Citation Nr: 1105259 Decision Date: 02/08/11 Archive Date: 02/18/11 DOCKET NO. 07-05 251 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio THE ISSUE Entitlement to an evaluation in excess of 10 percent for service- connected residuals of a fracture of the right wrist. REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD L. L. Mollan, Associate Counsel INTRODUCTION The Veteran served on active duty from February 1943 to November 1945. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2006 RO decision, which continued an evaluation of 10 percent for the Veteran's service-connected residuals of a fracture of the right wrist. In April 2007, a local hearing was held before a Decision Review Officer at the Cleveland, Ohio RO. A transcript of that proceeding has been associated with the claims folder. The Board notes that the Veteran was also scheduled for a hearing before a member of the Board on July 22, 2009. He failed to report for this hearing. As the Veteran has not shown good cause for his failure to report for this hearing, nor has he requested that this hearing be rescheduled, the Board will proceed to adjudicate the claim. This issue was remanded by the Board for further development in December 2009. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2010). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDING OF FACT The Veteran's service-connected residuals of a fracture of the right wrist is manifested by complaints of pain, weakened grip, locking, and limitation of motion. CONCLUSION OF LAW The criteria for a disability rating in excess of 10 percent for service-connected residuals of a fracture of the right wrist have not been met. See 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.159, 3.321, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5215 (2010). REASONS AND BASES FOR FINDING AND CONCLUSION I. Veterans Claims Assistance Act of 2000 (VCAA) With respect to the Veteran's claim, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2010). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his or her representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2010); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the United States Court of Appeals for Veterans Claims (Court) held that VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) request that the claimant provide any evidence in his or her possession that pertains to the claim. The requirement of requesting that the claimant provide any evidence in his possession that pertains to the claim was eliminated by the Secretary during the course of this appeal. See 73 Fed. Reg. 23353 (final rule eliminating fourth element notice as required under Pelegrini II, effective May 30, 2008). Thus, any error related to this element is harmless. A July 2006 VCAA letter substantially satisfied the duty to notify provisions. See 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2009); 38 C.F.R. § 3.159(b)(1) (2010); Quartuccio, at 187. The Veteran was aware that it was ultimately his responsibility to give VA any evidence pertaining to the claim. This letter informed him that additional information or evidence was needed to support his claim, and asked him to send the information or evidence to VA. See Pelegrini II, at 120-121. Additionally, this letter described how appropriate disability ratings and effective dates were assigned. The Board also concludes VA's duty to assist has been satisfied. The Veteran's service treatment records and relevant VA and private medical records are in the file. The Board notes that the Veteran indicated at the April 2007 local hearing that he had received medical treatment from a Dr. R.K. and a Dr. H.E. In a December 2009 letter, the Veteran was notified that he should submit Authorization and Consent to Release Information forms so that VA can obtain this treatment information. The Veteran submitted no such forms. Additionally, the Board notes that the Veteran submitted an Authorization and Consent to Release Information form for Cleveland Clinic-Beachwood. In February 2010, a response to the request for these records indicated that the wrong type of authorization had been submitted. The Veteran was notified of this and provided the proper authorization form required by this facility in May 2010. The Veteran did not return this authorization form. As such, the Board finds that all available, relevant records identified by the Veteran as relating to this claim have been obtained, to the extent possible. The Board finds that the record contains sufficient evidence to make a decision on the claim. VA has fulfilled its duty to assist. With respect to claims for increased ratings, the duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the Veteran. See Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of the Veteran's disability, a VA examination must be conducted. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2010). The RO provided the Veteran with a VA examination for his right wrist most recently in November 2010. There is no objective evidence indicating that there has been a material change in the severity of the Veteran's service-connected residuals of a fracture of the right wrist since he was last examined. See 38 C.F.R. § 3.327(a) (2010). