Citation Nr: 1124974 Decision Date: 06/30/11 Archive Date: 07/06/11 DOCKET NO. 07-02 992 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to an initial rating greater than 10 percent for residuals of right elbow (major) fracture. 2. Entitlement to an initial rating greater than 10 percent for residuals of left wrist (minor) fracture. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD C. J. Houbeck, Associate Counsel INTRODUCTION The Veteran served on active duty from February 1958 to January 1988. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2006 Regional Office (RO) rating decision in Cleveland, Ohio, which granted entitlement to service connection for residuals of right elbow fracture and residuals of left wrist fracture and assigned a 10 percent rating for each, effective from April 18, 2005. The Veteran's case was remanded by the Board for additional development in November 2009. The case is once again before the Board. FINDINGS OF FACT 1. The Veteran is right-hand dominant. 2. The Veteran's right elbow disability is manifested by loss of pronation beyond the middle of the arc and slightly limited flexion, extension, and supination. 3. The Veteran's left wrist disability is manifested by weakness of hand grip strength, decreased range of motion, and pain comparable to favorable ankylosis. 4. The Veteran's right elbow and left wrist disabilities do not present an exceptional or unusual disability picture. CONCLUSIONS OF LAW 1. Throughout the appellate time period, the criteria for a rating of 30 percent, but no more, for the Veteran's residuals of right elbow fracture have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.40, 4.45, 4.69, 4.71a, Diagnostic Codes (DCs) 5010, 5205-5213 (2010). 2. Throughout the appellate time period, the criteria for a rating of 20 percent, but no more, for the Veteran's residuals of left wrist fracture have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.40, 4.45, 4.69, 4.71a, DCs 5010, 5214, 5215 (2010). 3. Application of the extraschedular rating provisions is not warranted in this case. 38 C.F.R. § 3.321(b) (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all the evidence submitted by or on behalf of the Veteran. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). Veterans Claims Assistance Act of 2000 (VCAA) With respect to the Veteran's claims, the Department of Veterans Affairs (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. 2010); 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 Veteran and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2010); 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 Veteran 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 Veteran is expected to provide; and (4) request that the Veteran provide any evidence in his possession that pertains to the claim. The requirement of requesting that the Veteran 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. As to VA's duty to notify, this appeal arises from the Veteran's disagreement with the initial evaluations following the grants of service connection for residuals of right elbow and left wrist fractures. The United States Court of Appeals for the Federal Circuit and the United States Court of Appeals for Veterans Claims (Court) have held that once service connection is granted the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Nevertheless, the Board notes that VCAA letters dated in June 2005 and November 2008 fully satisfied the duty to notify provisions. See 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2010); 38 C.F.R. § 3.159(b)(1) (2010); Quartuccio, at 187. The Veteran was advised that it was ultimately his responsibility to give VA any evidence pertaining to the claims. The letters informed him that additional information or evidence was needed to support his claims, and asked him to send the information or evidence to VA. See Pelegrini II, at 120-121. The November 2008 letter also explained to the Veteran how disability ratings and effective dates are determined. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). If any notice deficiency is present in this case, the Board finds that any prejudice due to such error has been overcome in this case by the following: (1) based on the communications sent to the Veteran over the course of this appeal, the Veteran clearly has actual knowledge of the evidence the Veteran is required to submit in this case; and (2) based on the Veteran's contentions as well as the communications provided to the Veteran by VA, it is reasonable to expect that the Veteran understands what was needed to prevail. See Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009); Fenstermacher v. Phila. Nat'l Bank, 493 F.2d 333, 337 (3d Cir. 1974) ("[N]o error can be predicated on insufficiency of notice since its purpose had been served."). In order for the Court to be persuaded that no prejudice resulted from a notice error, "the record must demonstrate that, despite the error, the adjudication was nevertheless essentially fair." Dunlap v. Nicholson, 21 Vet. App. 112, 118 (2007). In this case, the Veteran has been continuously represented by an experienced Veteran Service Organization and has submitted argument in support of his claim. These arguments have referenced the applicable law and regulations necessary for a grant of an increased rating. Thus, the Board finds that the Veteran has actual knowledge as to the information and evidence necessary for him to prevail on his claim and is not prejudiced by a decision in this case. As such, a remand for additional notice would serve no useful purpose and would in no way benefit the Veteran. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on the VA with no benefit flowing to the Veteran are to be avoided). The Board also concludes VA's duty to assist has been satisfied. The Veteran's service treatment records and VA medical records are in the file. As directed by the November 2009 Board remand, VA treatment records from October 2007 were obtained and associated with the claims file. Private medical records identified by the Veteran have been obtained, to the extent possible. The Veteran has at no time referenced outstanding records that he wanted VA to obtain or that he felt were relevant to the claims. 