Citation Nr: 0002201 Decision Date: 01/28/00 Archive Date: 02/02/00 DOCKET NO. 96-12 293 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Paul, Minnesota THE ISSUE Entitlement to an increased evaluation of residuals of a fracture of the left wrist, currently evaluated as 20 percent disabling. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL Appellant and spouse ATTORNEY FOR THE BOARD G. R. Gleeson, Associate Counsel INTRODUCTION The veteran served on active military duty from February 1941 to February 1946. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 1995 rating decision of the Department of Veterans Affairs (VA) Regional Office in St. Paul, Minnesota (RO) which continued evaluation of the veteran's left wrist disability as 10 percent disabling. The evaluation was subsequently increased to 20 percent in a September 1996 decision of the hearing examiner. At his June 1996 hearing, the veteran raised the issue of a ganglion cyst on his left wrist, which he believes is related to the fracture. This matter is referred to the RO for appropriate action. FINDINGS OF FACT 1. The RO has obtained all evidence necessary for an equitable disposition of the veteran's claim. 2. The veteran's residuals of a fractured left wrist are productive of no more than moderate incomplete paralysis of the ulnar nerve. CONCLUSION OF LAW The criteria for an evaluation in excess of 20 percent for residuals of a fractured left wrist have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.71a, 4.124a, Diagnostic Codes 5215, 8516 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION The veteran contends that the evaluation assigned for a left wrist disability should be increased to reflect more accurately the severity of his symptomatology. As a preliminary matter, it is noted that the veteran's claim alleges an increase in severity of the service-connected disability, and is therefore a well-grounded claim for an increased evaluation. See Caffrey v. Brown, 6 Vet. App. 377, 381 (1994); Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992). In addition, the Board is satisfied that the record contains all evidence necessary for an equitable disposition of this appeal, and that the RO has fulfilled its duty to assist the veteran in developing the facts pertinent to his claim. Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Ratings Disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. The veteran's entire history is reviewed when making a disability evaluation. 38 C.F.R. § 4.1. However, the current level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The veteran was granted service connection in April 1946 for limitation of extension of his left wrist resulting from fractures sustained during World War II. Initial evaluation was 10 percent, and evaluation remained at that level until it was increased in a hearing examiner's decision of September 1996 to 20 percent. The claims file contains a record from the St. Cloud, Minnesota VA Medical Center (VAMC) indicating that the veteran telephoned requesting a note stating that he can use the VA golf driving range for the purpose of strengthening his left wrist. The responsive note from a VA doctor is to the effect that the veteran has not been treated for this disability since May 1991 and has therefore been discharged from the clinic. If he wished to receive a prescription for beneficial exercises he should schedule an appointment for evaluation and physical therapy. The veteran was informed of this by telephone, and he indicated that he was not interested in setting up an appointment at that time. The veteran did seek treatment later in May 1995 for hypertension and his wrist at the VAMC. He requested to use the golf driving range facility. X-rays were taken of the left wrist, which revealed a deformity of the distal radial metaphysis consistent with the history of old fracture. There was joint space narrowing and articular surface sclerosis at the radiocarpal joint, representing osteoarthritis, which may be post-traumatic in nature. There was linear calcification at the distal end of the ulna. There was no acute fracture seen. There are no other pertinent VAMC treatment records in the file. The only recent private clinical treatment record pertaining to the veteran's left wrist in the claims file, is a record from Central Minnesota Group Health, dated in July 1995. The veteran was noted to have a ganglion over the left wrist, which was injected with Aristospan. The veteran was primarily being treated for hypertension. A VA compensation and pension examination was performed in August 1996. The veteran reported that shortly after his in- service fracture he had residual discomfort in the left wrist and some slight weakness. Over the years the left hand had always been weaker than the right, however he is right- handed. He was currently experiencing pain and discomfort in the left wrist, particularly since the development of a ganglion cyst in the wrist in the previous couple of months. He had received a steroid injection from a private medical provider and the cyst had resolved. On physical examination, the right wrist was 18 centimeters in circumference and the left wrist was 19 centimeters. There was some deformity of the left wrist when compared with the right, including greater prominence at the distal ulna and distal radius on the left. He had full range of motion of the left wrist, including dorsiflexion, forward flexion, ulnar deviation and radial flexion. He had discomfort with motion and definite weakness of the left grip strength compared to the right. His grip strength on the left was estimated to be perhaps half or even less than half of the right. The veteran was not taking any arthritis medication. In July 1996, another VA examination was performed. The veteran stated that pressure on the left hand in a dorsiflexion position caused pain. He had difficulty pushing himself up off the floor. On one occasion he attempted to change a tire but did not have enough strength. He felt a constant ache in the left wrist. He had had a ganglion on the wrist that swelled with playing golf. On physical examination, both the right and left wrist measured 18 centimeters in circumference. Grip strength in pounds was 270 on the right and 40 on the left. Range of motion of the left wrist was dorsiflexion of 30 degrees, palmar flexion of 35 degrees, ulnar deviation of 5 degrees and radial deviation of 15 degrees, all of these with pain except for radial deviation. However, the veteran stated that the degree of pain was minor. There was no upper extremity atrophy. Diagnosis was status post fracture with residual deformity and loss of range of motion in all