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate examination was conducted. See VAOPGCPREC 11-95. The examiner reviewed the claims file and examined the Veteran. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). The Board finds this examination report to be thorough and consistent with contemporaneous medical records. Thus, the Board concludes that the examination in this case is adequate upon which to base a decision with regard to this claim. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). II. Analysis The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2010). Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2010). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2010). The Veteran's entire history is reviewed when making a disability determination. See 38 C.F.R. § 4.1 (2010). But where service connection has already been established, and increase in the disability rating is at issue, it is the present level of the disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, in such cases, when the factual findings show distinct time periods during which a claimant exhibits symptoms of the disability at issue and such symptoms warrant different evaluations, staged evaluations may also be assigned. Hart v. Mansfield, 21 Vet. App. 505 (2007). The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14 (2010). The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261- 62 (1994). When evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. See DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to weakened movement, excess fatigability and incoordination. In a September 2006 rating decision, the RO continued an evaluation of 10 percent for service-connected residuals of a right wrist fracture under Diagnostic Code 5215. The Veteran is seeking a higher evaluation. Under Diagnostic Code 5215, the only available schedular evaluation for limitation of motion of the wrist is 10 percent, whether the major or minor extremity, and requires either dorsiflexion of less than 15 degrees or palmar flexion limited in line with the forearm. 38 C.F.R. § 4.71a, Diagnostic Code 5215 (2010). The regulations define normal range of motion for the wrist as dorsiflexion (extension) to 70 degrees, palmar flexion to 80 degrees, ulnar deviation to 45 degrees, and radial deviation to 20 degrees. 38 C.F.R. § 4.71, Plate I (2010). Additionally, the Board notes that Diagnostic Code 5010 addresses the issue of arthritis due to trauma, substantiated by x-ray findings, which is to be rated as degenerative arthritis under Diagnostic Code 5003. See 38 C.F.R. § 4.71a, Diagnostic Code 5010 (2010). Degenerative arthritis, when established by x-ray findings, will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm or satisfactory evidence of painful motion. See 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2010). The Board notes that the Veteran underwent a VA examination in November 2010. The examiner reviewed the claims file and noted the Veteran's report of an injury in 1945 to his right wrist from a fall with an outstretched right hand. The Veteran sustained a nondisplaced navicular fracture, was casted, discharged, and worked in the United States Postal Office for 33 years until 1988 as a letter carrier. The Veteran is right handed. The examiner noted that the claims file contains June 2007 normal EMG and NCV studies of the right upper extremity. This June 2007 record noted that there is no definite electrophysiological evidence of brachial plexopathy on examined right upper extremity. At this examination, the Veteran endorsed pain, weakness, swelling, stiffness, and fatigability. He reported recent locking of the right thumb and small finger. He stated that he is still able to do all of the activities of daily living but is restricted in doing heavy work like plowing snow. Occasionally, he gets tingling from his shoulder down to his arm/wrist that wakes him up at night. He is particularly restricted with shoulder extension. He is still able to write and do fine movements. The Veteran requires no assistive devices. The Veteran is able to perform routine daily activities. Although, at times, it is painful to do so. The Veteran was noted as having a wrist dorsiflexion (extension) of 0 to 20 degrees with pain at extreme, a wrist palmar flexion of 0 to 45 degrees with pain at extreme, a wrist radial deviation of 0 to 15 degrees, and a wrist ulnar deviation of 0 to 30 degrees. The examiner noted that there is pain with motion and no swelling. The examiner noted that, after repetitively flexing and extending, testing for incoordination, pain, fatigability, or weakness, there was no additional limitation of motion on examination with repetition, only reported pain. Flare-ups consist of an increase in pain and occur with increase in activity and cold or moist weather. Upon physical examination, the examiner noted that the wrist is tender to palpitation dorsal aspect at mostly lateral aspect. There is no swelling or deformity. Pulses are palpable and sensory is intact. Plain films of the right wrist revealed osteoarthritic changes with no definite fracture or dislocation. A cervical CT revealed degenerative changes at C4-T2 with no significant neural foraminal stenosis in this nonenhanced CT study. The Veteran was diagnosed with residual, right wrist arthritis. The examiner noted