the lower half of the ulna.  The panel members noted pertinent references to support the 20% rating and discussed using code 5212-5211.  This addresses the initial radial and styloid fragment and captures the TFCC tear (for which there is no specific VASRD code) as well as the continued wrist pain and functional limitations sufficient enough for a recommendation of further surgery.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 20% for the right wrist pain condition, coded 5212-5211.  

BOARD FINDINGS:  In the matter of the right wrist pain condition, the panel unanimously recommends a disability rating of 20%, coded 5212-5211 IAW VASRD §4.71a.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Right Wrist Pain	5212-5211	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160911, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

MEMORANDUM FOR DEPUTY COMMANDANT (Manpower and Reserve Affairs)
COMMANDER, NAVY PERSONNEL COMMAND

Subj: PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS

Ref: (a) DoDI 6040.44
        (b) PDBR ltr dtd 03 Jan 18 ICO XXXXXXXXXXXXXXXXXX        
        (C) PDBR ltr dtd 07 Jan 18 ICO XXXXXXXXXXXXXXXXXX
        (d) PDBR ltr dtd 22 Dec 17 ICO XXXXXXXXXXXXXXXXXX
        (e) PDBR ltr dtd 03 Jan 18 ICO XXXXXXXXXXXXXXXXXX
        (f) PDBR ltr dtd 03 Jan 18 ICO XXXXXXXXXXXXXXXXXX

1. Pursuant to reference (a), the recommendations of the Physical Disability
Board of Review set forth in references (b) through (f) are approved. The
official records of the following individuals are to be corrected as follows:

a. XXXXXXXXXXXXXXXXXX, former USMC: Placement on the
Permanent Disability Retired List with a 30 percent rating (increased from 10
percent) effective date of discharge.

b. XXXXXXXXXXXXXXXXXX, former USMC: Placement on the
Permanent Disability Retired List with a 30 percent rating (increased from 10
percent) effective date of discharge.

c. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to
disability separation pay with a 20 percent disability rating (increased from
10 percent) effective date of discharge.

d. XXXXXXXXXXXXXXXXXX, former USN: Placement on the
Permanent Disability Retired List with a 30 percent rating (increased from 10
percent) effective date of discharge.

e. XXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent
Disability Retired List with a 30 percent rating (increased from 10 percent)
effective date of discharge.

2. Please take action to implement these decisions and provide notification
to the above individuals once those actions are complete.