directions and weakness of left handgrip strength. It was further noted that there was residual slight dorsal swelling of the left wrist and a ganglion of the left dorsal wrist, relationship of which to the fracture could not be determined at that time. X-rays showed a subacute fracture of the distal radius that was faintly perceptible, with surrounding sclerosis consistent with healing. There was narrowing of the radiocarpal joint consistent with degenerative joint disease. There was an ossific density overlying the distal ulnar styloid, probably representing an old avulsion fragment. A VA neurological examination was performed in September 1998. The veteran stated he had worked for his father after service in a meat packing business, followed by a 40-year tenure of working at the U.S. Postal Service. He noted diminished strength in his left hand for the past four to five years. He had no numbness or tingling in the hands or fingers. The wrist was definitely deformed and slightly larger than the right. On neurological examination, cranial nerve testing was intact. In the left upper extremity there was marked weakness of the left triceps muscle and atrophy of the left triceps muscle. Reflex of the triceps muscle was normal. In the left forearm supination was less than normal, and was held in a position of 10 degrees. There was a small ganglion cyst on the left that had not recurred since injection. There were no peripheral nerve findings. Grip strength was 180 on the right and 20 on the left. Range of motion was dorsiflexion of 30 degrees, palmar flexion of 35 degrees, ulnar deviation of 5 degrees and radial deviation of 15 degrees. The pain was minor. There was definite atrophy of the left triceps muscle, without any pain. X-rays showed little change since the July 1996 x-rays. The veteran also had an orthopedic examination in September 1998. The veteran stated he could not move heavy things or do push-ups due to his wrist. The veteran did not refer to loss of coordination or fatigability of the wrist. He did say he had pain in the left wrist which was there all the time, but he was sometimes less aware of it. The pain varied from mild to severe. It was aggravated by lifting and alleviated by rest. He also said he had no strength in his left wrist, and had difficulty playing golf, and could not change a tire. He also could not shovel snow. He stated that the dorsal nodule on the left wrist becomes large at times and if it is bumped it is painful. On examination, the veteran had grip strength of 150 in the right and 20 in the left. Circumference of the right wrist was 18 centimeters and of the left wrist was 20 centimeters. Dorsiflexion was 50 degrees, palmar flexion was 40 degrees, ulnar deviation was 15 degrees and radial deviation was 10 degrees. The veteran complained of mild pain on full dorsiflexion and full ulnar deviation. There was slight diffuse swelling of the left wrist. Other than as specified, there was no upper extremity redness, swelling tenderness, deformity or atrophy. As the examiner had reviewed the service medical records, his diagnosis included reference to the two different fractures sustained by the veteran in service. The first, in September 1945, was a comminuted fracture of the distal left radius. The second, incurred in November 1945, was a Colles' fracture of the distal left radius. It was also noted that the veteran had a small dorsal nodule on the left wrist consistent in appearance with a ganglion cyst, which was not definitely proven to be related to the service-connected injuries of the left wrist. The final piece of relevant evidence in the claims file is the transcript of the veteran's June 1996 personal hearing at the RO, at which both the veteran and his wife testified. In describing his current symptoms, the veteran focused on his loss of strength and limitation on his ability to do things such as change a tire, move furniture or play pool. He stated that he was now always conscious of the wrist because there was constant aching pain. He also experienced swelling after activities such as playing golf. He stated that he had pain if he placed his weight on the wrist, such as crawling on the ground after his granddaughter. The veteran stated he had been told by a VA doctor to engage in activities to exercise his wrist so that it would not stiffen. He regularly swam for exercise. The veteran also stated that he had received an elastic wrist splint from Group Health. The veteran stated that prior to retirement twelve years ago, he worked as a mail carrier and had no problems. He had had more strength at that time. The veteran's wife testified that the veteran's left wrist was slowly getting weaker. 38 C.F.R. § 4.71a, Diagnostic Code 5215 provides for a 10 percent evaluation for limitation of motion of the wrist where dorsiflexion is less than 15 degrees or palmar flexion is limited in line with the forearm. The veteran's disability of the left wrist does not cause compensable limitation of motion, and therefore criteria for evaluating limitation of motion of the wrist set forth at 38 C.F.R. § 4.71a, Diagnostic Code 5215 do not adequately assess the level of disability. Thus, the Board finds that the veteran's left wrist disability is appropriately evaluated by analogy to paralysis of the ulnar nerve. See 38 C.F.R. § 4.20. Paralysis of the ulnar nerve of the minor hand is assigned a 20 percent evaluation for incomplete moderate paralysis and a 30 percent evaluation for incomplete severe paralysis. 38 C.F.R. § 4.124a, Diagnostic Code 8516. The Board finds that the veteran's left wrist disability involves moderate symptomatology and is appropriately evaluated as 20 percent disabling. There is evidence that the veteran has greatly reduced grip strength in the left wrist, that he experiences swelling in the left wrist and constant, but relatively minor, pain. Although there is some limitation of function, such as an inability to change tires or crawl on the ground, the veteran is still able to engage in a variety of physical activities, including golf and swimming. He did not describe limitation of function that causes serious impairment of daily activities, nor does he experience severe pain. There is some discrepancy in the medical evidence as to whether the veteran has muscle atrophy of the left upper extremity, however the key findings pertaining to grip strength, pain, and functionality are consistent, and present a disability picture involving moderate symptomatology. ORDER The claim for an increased evaluation for residuals of a fracture of the left wrist, currently evaluated as 20 percent disabling, is denied. WARREN W. RICE, JR. Member, Board of Veterans' Appeals