RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-03182
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20060527

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Infantryman, medically separated for “injury to right dominant forearm” with a disability rating of 20%.  

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 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 - 20060204	VARD - 20061114	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Injury to Right Dominant Forearm	5213	20%	Missile Wound, Right Forearm with Defected Ulna and Residual Scar (Dominant)	5307	30%	20061031	
Hip and Pelvic Pain	Not Unfitting	Missile Injury, Right Thigh … 	5313	0%	20061031	
		Right Hip Donor Site Skin Graft Scar	7805	0%	20061031	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40% 	

ANALYSIS SUMMARY:  

Right Forearm Injury.  According to the service treatment record and MEB narrative summary (NARSUM), the CI suffered a right forearm injury in October 2004 from a vehicle-born improvised explosive device.  There was an open midshaft comminuted blast/shrapnel fracture of the middle third of the ulna with bone loss, and he underwent multiple surgeries including ORIF (open reduction internal fixation) and bone grafting.  At an orthopedic visit on 15 September 2005, 8 months prior to separation, the CI reported right forearm pain and limited pronation.  Physical examination showed well-healed surgical scars with full range of motion range of motion (ROM) of the right elbow and full supination, but only 15-20 degrees of pronation (normal 80).  There was slightly limited wrist ROM.  Although surgical intervention was considered, the CI reasonably declined and an MEB was initiated.  Occupational therapy (OT) pronation measurements in June, July, and August 2005 recorded pronation at 25 degrees.  

At the 7 November 2005 OT examination, 6 months before separation, the CI complained of right forearm pain and very limited pronation which made it difficult to engage in activities such as typing, brushing his teeth, carrying heavy objects, charging a weapon, or doing push-ups.  Physical examination revealed normal, active ROM in the right hand digits; scars were “nicely” healed, but there was diminished and loss of deep pressure sensation around suture areas.  Measured ROMs for the MEB showed right forearm pronation of 45 degrees, with passive pronation to 55 degrees, supination to 85 degrees (normal), elbow extension to 0 degrees (normal) and flexion to 140 degrees (normal).  The right wrist was without ROM limitations.  Right grip strength was 80 compared to 105 on the non-dominant side, and three-point pinch strength was 18 compared to 22 on the left side.  

The 6 January 2006 MEB NARSUM examination, 4 months prior to separation, noted CI complaints of decreased ROM and strength of the right hand and forearm following injury to, and bone loss of, the mid shaft ulna.  Pain was constant at 1-2/10, and limited right forearm pronation impacted functional capacity and activities of daily living such as writing, typing, brushing teeth and using a knife and fork.  Physical examination showed multiple right forearm scars with some keloid-type widening.  Elbow and wrist ROM measurements were essentially normal except for right active pronation limited to 45 degrees, with passive pronation to 55 degrees.  All joints of the right hand functioned within normal limits, as did the wrist.  There was some sensory loss on the dorsal and ulnar aspect of the distal third of the forearm to the wrist.  X-rays revealed a healed postoperative site at the mid shaft of the ulna (middle one-third).  

At the 31 October 2006 VA Compensation and Pension (C&P) examination, 5 months after separation, the CI reported right arm pain and limited motion due to a shrapnel injury and surgeries.  He had pain and weakness worsened by cold exposure, lifting, or repeated use (lack of endurance), and could not pull himself up ladders or position his hand to write or type.  There were flare-ups of pain and weakness and he sometimes missed work.  Physical examination showed an entry wound on the right forearm along two-thirds of the ulnar side with exit wounds on the volar surface; scars were not attached to deeper structures or tender.  Elbow and wrist ROMs were near normal without joint pain, but there was forearm pain at the site of the principle injury.  There was evidence of 90 degrees of supination and minus 30 degrees of pronation, and that he could not “pronate even to neutral so that his hand tends to face forward.”  There was a general weakness of the right arm and forearm and grasp muscles, and pain with muscle testing.  The examiner stated “on account of the weakened movement, fatigability, incoordination and painful movement I think he has lost 30% of the function of his right arm from the elbow distal ward.  I think this impairment in reference to the forearm and hand as a whole and is not just restricted to the change in degrees of pronation.”  The diagnosis was “missile wound of the right forearm with defect of the ulna status post internal fixation.” 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right forearm condition 20%, coded 5213 (supination and pronation, impairment of), citing limit of pronation to 45 degrees active (55 degrees passive motion) and full supination.  The VA rated the right forearm condition 30%, coded 5307 (muscle group VII), based on the C&P examination, citing moderately severe muscle injury.  Panel members noted that the CI had a shrapnel blast injury with a comminuted open fracture, bone loss and multiple cardinal complaints of a muscle injury following multiple surgeries and rehabilitation.  The panel considered that IAW VASRD §4.56 (evaluation of muscle injuries) and given the area of injury, a severe muscle injury was not mandated, but there was greater than minimal muscle damage.  The CI had loss of power, weakness, lowered threshold of fatigue, and fatigue-pain; that coupled with the significant limitation of pronation most nearly approximated the moderately severe (30%) muscle disability under code 5307.  Panel members also considered that multiple OT and orthopedic ROM examinations prior to the 11 November 2005 MEB ROM documented pronation of 15 to 30 degrees, which supported a 30% rating under code 5213 for motion lost beyond middle of arc.  Additionally, the NARSUM ROMs appeared to be a summary of the OT ROMs and not a separate evaluation, and it was preceded and followed by examinations documenting an inability to pronate to the middle of the arc.  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 forearm condition, coded 5213-5307.  

Contended PEB Condition:  Hip and Pelvic Pain.  The panel’s main charge is to assess the fairness of the PEB determination that the contended condition was not unfitting.  The contended condition was profiled as L2 and did not fail retention standards.  The hip was implicated in the commander’s statement, indicating the CI had “hip pain related to the bone graft whenever he stands for an extended period of time or conducts any strenuous lower-body activity…and could not climb into the cab of a 5-ton truck.”  The panel considered that that there was likely overlap between the dominant arm condition and the hip condition interfering with climbing into the truck.  Orthopedic evaluation showed the right hip with well-healed scars and full active ROM without pain.  The NARSUM noted no gross abnormalities aside from the right upper extremity, and noted the hip and pelvic pain as medically acceptable with the CI able to perform alternate physical fitness aerobic events.  There was therefore no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition, so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the right forearm condition, the panel recommends a disability rating of 30%, coded 5312-5307 IAW VASRD §4.71a and §4.73.  In the matter of the contended hip and pelvic pain, the panel recommends no change from the PEB determination as not unfitting.  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; 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	
Injury to Right Dominant Forearm	5213-5307	30%	

The following documentary evidence was considered:

AR20190008708, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a permanent 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 permanent 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), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557.

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

	      

Enclosure