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AF | PDBR | CY2012 | PD2012 00893
Original file (PD2012 00893.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX         CASE: PD1200893
BRANCH OF SERVICE: NAVY  BOARD DATE: 20130613
SEPARATION DATE: 20011024


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty AO1/E-6 (AO1/ Aviation Ordnanceman First Class), medically separated for a left wrist condition. The CI fractured his left wrist twice as a child prior to service and again in 1991 and 1999. After undergoing surgery and rehabilitative treatment in 1991, he was returned to duty. In 1999, he had a fourth fracture of his left wrist and underwent open reduction and internal fixation (ORIF) with ulnar shortening followed by post-surgical rehabilitation. He continued to have pain which lead to an arthrodesis (fusion) in 2001. He had been placed on two periods of limited duty (LIMDU) for his wrist during his career and the fusion was accomplished at the end of the second LIMDU period. The condition could not be adequately rehabilitated to meet the physical requirements of his Rating or satisfy physical fitness standards. He was referred for a Medical Evaluation Board (MEB). The left wrist condition, characterized as “left wrist arthrodesis” and “status post left wrist arthrodesis w/left distal ulna resection,” “diffuse upper left extremity paresthesias secondary to axillary bloc,” “allergy rhinitis,” and “gastroesophageal reflux disease” (GERD) were also forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E. The PEB adjudicated “left wrist arthrodesis” as unfitting, rated 20%. The remaining conditions were determined to be not separately unfitting . “Diffuse upper left extremity paresthesias” and “status post left wrist arthrodesis with left distal ulna resection secondary to prior distal radius fractures and radiocarpal and distal radial ulnar joint arthrosis” conditions determined to be Category II conditions (contributing to the unfit condition.) The “gastroesophageal reflux disease” and “allergic rhinitis” conditions were determined to be Category III conditions (not separately unfitting and not contributing to the unfit condition). The CI made no appeals and was medically separated.


CI CONTENTION: “Navy doctors advised me to have a total wrist fusion, promising to stabilize it and remove all pain. During the operation they damaged nerves in my hand and arm which continue to cause pain and grow worse. They cut out part of my arm bone and attached a tendon to tether my bones. The tendon now becomes inflamed and pops against the bone causing swelling and pain that has had to be treated by the VA. This tendon issue, along with the nerve damage has made my hand almost USELESS. So, instead of the strong, pain free hand the Navy promised me, I have a painful, numb and swollen hand and arm that is difficult to use for anything. I have problems grasping anything or even turning my hand over, much less working to provide for my family. I believe the Navy grossly underestimated the long-term effects of the operation and the nerve damage they caused. Also, the VA rated me for 8 other service connected conditions that were present at the VA exam. I also note, the VA exam was conducted while I was still on Active Duty. My total VA rating is 80%. I believe the Navy ignored the other 8 conditions, while underestimating the condition they separated me for. 20% doesn’t provide for me having the use of only one hand, and I believe I should be retired.”


SCOPE OF REVIEW: The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2). It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI. The rating for the unfitting left wrist condition is addressed below. Additionally, the “status post left wrist arthrodesis w/left distal ulna resection”, “diffuse upper left extremity paresthesias secondary to axillary bloc,” “allergy rhinitis,” and “gastroesophageal reflux disease” conditions are within the DoDI 6040.44 defined purview of the Board and will also be reviewed below. Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Board for Correction of Naval Records.


 RATING COMPARISON :

Service IPEB – Dated 20010914
 VA - (4 Days Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Left Wrist Arthrodesis 5214 20% Arthritis and Solid Fusion of the Left Wrist 5214 20% 20010918
Status Post Left Wrist Arthrodesis… Not Unfitting
Category II
Diffuse Upper Left Extremity Paresthesias Left Ulnar Cutaneous Neuropathy 8515 10% 20010918
GERD Not Unfitting
Category III
 GERD 7346 10% 20010918
Allergic Rhinitis Chronic Allergic Rhinitis… 6513 30% 20010918
No Additional MEB/PEB Entries
 Other x 5 20010918
Combined: 20%
 Combined: 80%
Derived from VA Rating Decision (VA RD ) dated 200 20405 ( most proximate to date of separation [ DOS ] ).