that the Veteran has significant cervical degenerative disc disease. He more than likely has shoulder pathology and possible de Quervain syndrome which are not secondary to his remote navicular fracture in 1945, but may be contributing to his symptomatology. The Veteran was able to work for 33 years sorting and delivering mail. It would be resorting to mere speculation to state that the residuals of his military related right wrist fracture have increased in severity, and his complaints are not secondary to nonservice-connected pathology. In June 2007, the Veteran underwent a VA examination. The examiner reviewed the claims file. The Veteran endorsed pain, weakness, swelling, stiffness, instability, and fatigability. It was noted that the Veteran is able to perform routine activities. Although, at times, it is painful to do so. The Veteran was noted as having a wrist dorsiflexion (extension) of 0 to 15 degrees, a wrist palmar flexion of 0 to 15 degrees with pain at extreme, a wrist radial deviation of 0 to 12 degrees, and a wrist ulnar deviation of 0 to 30 degrees. There was no pain with motion. There was no additional limitation of motion on examination with repetition. Flare-ups consist of an increase in pain and occur with increase in activity and cold or moist weather. Upon physical examination, the wrist was noted as tender to palpation and there is pain with passive range of motion. The Veteran was diagnosed with right wrist arthritis. In June 2007, the Veteran underwent a separate VA neurological examination. The examiner reviewed the claims file. The Veteran reported radiating pain from the hand and the wrist upward through the shoulder and to the neck. The Veteran reported that, at night, the hand can suddenly lock up to the point where it has to be loosened up by using the other hand to open it up. The hand does not lock up during writing or using the right hand for anything. Although, he preferentially used the left hand for things. The Veteran does drop things and estimates the strength of the right hand to be about 50 percent compared to the left side. He also reports occasional numbness and tingling of the entire hand and all the fingers when he awakens in the morning. Upon examination, the examiner noted no asymmetric features of the hand muscle groups on the right compared to the left. In both hands, there may be some mild thenar eminence flattening. The right hand clearly possesses less grip strength (graded 4-/5) compared to the left (+5/5). There is also weakness in opposition of the right thumb and forefinger (4-/5) compared to the left (+5/5). There is limitation of motion at the wrist joint in terms of flexion and extension secondary most likely to the remote fracture. There is moderate limitation in abduction and mild limitation of adduction of the right wrist compared to the left (pain is generated with these movements). He reports pain when asked to flex or extend the wrist. Sensory examination of the right upper extremity reveals a proximal to distal gradient of sensory loss which begins just below the right shoulder at the level of the lateral portion of the deltoid muscle and continues to the hand, including the palm, fingers (all equally decreased in sensation), and dorsum. The total decrement to pin prick and light touch sensation is approximately 30 to 40 percent in the right upper extremity compared to the left. Both sides of the face and upper shoulders and neck are symmetric and considered fully intact with respect to sensation. There is negative Tinel's and negative Phalen's sign bilaterally. It is at least as likely as not that a portion of the Veteran's current motor weakness is secondary to considerations of pain caused by residuals of the right wrist fracture. In other words, the Veteran may not be exerting full force of his right wrist, hand, and rest of the upper extremity due to the generation of pain. It is less likely than not that there is any peripheral nerve compromise or damage to any of the 3 major nerves (ulnar, radial, median) at or distal to the right wrist. In August 2006, the Veteran underwent a VA examination. It was noted that, in the past 61 years since fracturing his wrist in service, he has had some persistent pain in the wrist. Repetitive use and weather changes bother it. He gets aching, soreness, pain, and tenderness. He can do normal daily activity. Examination of the wrist does not show any deformity. There is some tenderness to palpation. He could dorsiflex 55 degrees, plantar flex 55 degrees, radially deviate 20 degrees, and ulnarly deviate 45 degrees. There is pain, especially at the extremes of motion. According to Deluca, repetitive use does cause increased aches, pains, soreness, tenderness, and fatigability. There is no other change noted on office examination. Any other range of motion change is speculative. An x-ray of the right wrist shows minimal arthritis. The claims file also contains VA and private treatment records. Specifically, in a December 2009 VA treatment record, the Veteran reported chronic pain in his right wrist, which now extends to his shoulder. In an April 2009 private treatment record from the Cleveland Clinic, the Veteran presented with right hand pain and swelling. It was noted that he has a history of gout. In a June 2007 VA