BVA9500250 
DOCKET NO.  93-06 982     )       DATE
          )
          )

On appeal from the decision of the
Department of Veterans Affairs Regional Office in Roanoke,
Virginia

THE ISSUE

Entitlement to an increased evaluation for residuals of gunshot
wound to the left forearm, currently evaluated as 20 percent
disabling.

REPRESENTATION

Appellant represented by: Disabled American Veterans

WITNESS AT HEARING ON APPEAL

Veteran

ATTORNEY FOR THE BOARD

Suzie St. Vil, Associate Counsel
INTRODUCTION

The veteran had active military service from July 1943 to
February 1946.  He has been represented throughout his appeal by
the Disabled American Veterans.

This matter came before the Board of Veterans' Appeals
(hereinafter Board) on appeal from a rating decision of July
1991, by the Roanoke, Virginia Regional Office (RO), which denied
the veteran's claim for an increased rating for his service-
connected residuals of gunshot wound to the left forearm.  The
veteran appeared and offered testimony at a hearing before a
hearing officer at the RO in January 1992.  A transcript of the
hearing is of record.  The hearing officer's decision was entered
in September 1992.  A rating action of September 1992 continued
and confirmed the denial of the veteran's claim for an increased
rating for residuals of gunshot wound to the left forearm.  The
appeal was received at the Board in March 1993.

CONTENTIONS OF APPELLANT ON APPEAL

The veteran essentially contends that he is entitled to an
increased evaluation for his service-connected disorder,
residuals of gunshot wound to the left forearm.  The veteran
maintains that the residuals of his gunshot wound have increased
in severity since he suffers chronic pain in the left arm.  The
service representative requests that the case be considered under
all applicable laws and regulations, including 38 C.F.R. § 4.7.
It is also requested that the veteran be accorded the benefit of
the doubt.

DECISION OF THE BOARD

The Board, in accordance with the provisions of 38 U.S.C.A.
§ 7104 (West 1991), has reviewed and considered all of the
evidence and material of record in the veteran's claims file.
Based on its review of the relevant evidence in this matter, and
for the following reasons and bases, it is the decision of the
Board that the evidence supports the veteran's claim for an
increased rating of 30 percent for service-connected residuals of
gunshot wound to the left forearm.

FINDINGS OF FACT

1.  All relevant evidence necessary for an equitable disposition
of the veteran's appeal has been obtained by the RO.

2.  As a result of the gunshot wound in service, the veteran
sustained a compound, comminuted fracture of the ulna; the RO has
determined that there is involvement of two muscle groups, VII
and VIII.

3.  The gunshot wound residuals of the left (minor) forearm
currently include well-healed scars, limited hyperextension of
the wrist, complaint of pain, and weakness; there is no evidence
of muscle atrophy or ankylosis.

4.  There is X-ray evidence of old, slight deformity of the
distal ulna and a retained metallic fragment in the soft tissues
of the mid forearm.

CONCLUSION OF LAW

The criteria for an increased evaluation of 30 percent and no
more for residuals of gunshot wound of the left (minor) forearm
are met.  38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R.
§§ 3.321, 4.7, 4.55, 4.56, 4.70, 4.72 Codes 5214, 5307, 5308
(1993).

REASONS AND BASES FOR FINDINGS AND CONCLUSION

Initially, we note that we have found that the veteran's claim is
"well-grounded" within the meaning of 38 U.S.C.A. § 5107(a);
effective on and after September 1, 1989.  That is, we find that
he has presented a claim which is plausible.  Moreover, after
careful review of the evidentiary record, we are also satisfied
that all relevant facts have been properly developed.  Therefore,
no further assistance to the veteran is required to comply with
the duty to assist as mandated by 38 U.S.C.A. § 5107(a).

The pertinent facts in this case are not in dispute and may be
briefly described.  Service medical records indicate that the
veteran sustained a gunshot wound to the lower left forearm in
April 1945; he was then taken to a hospital where the wounds were
debrided and a cast was applied to his left forearm.  On April
30, 1945, the veteran had a closed reduction of the left ulna.
The final diagnosis was fracture, compound, comminuted, severe,
ulna, left.  In November 1945, it was noted that the wounds had
healed without difficulty, although the veteran had continued to
experience "electric shock" pain in the ulnar nerve distribution.
He underwent resection of the painful scar of the wrist in
January 1946.  On the occasion of the separation examination in
February 1946, it was noted that the veteran had pain in the left
wrist at the site of the healed fracture.  X-ray study of the
left wrist revealed an old fracture distal third of ulna in
excellent position and alignment.  The service medical records do
not specify which muscle groups were involved.

Based upon the above findings, a rating action of April 1946
granted service connection for bullet wound, left arm; a 10
percent evaluation was assigned effective February 8, 1946.  By
rating action of October 1946, the 10 percent rating was
confirmed, under Diagnostic Code 5307.

Subsequent to service, VA examinations of September 1946 and
April 1950 reflect that the veteran continued to complain of pain
in the left arm, especially during rainy weather.  These
examinations both revealed a full range of motion in the
veteran's left arm.  X-ray study of the left wrist in 1946
revealed a slight deformity of the radial side of the lower end
of the ulna, reported to be of no clinical significance.  X-ray
study in 1950 revealed an irregularity of the distal portion of
the ulna with postoperative scar on the lateral aspect, secondary
to gunshot wound.  There was no sensory nerve disturbance.
Neither examination indicated with specificity which muscle group
or groups were involved.

A rating action of May 1950 increased the evaluation for the
veteran's service-connected left arm disability from a 10 percent
to a 20 percent rating, effective April 20, 1950, on the basis of
involvement of two muscle groups VII and VIII, under Diagnostic
Codes 5307 and 5308, each with a moderate level of disability.

The veteran was afforded a VA compensation examination in August
1989, at which time he indicated that he had complained about his
left arm for years and was told that he would have to get used to
it, because there was nothing that could be done for him.  The
veteran reported that the left arm ached after extended use; he
also complained of weakness in the left arm.  Examination of the
left forearm revealed a well-healed entrance scar on the dorsum
of the wrist, and an exit scar along the shaft of the ulna.  The
examiner reported normal elbow flexion and extension, as well as
pronation and supination range.  X-ray study showed a healed
fracture of the distal ulna in good position; there was also a
mild metal particle in the soft tissue over the mid 1/3 of the
left forearm.  The diagnosis was residuals of fracture of the
left ulna from bullet.

Received in July 1991 were VA outpatient treatment notes covering
the period from June 1990 to June 1991 which show that the
veteran complained of chronic pain in the left forearm.  These
records show that he obtained relief of arm pain with medication.
The records also indicate that the veteran's left forearm
disability was stable.

Received in October 1991 was a lay statement from Murray M.
Moore, who served with the veteran and recalled the assignment
during which the veteran sustained a gunshot wound to the arm.

At his personal hearing before the hearing officer at the RO in
January 1992, the veteran testified that the left arm ached
approximately once to twice per week.  He indicated that when he
put a brace on the arm the pain was relieved for about a week.
The veteran reported that he had pretty good use of the left arm,
except when he lifted something heavy; he stated that the left
arm was not as strong as it used to be.  The veteran testified
that he was right-handed and, therefore, used that hand to do a
lot of things.  The veteran also reported that the left arm had a
tendency to give out when he twisted it.  The veteran testified
that he had been given pain pills in the past.

Received in January 1992 were VA outpatient treatment notes for
the period from June 1991 to December 1991 which show that the
veteran continued to receive clinical attention for complaints of
pain in the left arm.  The records indicate that the veteran's
left arm disability has remained stable.

The veteran was again examined by the VA in February 1992.  On
examination of the left wrist, there was a scar across the dorsum
of the wrist from a bullet wound.  The scar measured 1" x 3/4"
and was well-healed.  The examiner reported that motion in the
left wrist was mildly limited in flexion and more severely
limited in extension.  Flexion was 45 degrees and extension was
40 degrees.  Pronation and supination was to 80 degrees.  No
nerve injury was noted in the left wrist.  Function of the left
hand was reported to be good.  X-ray findings were similar to
those previously reported in August 1989.  The examiner stated
that the wrist showed limited hyperextension; flexion range was
good at 45 degrees; no nerve injury, and the joint was normal.

The Board notes that the Rating Schedule differentiates between a
disability of the major or minor upper extremity.  38 C.F.R.
§ 4.69 (1993).  For a right-handed person, such as the veteran in
this case, the right arm is major and the left is minor, with the
reverse being true for a left-handed person.  For Muscle Group
VII, flexor muscles of the wrist and hand, minor extremity, a
10 percent rating will be assigned for moderate muscle injury; a
20 percent evaluation where the damage is moderately severe; and
a 30 percent evaluation where damage is severe.  38 C.F.R. Part
4, Code 5307 (1993).  For Muscle Group VIII, extensor muscles of
the wrist and hand, a 10 percent rating will be assigned where
there is moderate disability and a 20 percent where disability is
moderately severe or severe.  38 C.F.R. Part 4, Code 5308 (1993).

Muscle injuries in the same anatomical region, i.e. forearm and
hand, will not be combined, but instead the rating for the major
group will be elevated from moderate to moderately severe, or
from moderately severe to severe, according to the severity of
the aggregate impairment of function of the extremity.  Two or
more severe muscle injuries affecting the motion (particularly
strength of motion) about a single joint may be combined but not
in combination receive more than the rating for ankylosis of that
joint at an "intermediate" angle.  38 C.F.R. § 4.55 (1993).
Ankylosis of the minor wrist, unfavorable, in any degree of
palmar flexion, or with ulnar or radial deviation, warrants a
30 percent rating.  In any other position, except favorable, a
30 percent rating is in order, and where ankylosis is favorable
in 20 degrees to 30 degrees dorsiflexion, a 20 percent rating
will be assigned.  38 C.F.R. Part 4, Code 5214.