ANALYSIS SUMMARY:

Left Wrist Arthrodesis Condition. The CI reported two injuries to his left wrist prior to accession, but had apparently healed sufficiently that he was qualified for accession. The MEB Report of Medical Board, dated 20 July 2001, notes the right-handed CI was treated successfully for a left wrist fracture in 1991 with closed reduction and casting. He had fallen on his outstretched hand (FOOSH). He was placed on LIMDU for 6 months, beginning 19 August 1991, and then returned to full duty. On 14 August 1999, the CI sustained another FOOSH injury with repeat intra-articular distal radius fracture and distal radial ulnar joint injury. He was initially treated with closed reduction and casting, but then had an ORIF with an ulnar shortening osteotomy and plating on 10 November 1999. The surgeon noted in the operative report “the plate gave a nice position to the wrist with approximately 15-20 degrees of dorsiflexion and essentially neutral-to-slight ulnar deviation.” Postoperatively, he had improved wrist range of motion (ROM). He initially did well and requested a return to full duty. However, he had recurrent pain with a decline in wrist ROM. On 29 May 2001, the CI underwent total left wrist arthrodesis using a wrist fusion plate, left distal ulna hardware removal, and Darrach shortening of the ulna along with a right iliac crest bone graft to the left wrist. Postoperatively, the CI reported left axillary pain and numbness and pain in the left upper extremity that was attributed to the left axillary nerve block. An X-ray showed a good fusion mass. The electrodiagnostic studies (EDX) of the left arm in July 2001 showed mild axonal loss of left ulnar, median and radial nerves, without localization of the level of the lesion. A 20 July 2001 orthopedic note documented that the findings were non-focal.

The MEB report dictated on 20 July 2001, 3 months prior to separation and 2 months after surgery. It noted that the EDX studies were consistent with a “diffuse probably transient nerve injury” and that there was no “further evidence of distal compression at either the carpal or cubital tunnels or elsewhere…” He was noted to be improving. On examination, it was noted that “He has full range of motion of his thumb and digits and is able to make a fist. There is no motion within the wrist joint itself and he has 75 degrees of pronation (normal 80⁰) and 60 degrees of supination (normal 85⁰).” The sensory examination was normal and signs of irritation of the median or ulnar nerves were absent on provocative testing. The surgical scar was well healed. He was using a removable splint. In August 2001, the CI’s commander noted in the nonmedical assessment that the CI was not world-wide assignable and that his condition precluded him from “lifting anything using his left wrist.”

At the VA Compensation and Pension (C&P) orthopedic examination on 18 September 2001, a month prior to separation, the CI reported he was unable to do any pushing with the outstretched hand and difficulty with rotary motions. Sensory examination showed some generalized decrease from the elbow down. Strength in the left arm was decreased to 3+-4/5 with “give-way, at least in part, because of pain.” His grip strength was less than normal and there was a suggestion of a very slight limitation of full extension and flexion of the fingers of the left hand. The examiner noted the left wrist was fused with “about 10⁰ of dorsiflexion (extension),” and fingertips lacked less than half an inch of touching the palm. The examiner recorded left forearm pronation of 70 degrees (normal 80 degrees Veterans Affairs Schedule for Rating Disabilities [VASRD]) and supination 45 degrees (normal 85 degrees VASRD). The examiner further noted that the surgery had been done “only within the past few months and re-evaluation of this individual in the future may be necessary.” An X-ray performed that day noted postoperative changes and osteopenia, but did not comment on the degree of dorsiflexion of the fused wrist. At the follow up electromyogram performed on 26 September 2001, the left median and ulnar motor branches were normal now and the left ulnar D5 (5th digit) sensory study was normal. The left dorsal ulnar cutaneous sensory study showed a greater than 50% drop in amplitude as compared to the right. Both sides had normal velocity and the right had normal amplitude. The conclusions were that there was a residual dorsal ulnar cutaneous neuropathy, borderline slowing for the left median nerve at the wrist without definite carpal tunnel syndrome and no evidence for left ulnar neuropathy or large fiber polyneuropathy in the arms.

The Board directs attention to its rating recommendation based on the above evidence. Both the PEB and the VA coded 5214 for wrist ankylosis, and rated 20% for non-dominant wrist in favorable fusion of 20-30 degrees dorsiflexion. The Board agreed that 5214 best described the CI’s wrist fusion condition. The VA examination noted that the position of fusion was about 10 degrees dorsiflexion. Previously, a large fusion mass had been noted on postoperative x-rays. There was no mention of the impact that this might have had on the measurement by the C&P examiner. In addition, it is not clear if this is a goniometric measurement or if it was an estimation of the degree of extension. The Board found no evidence in the record that the dorsiflexion was ever measured radiographically. At the time of surgery, the fusion was measured at 15-20 degrees dorsiflexion. The measurements at surgery would have been direct whereas those at the C&P, less than four months after surgery, would have possibly been influenced by both soft tissue changes and the bony formation in the acute healing process. The Board also noted that the C&P examiner commented on the proximity of the examination to surgery and the possible need for future reexamination. The Board therefore assigned a higher probative value to the measurements taken at surgery rather than at the C&P examination. Under code 5214, a favorable rating (20-30 degrees of dorsiflexion) is rated at 20% for the non-dominant hand. A position other than favorable or unfavorable is rated at 30%. The unfavorable rating is 40% and assigned for “any degree of palmar flexion, or with ulnar or radial deviation.” The Board again noted the operative report which stated “the plate gave a nice position to the wrist with approximately 15-20 degrees of dorsiflexion and essentially neutral-to-slight ulnar deviation.” It was determined that this did not support a finding of “unfavorable” and that the consideration was between a “favorable” and “other than favorable” determination. The Board majority found that the language of the surgeon in the operative report was most consistent with a favorable determination and thus supported a 20% disability rating. The minority voter opined that the “15-20 degrees” of dorsiflexion was sufficiently vague as to argue for an “other than favorable” determination and that 30% was the appropriate rating. The minority voter, while recognizing the limitations of the C&P examination, found that it also supported a 30% rating. The Board incidentally noted that 10 degrees dorsiflexion is actually the recommended value for best preservation of activities of daily living and argues for a favorable clinical outcome independent of the VASRD criteria for favorable (20-30 degrees of dorsiflexion). (See Wheelessonline.) However, this case was adjudicated IAW VASRD criteria. The Board then considered supination and pronation of the hand. The Board noted that under VASRD 5213 (impairment of supination and pronation) there was no compensable disability for limitation of supination to 45 degrees or pronation to 70 degrees. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the left wrist condition.