treatment record, the Veteran was noted as having weakness or weak grip and numbness of the right hand, especially the little finger, since his fracture of the right wrist in service in 1945. EMG and NCV studies of the right upper extremity were normal. This June 2007 record noted that there is no definite electrophysiological evidence of brachial plexopathy on examined right upper extremity. In a March 2007 private treatment record from the Cleveland Clinic Foundation, the Veteran reported wrist pain that goes up the arm and down into the hand. His fingers swell. He experiences weakness and drops things. He has tremors in his hands. The physician noted that, on examination, the Veteran has weakness throughout the right side, arm more than leg. There is reduced sensation in the right hand, but it is difficult to know if this is related to his prior trauma or if it is a new finding. The presence of diffuse right-sided weakness is concerning for an intracranial process. The progressive nature of his symptoms would indicate a mass lesion or a stroke. The physician noted that MRI scans are unrevealing. At this point, it is unclear to the physician what is causing the right hand weakness. In a February 2006 private treatment record from the Cleveland Clinic, it was noted that the Veteran fell and injured his right thumb. The Veteran was diagnosed with a sprain of the hand, not otherwise specified, and fitted for a right wrist brace with thumb spica. With regard to increasing the evaluation assigned to the Veteran's service-connected residuals of a fracture of the right wrist under Diagnostic Code 5215, the Board notes that 10 percent is the maximum evaluation allowed under this diagnostic code. As such, an increased evaluation is not warranted under Diagnostic Code 5215. The Board notes that the alternative diagnostic code available for evaluating wrist disabilities is Diagnostic Code 5214 (ankylosis of the wrist). However, as there is no evidence of record showing that the Veteran has ankylosis of the right wrist, this diagnostic code is not applicable. With respect to granting an increased rating under Diagnostic Code 5010, the Board notes that the Veteran is already receiving a 10 percent evaluation for limitation of motion of the wrist. As this is the maximum evaluation allowed for the Veteran's symptoms under Diagnostic Code 5010, an increased rating cannot be assigned under this diagnostic code for limitation of motion of the wrist. The Board acknowledges that the Veteran reported at the November 2010 VA examination that he experiences recent locking of the right thumb and small finger. At the April 2007 hearing, the Veteran reported pain and stiffness in his fingers. He reported that his small finger is the worst of all. However, the objective medical evidence of record does not reveal that the Veteran has ankylosis of the thumb or any finger as a result of his service-connected residuals of a right wrist fracture. Therefore, an increased evaluation cannot be assigned for ankylosis of the digits of the hand. See 38 C.F.R. § 4.71a, Diagnostic Codes 5216-5227 (2010). With regard to assigning an increased evaluation for limitation of motion of the individual digits, the objective clinical evidence of record does not reveal that the Veteran experiences limitation of motion of the thumb or any of the digits as a result of his service-connected residuals of a right wrist fracture sufficient to warrant a compensable evaluation under Diagnostic Codes 5228, 5229, or 5230. Therefore, an increased evaluation cannot be assigned for limitation of motion of the digits of the hand. See 38 C.F.R. § 4.71a, Diagnostic Codes 5228-5230 (2010). With respect to granting an increased rating under Diagnostic Code 5010 for degenerative arthritis of the fingers or thumb, the Board notes that x-rays of the hand have revealed degenerative changes involving the distal interphalangeal joints and x-rays of the wrist have revealed degenerative changes involving the carpal metacarpal joint of the thumb, as well as the scaphoid trapezium joint. However, the Board notes that the Veteran is service connected specifically for residuals of a fracture of the right wrist. There is no indication in the medical evidence of record that the Veteran's degenerative changes involving the distal interphalangeal joints are related to his right wrist fracture. Furthermore, with regard to the Veteran's degenerative changes involving the carpal metacarpal joint of the thumb, the Board notes that Diagnostic Code 5003 provides a 10 percent rating for each major joint or group of minor joints affected by limitation of motion. The Veteran's carpal metacarpal joint of the thumb does not constitute a major joint group. With regard to the degenerative changes of the Veteran's scaphoid trapezium joint, as noted above, the Veteran is already receiving a 10 percent evaluation for limitation of motion of the wrist. As such, an increased evaluation is not warranted under Diagnostic Code 5010 for degenerative arthritis of the fingers or thumb. The Board also notes that the Veteran reported at the November 2010 VA examination that he gets tingling from his shoulder down to his arm/wrist that wakes him up at night. However, the examiner at this examination noted that the Veteran has