BVA9500327 DOCKET NO. 93-06 386 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUE Entitlement to an increased (compensable) evaluation for residuals of fractures of the right fourth and fifth metacarpals. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The appellant ATTORNEY FOR THE BOARD Nancy R. Kegerreis, Associate Counsel INTRODUCTION The veteran served on active duty from January 1965 to January 1968. This matter comes before the Board of Veterans' Appeals (Board) from a January 1990 rating decision by the Department of Veterans' Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania, which denied an increased (compensable) evaluation for residuals of fractures of the right fourth and fifth metacarpals. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends, essentially, that he sustained a crush injury to his right hand in Vietnam and that he has not had the normal use of his hand since that time. He maintains that he experiences cramping and numbness on prolonged use and that the pain travels from his fingers up his arm to his shoulders; this condition becomes worse in cold weather. He states that he uses a TENS unit and a brace as a source of relief and alleges that his hand has become weaker over the years. 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 preponderance of the evidence is against the veteran's claim for an increased (compensable) evaluation for the residuals of fractures of the right fourth and fifth metacarpals. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the appeal has been obtained. 2. Residuals of fractures of the fourth and fifth metacarpals of the right hand are manifested by complaints of cramping and numbness after prolonged use, sensitivity to cold, and loss of grip strength; there are no significant objective findings. CONCLUSION OF LAW The schedular criteria for an increased (compensable) rating for residuals of fractures of the right fourth and fifth metacarpals have not been met. 38 U.S.C.A. §§ 1155, 5107(a) (West 1991); 38 C.F.R. §§ 4.1-4.14, 4.40-4.46, 4.71a , Diagnostic Code 5223 (1993). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Board notes that the veteran's claim for an increased rating is well grounded within the meaning of 38 U.S.C.A. § 5107 (West 1991). That is, the Board finds that he has presented a claim which is plausible. The Board is also satisfied that all relevant and available facts have been properly developed. No further assistance to the veteran is required to comply with the duty to assist mandated by 38 U.S.C.A. § 5107. Although the Board must consider the whole record, those documents created in proximity to the recent claim are the most probative in determining the current extent of impairment. See 38 U.S.C.A. § 5110(b)(2) (West 1991). In this regard, and to provide continuity, the Board will merely summarize briefly the veteran's medical history at the time of and immediately following a December 1989 Board decision granting service connection for residuals of fractures of the 4th and 5th metacarpals of the right hand. The Board initially granted service connection based upon the veteran's service medical records, which showed that he had injured his right hand several times during service and on more recent x-rays revealing old healed fractures of the fourth and fifth metacarpals of the right hand. In resolving all reasonable doubt in the veteran's favor, the Board found that the residuals of the fractures were related to his period of service. By rating decision in January 1990, the RO implemented the Board's decisions and assigned a noncompensable evaluation, effective from January 1986, for residuals of fractures of the fourth and fifth metacarpals of the right hand. A December 1990 VA disability evaluation examination revealed a full range of motion in both hands. Aside from a decrease in grip strength, the right hand was essentially normal, although the veteran stated that he had to use a TENS unit for the pain, which was aggravated by cold and damp weather. At a hearing in September 1991 at the RO, the veteran testified that while he was in Vietnam, he was riding in a trailer with a water bladder, when the truck pulling the trailer accelerated quickly and hit a hole, with the result that he was pinned in between the bladder and the trailer, and his hand was crushed. He stated that he was evacuated, treated for two weeks, and then sent back to his unit. He mentioned that after service he did factory and construction work, but that his right hand would cramp up on him and become numb, especially on cold, damp days. He stated that his grip in the right hand was not at all good and that he had to use a a brace to support his arm and a TENS unit for the pain in his hand, which would spontaneously shoot from his hand to his shoulder, even while he was watching television. He had been taking Tylenol and receiving physical therapy. A VA orthopedic examination in December 1991 revealed a reported medical history of an injury to the right hand occurring in 1967 when a very heavy water bladder rolled over his right extremity causing the fracture in the hand. Approximately a year or two prior to this examination, he began to have trouble with his entire right arm and was fitted with a wrist and hand immobilizer. He then began receiving physical therapy, which consisted of hot packs to his right shoulder and right hand and the use of a TENS unit. His present complaints were of aching pain that occurred throughout the entire right arm from the shoulder all the way down, particularly with any twisting movements of his arm. Examination showed that the veteran was wearing a splint on the right forearm and hand and was very cautious about moving his hand and arm. He would elevate the arm at the shoulder only to about 50 degrees, complaining that he did not want to lift it further because of the pain. He was also cautious of any movement in the arm, even at the elbow, wrist, or fingers, but there was no limited range of motion in these joints. The dorsum of the right hand looked slightly puffy as compared to the left, but, other than that, there was no abnormality noted. He reported tenderness along the dorsum of the hand. The muscles on the right upper extremity, both above and below the elbow, were at least a quarter of an inch larger than the muscles on the left, indicating that he was still using his right arm as his dominant arm, in spite of the appearance that he hardly ever used it. There were normal reflexes and pulses in both arms. He complained of numbness in his right hand at times, but at the present time, he had no numbness anywhere in his arms or hands. Both x-rays and a bone scan of the right hand showed no significant abnormalities. The examiner stated that, clinically, he was unable to make an orthopedic diagnosis that would explain the veteran's extensive complaints. The veteran was also afforded a VA neurology examination in December 1991 in connection with his appeal. The examination showed the veteran to be right handed, wearing a wrist brace. There was well-built muscle bulk in both arms and in both hands. There was no evidence of atrophy or evidence of fasciculation. No trophic change of the skin or of the fingernails was noticed. There was no definite evidence of dysesthesia. His complaints of pain in raising his right arm gave an appearance of a limitation of shoulder joint movement. Muscle power testing could not be definitely ascertained because he appeared not to be trying his best, but muscle bulk appeared equal and well built in both hands. There was no Tinel sign on percussion of the median nerve at the wrist. The examiner noted that, in spite of the veteran's numerous complaints, he was unable, objectively, to see any definite abnormality. Communications, dated in August and September 1992, from Santina A. Whited, D.C., revealed that she had been treating the veteran for cervical, right shoulder, and right hand pain. Her examination revealed a fullness of the dorsum of the right hand and a slight weakness of the right biceps, wrist flexors, finger flexors and finger abductors as compared to the left. There was a flattening of the right fourth metacarpal phalangeal joint, but no discernible upper extremity muscle atrophy. Deep tendon reflexes were 2+ brisk bilaterally. Light touch and joint position sense were intact, but the veteran reported decreased sensitivity to pinprick over the dorsum of the right hand. Motion palpation of the right hand revealed joint fixation at the right radial head and carpals. Treatment consisted principally of manipulation to the affected joints to increase joint mobility. When last treated, the veteran stated that his hand was feeling somewhat better. It was recommended that he squeeze a ball or putty with the right hand to improve strength. Disability evaluations are administered under the Schedule for Rating Disabilities, located in 38 C.F.R. Part 4 (1993), which is designed to compensate a veteran for reductions in earning capacity as a result of injury or disease sustained as a result of or incidental to military service. See 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. §§ 4.1, 4.2 (1993); Bierman v. Brown, 6 Vet.App. 125, 129 (1994). In evaluating a disability, the VA is required to consider the functional impairment caused by the specific disability. 38 C.F.R. § 4.10 (1993). Each disability must be evaluated in light of the veteran's medical and employment history, and from the point of view of the veteran's working or seeking work. Schafrath v. Derwinski, 1 Vet.App. 589, 592 (1991). The veteran is currently evaluated under 38 C.F.R. § 4.71a, Diagnostic Code 5223, which rates favorable ankylosis of two digits of one hand. Pursuant to this code, favorable ankylosis of the metacarpal joints of the ring and little fingers of the dominant hand may be evaluated at 10 percent, providing that the limited motion permits flexion of the finger tips to within two inches of the transverse fold of the palm. Limitation of motion of less than one inch in either direction is not considered disabling. Aside from the veteran's subjective complaints, the residuals of fractures of the veteran's fourth and fifth right metacarpals are not shown to be productive of any functional impairment. The veteran exhibits no significant objective symptomatology other than a slight puffiness of the dorsal aspect of the right hand. Although Dr. Whited observed a minor weakness and stiffness in the joints of the affected hand, the findings, and the veteran's multi-joint complaints generally, were not attributed to the service-connected residuals of metacarpal fractures, which are well healed. In any event, the schedular criteria for a compensable rating under Diagnostic Code 5223 are not met. The veteran's fingers are not ankylosed. Nor does the record afford a basis to relate the veteran's complaints of pain and subjective symptomatology to his service- connected disability. The veteran's complaints in this case are not supported by adequate pathology, such as loss of muscle strength or muscular atrophy. See 38 C.F.R. § 4.40 (1993). Although the Board has considered reasonable doubt pursuant to 38 C.F.R. §§ 3.102 and 4.3 (1993), it finds that the doctrine is inapplicable here because the evidence is not in equipoise or an approximate balance of positive and negative evidence. Further, the residuals of fractures of the fourth and fifth metacarpals of the right hand have not resulted in repeated hospitalization or impairment of earning capacity sufficient to warrant a compensable evaluation on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1) (1993). Accordingly, an increased (compensable) evaluation is not warranted and the appeal must be denied. ORDER An increased (compensable) evaluation for residuals of fractures of the fourth and fifth metacarpals of the right hand is denied. CHARLES E. HOGEBOOM 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.