RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01265
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040404

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Wire System Installer, medically separated for “chronic pain and decreased grip strength right (dominant) hand” with a disability rating of 20%.   

CI CONTENTION:  No specific contention was made.  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 Medical Evaluation Board (MEB), but determined by the PEB 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.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for 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, which operates 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 disability at the time of separation.    

RATING COMPARISON:  

SERVICE PEB - 20040130	VARD - 20040403	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Hand Chronic Pain and Decreased Grip Strength 	5099-5003	20%	Healed Right Ring Finger Fracture	5223	10%	20030722	
			Healed Right Long Finger Fracture	5229	10%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Right Hand.  According to the service treatment record and MEB narrative summary (NARSUM), the right-hand-dominant CI’s chronic pain and decreased grip strength condition began on 7 May 2003 when a hitch support collapsed thereby crushing his hand between the support and wheel of the trailer.  The CI underwent surgery on 11 May 2003 with open reduction and internal fixation (ORIF) of third and fourth metacarpal fractures.  Shortly after the surgery, he developed a decreased pulse and circulation and underwent fasciotomies on multiple sites in his hand for compartment syndrome.  On 15 May 2003, an occupational therapist (OT) measured the CI’s left hand grip strength to be 115 pounds and deferred measurement of the right hand grip strength secondary to pain and swelling.  X-rays of the right hand on 20 May 2003 demonstrated ORIF of fractures of the third and fourth metacarpal bones with anatomic alignment present at the fracture sites.  No callus was noted and no fixation device complications were detected.  

An OT note dated 25 June 2003, 10 months prior to separation, indicated the CI attended OT three times weekly and had some increased range of motion (ROM), but was still restricted in his activity.  On examination, his right hand was neurovascularly intact with well-healed scars over the fasciotomy and ORIF sites.  There was approximately 90 degrees flexion available at the distal interphalangeal joints and about 60 degrees flexion of the metacarpophalangeal joints.  He was unable to make a fist and there was a mild rotational deformity of the middle finger that was cosmetic more than functional.  

At a primary care clinic appointment on 18 August 2003, 6 months prior to separation, examination of the right upper extremity showed a flexion deformity of the right middle finger.  He could not make a fist completely.  He had no side-to-side motion in his lumbrical muscles on the right hand in the middle and second finger.  Sensation was generally within normal limits and motor strength was 4+/5 on the right for hand grip strength.  At 3 months postoperatively the CI had 30 degrees extension lag of the right middle finger at the PIP (proximal interphalangeal joint).  Measurements at Jamar position II of the right hand showed grip strength as follows over the course of 3 months:  the right hand was 40 pounds, the left hand was 95 pounds (4 September 2003); 30 pounds on the right and 80 pounds on the left (7 October 2003); and 60 pounds on the right and 120 pounds on the left (21 November 2003).  

Furthermore, at several OT visits during the same timeframe testing with a work simulator device to determine voluntary effort showed significant variations both positively and negatively in grip and pinch strength related to pain with use.  X-rays dated 9 December 2003 demonstrated satisfactory healing of known fractures involving the third and fourth metacarpals with an orthopedic fixation plate and screws present and without evidence of osteomyelitis.  After extensive OT over 7 months there was some improvement in his hand grip strength, but the CI was unable to perform many of the required tasks of his military occupational specialty (MOS).  

During the 9 December 2003 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, the CI reported right hand pain.  Physical examination showed several well-healed scars on the right hand with limited third finger extension.  There was also decreased hand grip (strength) on the right. 

The 9 December 2003 MEB NARSUM examination, 4 months prior to separation, noted the complaint of daily right hand pain, which increased in cold weather and when gripping certain objects.  Physical examination showed several well-healed scars over the posterior and lateral hand.  There was a persistent lack of extension of the middle finger on the right hand.  He could only extend this to 25 degrees active however, it did extend to 0 degrees passive.  All the other fingers had full ROM.  There was some restriction in the fingertip touch of the thumb to the small finger on the right hand however, he was able “to comply with this.”  The hand grip strength was somewhat decreased on the right.  Pulses and sensory examination were grossly within normal limits of the right hand and the neurological examination was without any deficits.  

Grip strength performed by OT as requested by the MEB on 10 December 2003, 4 months prior to separation, was 12/12/12 pounds of the right hand and 44/46/50 pounds of the left hand.  In response to a PEB inquiry, on 20 January 2003 the surgeon referred to the above grip strength test and stated, “There is no gap between any fingertip and the proximal transverse crease of the palm.  He can make a fist; he just has decreased grip strength with his hand and decreased coordination due to the injury.”

At the 22 July 2003 VA Compensation and Pension (C&P) evaluation, 3 months after separation, the CI reported constant stiffness and soreness in the right hand.  The functional impairment was reduced grip and difficulty picking up small objects, tying shoelaces, fastening buttons, and picking up a piece of paper and tearing it with the right hand.  The condition resulted in 28 days of time lost from work.  Physical examination of hand dexterity showed a 2 cm gap between the proximal transverse crease of the palm to the right hand index fingertip; the long, right and little fingertips were each 2 cm.  The left hand fingertips could approximate the proximal transverse crease of the palm.  His right hand strength was slightly reduced and his left hand strength was within normal limits.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the hand condition 20%, coded 5099-5003 (degenerative arthritis) citing “rated as moderate/constant.”  The VA rated the healed right ring finger fracture coded 5223 (two digits of one hand, favorable ankylosis) and healed right long finger fracture coded 5229 (index or long finger, limitation of motion) 10% each, citing limitation of motion with pain.  

Members extensively discussed the degree of which the CI’s grip strength was impaired.  The panel majority relied on statements by the NARSUM examiner that “the hand grip strength was somewhat decreased on the right” and those by the VA examiner that the CI’s “hand grip was slightly reduced.” Panel members reviewed the mechanism of injury, surgical procedures, and OT notes.  Use of code 8514 (paralysis of the musculospiral nerve (radial nerve)) where the CI could not extend his middle finger more than 25 degrees (“extend proximal phalanges of fingers”) was considered; however, the panel majority did not consider the condition to rise to a moderate disability, which warrants a 30% rating.  

Members noted the VA ratings of 10% each for the long and ring fingers; however, that approach using code 5229 does not offer a higher rating since the gap between the fingertip and the proximal transverse crease was not more than 2.5 cm nor was extension limited by more than 30 degrees.  Code 5223 likewise does not offer a higher rating since there was no involvement of the index finger nor does code 5003 since 20% is the maximum rating when there is “X-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations.”  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority concluded there was insufficient cause to recommend a change in the PEB adjudication for the chronic pain and decreased grip strength condition in the right (dominant) hand.

BOARD FINDINGS:  In the matter of the chronic pain and decreased grip strength condition in the right (dominant) hand and IAW VASRD §4.71a, the panel majority recommends no change in the PEB adjudication.  The single voter for dissent submitted the appended minority opinion.  There are no other conditions within the panel’s scope of review for consideration.  Therefore, the panel majority recommends no modification or re-characterization of the CI’s disability and separation determination. 

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20161001, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

Minority Opinion.  The minority voter determined there is a higher rating option since the CI’s grip strength was more than mildly impaired.  In fact it was sufficiently impaired such that he could not perform his MOS as a wire system installer.  Use of code 8514 (paralysis of the musculospiral nerve (radial nerve)) is not only reasonable, but it accurately captures the CI’s condition where he could not extend his middle finger more than 25 degrees (“extend proximal phalanges of fingers”) and he had impaired grip strength.  However, there was no report of “loss of synergic motion of extensors” impairing “the hand grip seriously.”   

Nevertheless, the CI did suffer a crush injury resulting in fractures and compartment syndrome that necessitated surgical procedures—an ORIF to repair the fractures and fasciotomies to relieve the increased pressure on all structures in and around the third and fourth fingers. More importantly, while the PEB and VA assigned a 20% rating to the condition, the panel majority relied on statements in the NARSUM and VA examination respectively that “the hand grip strength was somewhat decreased on the right” and “hand grip was slightly reduced.”  However, based on OT quantitative measurements, grip strength in September 2003 was 40 pounds on the right and 95 pounds on the left, while in October 2003 grip strength was 30 pounds on the right and 80 pounds on the left.  In November 2003 the grip strength measured at Jamar position II of the right hand was 60 pounds and 120 pounds of the left hand.  Grip strength performed by OT as requested by the Medical Board on 10 December 2003, 5 months prior to separation, was recorded as 12/12/12 pounds of the right hand and 44/46/50 pounds of the left hand.  Therefore, from a quantitative standpoint in November 2003, the CI’s right hand grip strength was 50% of the left hand grip strength in November 2003.  

The fact that the CI was right-hand dominant where grip strength should be higher than the non-dominant hand clearly unequivocally demonstrates a significant impairment of the right hand grip strength.  While the measurements in December 2003 are disparate from those of November 2003, it is not clear what exact test was performed and by what instrument the measurements were made, albeit the measurements were at the request of the Medical Board.  However, a reasonable explanation is that the Jamar dynamometer used to measure grip strength has two scales printed on its display face, one in pounds and the other in kilograms. Therefore, although the OT recorded the 12, 12, 12  for the right hand and 44, 46, 50 for the left hand using the symbol (#) to stand for pounds, it is not unlikely that in essence the readings were actually in kilograms, which convert to 26.4, 26.4, 26.4 pounds for the right hand and 96.8, 101.2, 110 pounds.  

Recall that the CI had a baseline of 115 pounds grip strength of the left hand on 15 May 2003.  Therefore, the measurement for the Medical Board, at least for the left hand has a high level of consistency over time.  Furthermore, at several OT visits during the same timeframe, testing with a work simulator device showed significant variations both positively and negatively in grip and pinch strength related to pain with use.  Nevertheless, the CI’s right hand grip strength was approximately one-fourth of the left hand grip strength based on measurements for the Medical Board.  

Further evidence to support the impaired grip strength comes from the VA examination where hand dexterity showed the gap between the proximal transverse crease of the palm to the right hand index fingertip was 2 cm; the long, right and little fingertips were each 2 cm.   The left hand fingertips could approximate the proximal transverse crease of the palm.  The fact that the CI could not make a tight fist or approximate the aforementioned fingertips to the transverse crease correlates with the decreased grip strength despite the VA examiner’s report that the “hand grip was slightly reduced.”  Most importantly the PEB rated the CI’s right hand chronic pain and decreased grip strength condition as “moderate/constant,” which comports with a moderate disability.  

Therefore, the minority voter considers a 30% rating to be reasonable using an analogous code 8499-8514 IAW the PEB’s basis for its rating, and recommends the ROP be modified to read:
After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 30% for the right hand chronic pain and decreased grip strength condition, coded 8499-8514.  

In the matter of the chronic pain and decreased grip strength condition in the right (dominant) hand, the panel recommends a disability rating of 30%, coded 8499-8514 IAW VASRD §4.124a.  

The panel recommends 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 the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Pain and Decreased Grip Strength Right (Dominant) Hand 	8499-8514	30%	

AR20180008784, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

Sincerely,					      
Enclosure