RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-03468
BRANCH OF SERVICE:  air force 	SEPARATION DATE:  20071109

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Command Post Specialist, medically separated for “left wrist pain” with a disability rating of 10%.

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 - 20070926	VARD - 20080320	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Wrist Pain	5211	10%	Residuals of Left Ulna Fracture	5215-5020	10%	20071215	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10% 	

ANALYSIS SUMMARY:  

Left Wrist Pain.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s left (dominant) wrist condition began in June 2004 when he fractured his left ulna while playing softball.  He underwent an open reduction, internal fixation of the left ulna with plating and screws.  A note dated 21 February 2006 indicated the CI had intense pain whenever he put weight on the wrist.  On examination he had reduced dorsiflexion.  All of the other ranges of motion (ROM) were full and equal bilaterally.  Post-surgical X-rays demonstrated postsurgical changes and a distal orthopedic fixation screw extended into the volar soft tissues.  

At an orthopedic visit on 29 March 2006 the CI reported he was unable to do pushups without pain.  X-rays revealed healed fracture and the plate and screws were in proper alignment.  Examination revealed good flexion and extension of the wrist and there was good grip strength.  There was no swelling, instability, neurologic deficits or sensory deficits appreciated.   

On 24 April 2006, the CI indicated constant 5/10 pain and 10/10 pain if stretched.  At a family practice clinic visit on 6 December 2006, examination revealed intact sensation to soft touch and pinprick.  There was decreased grip strength and movement against resistance compared to the right wrist/hand.  The wrist appeared normal without edema with a well-healed linear scar noted that extended to the left forearm.  

Neurologic evaluation on 11 January 2007, revealed discomfort during pronation and supination of the left wrist.  There was no evidence of focal atrophy or fasciculations.  There was no evidence of weakness proximally versus distally, lateralizing or focally.  There was decreased sensation to light touch demonstrated around the surgical site of the left wrist.  The examiner recorded the CI did not appear to have evidence of peripheral compression neuropathy or radiculopathy.  Most of his symptoms appeared to be mechanical in relationship to his fracture and subsequent surgery.     

On 24 January 2007, the CI indicated the pain, which was constant, radiated from his wrist to the plate in the wrist to about halfway down his forearm.  He reported inability to lift more than 10-15 pounds, perform pushups, or type.  A second orthopedic opinion on 20 February 2007 was the CI’s left wrist pain was secondary to the retained plate and screws and that he would most likely do better with removal of the plate and screws.  The CI was re-evaluated on 21 February 2007 where he had full active and passive ROM without swelling or instability.  Grip strength was good.  There was tenderness to deep palpation to the wrist joint.  No neurological or sensory deficits were appreciated.  The examiner explained there was no guarantee that removing the plate would help with the discomfort, and could even be worse after surgery.  The CI preferred not to have the plate removed.  Physical examination on 13 March 2007 showed left wrist ROM limited by pain at the limits of wrist flexion and extension.  Some crepitus (grinding sensation) was felt with wrist flexion and extension.  Pronation was not full and was limited by pain.  

On 20 March 2007, the physical therapy (PT) ROM measurements of the left wrist, after three repetitions, were flexion of 78 degrees (normal 80) with pain, extension of 63 degrees (normal 70) with pain, radial deviation of 15 degrees (normal 20) and ulnar deviation of 30 degrees (normal 45).  The ROM measurements of the forearm were pronation of 59 degrees (normal 80) with pain and supination of 52 degrees (normal 85) with pain. 

The 12 July 2007 PT ROM evaluation of the left wrist after three repetitions showed flexion of 70 degrees, extension of 39 degrees, radial deviation of 16 degrees and ulnar deviation of 37 degrees.  ROM measurements of the forearm were pronation of 56 degrees with pain and supination of 57 degrees.  Pain was reported during passive ROM testing with flexion, extension, pronation and supination.  At an orthopedic examination of the left wrist on 17 July 2007 there was full, but stiff ROM with no effusion, redness, temperature change, tenderness or instability.  There was good grip strength without neurologic deficits.  

The 31 July 2007 MEB NARSUM examination, 3 months prior to separation, noted complaints of chronic left wrist pain that required work limitations and restrictions.  The examiner referred to the PT ROMs noted above.  During the 4 October 2007 separation physical, 1 month prior to separation, the CI reported left wrist pain.  Physical examination showed sensation was decreased around the left wrist plate. 

At the 15 December 2007 VA Compensation and Pension (C&P) ROM evaluation, 1 month after separation, showed left wrist radial deviation of 20 degrees with pain at 20 degrees; ulnar deviation of 45 degrees with pain beginning at 40 degrees; dorsiflexion of 70 degrees with pain beginning at 70 degrees; palmar flexion was 80 degrees with pain beginning at 70 degrees.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left wrist condition 10%, coded 5211 (ulna impairment).  The VA also rated the left wrist condition 10%, coded 5215-5020 (wrist limitation-synovitis), based on the C&P examination 1 month after separation, citing “painful or limited motion of a major joint or group of minor joints.”  Panel members noted that although the ROMs of flexion and extension decreased from 8 months prior to separation to 4 months prior to separation, by 1 month after separation flexion and extension were normal with painful motion.  Therefore, in the absence of wrist ankylosis (code 5214), an insufficient limitation of wrist motion (code 5215) to warrant a rating or X-ray evidence of involvement of 2 or more major joints, with occasional incapacitating exacerbations (code 5003), there was no higher rating under any applicable code.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the left wrist condition.  

BOARD FINDINGS:  In the matter of the left wrist condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  There are no other conditions within the panel’s scope of review for consideration.  Therefore, the panel 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 20170309, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-03468.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

						Sincerely,

								XXXXXXXXXXXXXXXXXX
								Director
								Air Force Review Boards Agency

Attachment:
Record of Proceedings