Contended PEB Conditions. The Board’s main charge is to assess the fairness of the PEB’s determination that the Category II and Category III contended conditions were not unfitting. The Category II conditions that contributed to the unfit condition were “status post left wrist arthrodesis w/left distal ulna resection secondary to prior distal radius fractures and radiocarpal and distal radial ulnar joint arthrosis” and “diffuse upper left extremity paresthesias secondary to axillary bloc.” The Category III conditions, not separately unfitting and not contributing to the unfit condition, were “allergic rhinitis” and “gastroesophageal reflux disease.” The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard. The Board considered each condition in turn.

Status Post Left Wrist Arthrodesis with Left Distal Ulna Resection Secondary to Prior Distal Radius Fractures and Radiocarpal and Distal Radial Ulnar Joint Arthrosis Condition. This condition was a statement of the components and history of the CI’s unfitting condition. The Board considered if the components as described were separate from the unfitting condition left wrist arthrodesis, and concluded that the components led to the arthrodesis and were not separately unfitting, nor ratable without pyramiding on the symptoms of the CI’s left wrist condition per IAW VASRD §4.14 (avoidance of pyramiding). After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the status post left wrist arthrodesis with left distal ulna resection secondary to prior distal radius fractures and radiocarpal and distal radial ulnar joint arthrosis condition.

Diffuse Upper Left Extremity Paresthesias Secondary to Axillary Block Condition. The Board noted the condition was not profiled or implicated in the commander’s statement and was not judged to fail retention standards. The condition was reviewed by the action officer and considered by the Board. The sensory loss improved and was expected to continue to improve. Even if static, there is no evidence that this would have impaired duty separate from the underlying unfitting fusion. There was also weakness of the hand grip and the left upper extremity in general. This is a normal outcome after surgery secondary to the attendant disuse necessary for healing of the arthrodesis. The EDX study showed no neurological motor loss. Again, the expectation is that the CI would recover function (strength) over time. After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the diffuse upper left extremity paresthesias secondary to axillary block condition.

Allergic Rhinitis and Gastroesophageal Reflux Disease Conditions. These conditions were not profiled or implicated in the commander’s statement and were not judged to fail retention standards. Both were reviewed by the action officer and considered by the Board. There was no performance based evidence from the record that either of these conditions significantly interfered with satisfactory duty performance. After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the allergic rhinitis and GERD conditions thus no additional disability ratings are recommended.
BOARD FINDINGS: IAW DoDI 6040.44, provisions of DoDI or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication. The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised. In the matter of the left wrist arthrodesis condition and IAW VASRD §4.71a, the Board recommends, by a vote of 2:1, recommends no change in the PEB adjudication. The single voter for dissent (who recommended 30% disability rating), did not elect to submit a minority opinion. In the matter of the contended diffuse upper left extremity paresthesias (secondary to axillary block) and status post left wrist arthrodesis w/left distal ulna resection secondary to prior distal radius fractures and radiocarpal and distal radial ulnar joint arthrosis conditions, the Board unanimously recommends no change from the PEB determinations as Category II conditions. In the matter of the contended allergic rhinitis and GERD conditions, the Board unanimously recommends no change from the PEB determinations as Category III conditions.


RECOMMENDATION: The Board, therefore, recommends that there be no recharacterization of the CI’s disability and separation determination, as follows:

UNFITTING CONDITION VASRD CODE RATING
Left Wrist Arthrodesis Condition 5214 20%
COMBINED 20%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20120625, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record





XXXXXXXXXXXXXXXXXX
President
Physical Disability Board of Review


 MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
BOARDS

Subj: PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS

Ref: (a) DoDI 6040.44
(b) CORB ltr dtd 17 Dec 13

In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their respective forwarding memorandums, approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:
- XXXXXXXXXXXXXXXXXX former USN



                                                      XXXXXXXXXXXXXXXXXX
                                                     Assistant General Counsel
                                                      (Manpower & Reserve Affairs)

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