significant cervical degenerative disc disease. He more than likely has shoulder pathology and possible de Quervain syndrome which are not secondary to his remote navicular fracture in 1945, but may be contributing to his symptomatology. The Veteran was able to work for 33 years sorting and delivering mail. It would be resorting to mere speculation to state that the residuals of his military related right wrist fracture have increased in severity, and his complaints are not secondary to nonservice- connected pathology. At the June 2007 VA neurological examination, the Veteran reported occasional numbness and tingling of the entire hand and all the fingers when he awakens in the morning. The examiner determined that it is at least as likely as not that a portion of the Veteran's current motor weakness is secondary to considerations of pain caused by residuals of the right wrist fracture. The examiner further determined that it is less likely than not that there is any peripheral nerve compromise or damage to any of the 3 major nerves (ulnar, radial, median) at or distal to the right wrist. Additionally, the Board notes that a June 2007 medical record noted that there is no definite electrophysiological evidence of brachial plexopathy on examined right upper extremity. Therefore, while the Board has considered assigning the Veteran a separate disability rating under the rating criteria for diseases of the peripheral nerves for his complaints of tingling, numbness, and shooting pain, the Board finds that the greater weight of clinical evidence is against finding that the Veteran demonstrates neurological symptoms relating specifically to his service-connected right wrist disability warranting a separate compensable evaluation. The Veteran has been determined to have a separate shoulder pathology and possible de Quervain syndrome which are not secondary to his remote navicular fracture in 1945. It has also been determined that it is less likely than not that there is any peripheral nerve compromise or damage to any of the 3 major nerves (ulnar, radial, median) at or distal to the right wrist. Therefore, as the greater weight of clinical evidence is against finding the Veteran has a nerve injury or neurological symptoms as a result of his service-connected residuals of a fracture of the right wrist sufficient to warrant a separate compensable evaluation, an increased evaluation cannot be assigned under the diagnostic criteria for rating diseases of the peripheral nerves. With regard to assigning a higher disability rating based on functional loss as contemplated by the Court's holding under Deluca, the Board acknowledges that the Veteran's complaints of pain, weakness, swelling, stiffness, instability, and fatigability. Specifically, the Veteran asserted in his October 2006 notice of disagreement (NOD) that repetitive use of his right wrist causes pain, swelling, and fatigue. At the August 2006 VA examination, it was noted that, according to Deluca, repetitive use does cause increased aches, pains, soreness, tenderness, and fatigability. However, at the June 2007 VA examination, there was no additional limitation of motion on examination with repetition. Additionally, the examiner at the November 2010 VA examination noted that, after repetitively flexing and extending, testing for incoordination, pain, fatigability, or weakness, there was no additional limitation of motion on examination with repetition, only reported pain. More importantly, as noted above, the Veteran is already receiving a 10 percent evaluation for his right wrist under Diagnostic Code 5215 for limitation of motion. This is the maximum evaluation allowed for limitation of motion of the wrist. Therefore, an increased evaluation is not available under 38 C.F.R. §§ 4.40 or 4.45 or under the provisions of Deluca. The Board has also considered the potential application of other various provisions, including 38 C.F.R. § 3.321(b)(1), for exceptional cases where scheduler evaluations are found to be inadequate. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three- step inquiry for determining whether a Veteran is entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the Veteran's service- connected residuals of a fracture of the right wrist is inadequate. A comparison between the level of severity and symptomatology of the Veteran's disability with the established criteria shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. There is no evidence in the medical records of an exceptional or unusual clinical picture. The Board, therefore, has determined that referral of this case for extra-schedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted. The Board concludes that the preponderance of the evidence is against the claim for an increased rating, and the benefit of the doubt rule enunciated in 38 U.S.C.A. § 5107(b) is not for application. There is not an approximate balance of evidence. See generally Gilbert, supra; Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). Assignment of staged ratings has been considered and is not for application. Hart, supra. ORDER Entitlement to an evaluation in excess of 10 percent for service- connected residuals of a fracture of the right wrist is denied. ____________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs