RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-03335
BRANCH OF SERVICE:  army	SEPARATION DATE:  20050416

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E3, Avionic Radar Repairer, medically separated for “chronic pain and limitation of motion specifically pronation decreased to 10 degrees, status post fracture proximal left humerus, radial head fracture and subluxation of left wrist” 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 - 20050401	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain and Limitation of Motion Specifically Pronation Decreased to 10 Degrees Status Post Fracture Proximal Left Humerus, Radial Head Fracture and Subluxation of Left Wrist	5213	20%	No VA Examination in Evidence Proximate to Separation	
Chronic Low Back Pain due to Compression Fracture	Not Unfitting 		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Chronic Pain and Limitation of Motion Specifically Pronation Decreased to 10 Degrees Status Post Fracture Proximal Left Humerus, Radial Head Fracture and Subluxation of Left Wrist.  The PEB combined the left shoulder, left elbow, and left wrist conditions under a single disability rating, coded 5213 (supination and pronation, impairment of) and rated 20%.  This approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications.  The panel’s initial charge in this case was therefore directed at determining if combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the panel considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the DES or be found unfit because of physical disability.  When the panel recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  

According to the service treatment record and MEB narrative summary (NARSUM), the right hand dominant CI fell from a third floor height on 9 October 2004 and sustained a fracture of the proximal left humerus (upper arm, near the shoulder), fracture of the left radial head at the elbow, and a subluxation of the distal left radioulnar joint at the wrist.  The CI underwent immediate surgical repair (open reduction internal fixation with screws and fixation plate) of the left humerus, and 10 days later underwent operative repair of the wrist (pinning) for instability.  Despite extensive physical and occupation therapy (PT and OT), the CI had continued pain and loss of motion in his left shoulder, elbow, and wrist.  Left shoulder X-rays showed a surgical plate and screws utilized to transfix the left humeral neck with blurring of the fracture line indicating ongoing healing.  Left forearm X-rays showed some linear lucencies in the distal radius from prior hardware removal without other significant findings.  The left wrist X-rays showed multiple lucencies in the distal ulna and radius (previous pin removal) with a well healed fracture.  

The 15 February 2005 MEB NARSUM examination, 2 months prior to separation, noted complaints of chronic pain and decreased range of motion (ROM) of the left shoulder, left elbow, and left wrist.  Physical examination showed surgical scars at the left shoulder and left wrist.  There was tenderness of the left upper humerus, the left radial head at the elbow, and the left distal radius and ulnar at the wrist.  There were no neurologic or vascular deficits noted.  There was “decreased ROM in the left shoulder, left elbow, and left wrist and this was corroborated by OT findings.”  

The PT and OT ROMs from 3 March 2005 showed left shoulder painful motion with flexion and abduction each to 145 degrees (normal 180) with slight weakness (4- to 4 out of 5); left elbow flexion was 145 degrees (normal) and extension to 0 degrees (normal).  Forearm ROM was supination 65 degrees (normal 85), and pronation 10 degrees (normal 80).  Wrist dorsiflexion was 50 degrees (normal 70) and palmar flexion was 35 degrees (normal 80).  There was slight weakness (4/5) in the forearm and wrist flexions and forearm movements, and grip strength was 65 pounds (59% of normal).  There was mild forearm atrophy noted with no neurologic deficits.  There was no VA examination in evidence proximate to separation.  However, remote examination in 2009 and subsequent VA ratings were noted (see below).  

The panel directed attention to its rating recommendation based on the above evidence.  As noted above, the PEB bundled the left shoulder, left elbow, and left wrist conditions and applied a single 20% rating (coded 5213).  Over 3 years remote from separation (2009), the VA rated the left radial head fracture at 20%, coded 5010-5213; and the residuals of the left humerus fracture at 10% coded 5202-5010.  

The panel considered whether the left shoulder (fractured proximal humerus), left elbow (fractured radial head), and/or left wrist (operative repair of wrist subluxation) conditions, when considered separately, were unfitting for continued military service.  In this case, the left shoulder, left elbow, and left wrist conditions were considered to fail retention standards (separately listed on the MEB), were implicated by the NARSUM, and were listed in the profile.  Panel members agreed that the evidence reasonably justified that the functional limitations of the left shoulder and left wrist/forearm conditions contributed to the CI’s inability to perform his military duties; each was reasonably unfitting, and accordingly a separate disability rating is recommended for each.  Since the CI was right-hand dominant, the VASRD “minor” ratings are applicable.  

With regards to the left elbow (fractured radial head), and left wrist (operative repair of wrist subluxation) conditions, both conditions are rated together under the VASRD and rating policy in effect at the time of separation.  There was limited forearm ROM which met the 20% rating criteria under code 5213 for limitation of pronation; motion lost beyond middle of arc.  There was no loss of (bone fusion) with the hand fixed in supination or hyperpronation, no radius nonunion, no wrist ankylosis, and no ankylosis or ratable limitation of the elbow for any higher rating under alternative coding under the elbow and forearm or wrist disability codes.  After due deliberation, and considering all of the evidence, the panel recommends a separately unfit determination for the left elbow (fractured radial head) and wrist (operative repair of wrist subluxation) with a disability rating of 20%.  

With regard to the CI’s unfitting left shoulder (fractured proximal humerus) condition, there was pain-limited flexion of the shoulder on all examinations with slight muscle atrophy.  The VASRD §4.71a threshold for rating for ROM impairment (code 5201, arm limitation of motion) is “at shoulder level” (approximately 90 degrees from the side), and the examinations in evidence demonstrated motion above this level.  However, panel members agreed that a 10% rating was justified with application of VASRD §4.59 (painful motion).  There was no malunion or recurrent dislocation of the humerus and no dislocation or nonunion of the clavicle or scapula to justify a higher rating under the 5202 (humerus, other impairment of) or 5203 (clavicle or scapula, impairment of) codes.  Given the humerus fracture repair with retained hardware, pain-limited shoulder motion and weakness, analogous coding as 5099-5021 (myositis) was predominant.  After due deliberation, and considering all of the evidence, the panel recommends a separately unfit determination for the left shoulder (fractured proximal humerus) with a disability rating of 10%.  

Contended PEB Condition:  Chronic Low Back Pain Due to Compression Fracture of L1-L2.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition was profiled L2, the commander’s statement was non-specific, and the back condition was not judged to fail retention standards.  At the 15 February 2005 NARSUM examination the CI reported the lower back was a relatively minor problem.  There was full lumbar spine ROM and minimal tenderness over L1 and L2.  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended back condition, so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the bundled left upper extremity conditions, the panel recommends that they be adjudicated for two separate conditions as follows:  an unfitting chronic pain and limitation of motion of the left elbow and wrist s/p repair of radial head fracture and subluxation of left wrist condition coded 5213 and rated 20%, and an unfitting chronic pain and limitation of motion of the left shoulder s/p repair proximal left humerus fracture, coded 5099-5021 and rated 10%, both IAW VASRD §4.71a.  In the matter of the contended back condition, 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 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 the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Pain and Limitation of Motion of the Left Elbow and Wrist S/P Repair of Radial Head Fracture and Subluxation of Left Wrist	5213	20%	
Chronic Pain and Limitation of Motion of the Left Shoulder S/P Repair Proximal Left Humerus Fracture	5099-5021	10%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170405, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record  

AR20180005925, 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 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), XXXXXXXXXXXXXXXXXX.

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

Sincerely,					      
Enclosure