In rating disability from injuries of the musculoskeletal system,
attention is first given to the deeper structures injured, bones,
joints and nerves.  A compound comminuted fracture, for example,
with muscle damage from the missile, establishes severe (emphasis
added) muscle injury.  Entitlement to a rating of severe grade is
established when there is history of compound comminuted fracture
and definite muscle or tendon damage from the missile.  There are
locations, as in the wrist, where muscle damage might be minimal
and in such cases requirements for severe ratings are not
necessarily met.  38 C.F.R. § 4.72 (1993).  Where there is a
question as to which of two evaluations shall be applied, the
higher evaluation will be assigned if the disability picture more
nearly approximate the criteria required.  for the rating.
Otherwise, the lower rating will be assigned.  38 C.F.R. § 4.7.

In evaluating the degree of disability in this case, the Board
has carefully reviewed the record, with special attention to the
service medical records, which showed that the veteran sustained
a compound, comminuted fracture of the ulna.  38 C.F.R. § 4.72
provides that in such cases, with definite muscle or tendon
damage from the missile, a level of severe muscle injury is
established.  However that regulation also suggests that in
certain anatomical areas, such as the wrist, as in this case, the
requirements for a severe rating might be not necessarily be met,
if the muscle damage were minimal.  Unfortunately, the service
medical records provide only scanty information about the muscle
damage sustained by the veteran, and do not, for example, reflect
the extent of involvement of the muscle groups.  Nor do the
initial post-service VA examinations shed additional light.  The
RO, in rating the gunshot wound in 1950, evaluated each muscle
group which it determined to have been involved, Muscle Group VII
and Muscle Group VIII, at a moderate level of impairment, thereby
warranting elevation to a moderately severe level under 38 C.F.R.
§ 4.55 and assignment of a 20 percent rating.  If, however, the
injury to each muscle group were at a moderately severe level,
then elevation to the severe level, with resultant assignment of
a 30 percent rating, for the minor extremity, would be in order.

Even if the injury to the muscle groups were considered to be
severe, pursuant to 38 C.F.R. § 4.72, on the basis of the
compound, comminuted fracture of the ulna, a rating higher than
30 percent would not be in order.  This is because two or more
severe muscle injuries affecting motion about the joint (the
wrist in this case) may not receive, in combination, more than
the rating for ankylosis of that joint at an "intermediate"
angle.  Plate I, referenced in 38 C.F.R. § 4.71, describes wrist
joint motion as ranging from 70 degrees of dorsiflexion
(extension) to 80 degrees of palmar flexion.  Other than
unfavorable ankylosis of the wrist, which warrants assignment of
a 40 percent rating for the minor extremity, a 30 percent rating
is in order if the ankylosis is in any other position other than
favorable in 20 degrees to 30 degrees of dorsiflexion.  38 C.F.R.
Part 4, Code 5214.

Although the veteran has only mildly limited flexion of the
wrist, no nerve injury and good hand function, he does have more
severe limitation of extension.  He describes weakness of the
left forearm and complaints of periodic pain, consistent with
muscle injury.  Resolving any doubt in the veteran's favor, the
Board finds that a higher evaluation of 30 percent is in order,
on the basis of current symptoms demonstrated and the nature of
the injury sustained during service.

In finding that an increased rating is warranted for the
veteran's left forearm disability, the Board has also considered
the provisions of 38 C.F.R. § 3.321(b)(1).  The Board finds that
the veteran's disability is not so unusual or exceptional as to
render impractical the application of the regular schedular
standards, so as to warrant assignment of a rating greater than
30 percent.

ORDER

An increased evaluation of 30 percent for service-connected
residuals of gunshot wound to the left forearm is granted.  To
this extent the appeal is allowed, subject to the law and
regulations governing the payment of monetary benefits.

          N. R. ROBIN
          Member, Board of Veterans' Appeals

The Board of Veterans' Appeals Administrative Procedures
Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___
(1994), permits a proceeding instituted before the Board to be
assigned to an individual member of the Board for a
determination.  This proceeding has been assigned to an
individual member of the Board.

NOTICE OF APPELLATE RIGHTS:  Under 38 U.S.C.A. § 7266 (West
1991), a decision of the Board of Veterans' Appeals granting less
than the complete benefit, or benefits, sought on appeal is
appealable to the United States Court of Veterans Appeals within
120 days from the date of mailing of notice of the decision,
provided that a Notice of Disagreement concerning an issue which
was before the Board was filed with the agency of original
jurisdiction on or after November 18, 1988.  Veterans' Judicial
Review Act, Pub. L. No. 100-687, § 402 (1988).  The date which
appears on the face of this decision constitutes the date of
mailing and the copy of this decision which you have received is
your notice of the action taken on your appeal by the Board of
Veterans' Appeals.