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 examinations for his left wrist and right elbow in December 2005 and April 2008. In addition, he was provided additional examination in January 2010 pursuant to the Board's November 2009 remand based on a potentially worsening condition since the last examination. The RO found that the January 2010 examination was inadequate and the Veteran received an additional VA examination in April 2010. The VA examination reports are thorough and supported by VA outpatient treatment records. The examination reports discussed the clinical findings and the Veteran's reported history as necessary to rate the disability under the applicable rating criteria. The examinations also discussed the impact of the disability on the Veteran's daily living. Based on the examinations and the fact there is no rule as to how current an examination must be, the Board concludes the examinations in this case are adequate upon which to base a decision. See 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). Based on the April 2010 VA examination and the association of VA treatment records from October 2007, the Board finds that there has been substantial compliance with its November 2009 remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (a remand by the Board confers upon the claimant, as a matter of law, the right to compliance with the remand instructions, and imposes upon the VA a concomitant duty to ensure compliance with the terms of the remand); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). 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). Increased Initial Ratings 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 & Supp. 2010); 38 C.F.R. § 4.1 (2010). Separate DCs 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). As this claim is on appeal from a decision that granted service connection and assigned an initial rating, "staged" ratings may be assigned, if warranted by the evidence. Fenderson v. West, 12 Vet. App. 119 (1999). 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. As discussed above, a February 2006 rating decision granted service connection for residuals of right elbow and left wrist fractures and, in relevant part, assigned the Veteran an initial compensable rating of 10 percent for each, effective from April 18, 2005. The Veteran claims the ratings do not accurately depict the severity of his current conditions. The Veteran was afforded a VA examination for his left wrist and right elbow in December 2005. The examiner noted that the Veteran was right-handed. The Veteran reported that during service he fell from a plane onto the deck of an aircraft carrier about fourteen or fifteen feet below and fractured his left wrist and right elbow. He reported current pain in the left wrist at the base of the left thumb, present since discharge. The Veteran indicated that past x-rays had shown arthritis of the left wrist. He had intermittent mild pain until 2000, but since then had experienced constant dull discomfort, weakness, swelling, and stiffness in the left wrist. Past studies had shown mild bilateral carpal tunnel syndrome, for which he had been on anti-inflammatories and pain medication. He denied any flare-ups, instability, giving way, locking, or lack of endurance. As to the right elbow, the Veteran reported that since 2001 he had experienced sharp pain in the inner aspect of the elbow, without swelling, weakness, instability, or locking, but with occasional stiffness. The Veteran stated that he liked to work around the house, but that using a hammer or saw caused discomfort in the left wrist and right elbow. He was able to do light housework and was independent in his activities of daily living. On examination, there was tenderness over the medial aspect of the right elbow joint, but no evidence of weakness, fatigue, or lack of endurance. Range of motion of the right elbow was 0 to 140 degrees of flexion/extension, 0 to 20 degrees of supination with pain and stiffness, and 0 to 80 degrees of pronation. There was no decreased motion on repetition. With respect to the left wrist, there was slight tenderness at the base of the left thumb, with no evidence of fatigue, weakness, lack of endurance, or instability. Range of motion of the left wrist was 0 to 60 degrees of palmar flexion with pain and stiffness from 55 degrees, radial deviation from 0 to 20 degrees with pain and stiffness, ulnar deviation from 0 to 25 degrees with pain and stiffness from 20 degrees. There was minimal weakness of hand grip strength and interosseous function, but no decreased movement of the wrist on repetition. The examiner noted that a March 2004 EMG study showed mild bilateral carpal tunnel syndrome and May 2004 x-rays showed mild osteoarthritis of the first carpal/metacarpal joint. The examiner diagnosed status post left wrist and right elbow fractures, degenerative arthritis of the left wrist and right elbow that were as likely as not due to the in-service wrist and elbow fractures, and bilateral carpal tunnel syndrome that was not due to the wrist fracture. In March 2007, the Veteran underwent a left thumb arthroscopy and left carpal tunnel release. The Veteran was afforded another VA examination in April 2008. After noting the Veteran's in-service history of fractures, the report indicated he had current constant, flaring pain in the left wrist that was a 7 to 9 out of 10. Despite the March 2007 surgery, the left wrist pain continued to limit the Veteran's activities, including difficulty grasping objects, dropping objects, and trouble lifting and carrying certain objects. With respect to the right elbow, the Veteran had pain of 7 to 8 out of 10 that made lifting objects and performing activities of daily living difficult. On examination, there was a 4 cm scar over the dorsum of the left wrist. Range of motion of the left wrist was 50 degrees of extension, 30 degrees of flexion, 10 degrees of radial deviation, and 20 degrees of ulnar deviation. He was able to complete three repetitions with complaints of pain but no further decreased range of motion. The wrist was tender medially and laterally. As to the right elbow, there was diffuse tenderness with range of motion to 20 degrees of extension and 120 degrees of flexion, with complaints of pain on repetition but without further decreased range of motion. An October 2009 VA treatment record indicated bilateral upper extremity strength of 5 out of 5 except for the left thumb. The examiner noted that prior testing had ruled out a left arm radiculopathy. Pursuant to the November 2009 Board remand, the Veteran was afforded another VA examination in January 2010. The Veteran noted limitations in bathing, eating, dressing, and grooming due to his left wrist and right elbow disability, stating that he was able to perform most activities but that he moved more slowly and had a tendency to drop objects. The examiner discussed the Veteran's in-service fractures. On examination, there was decreased sensation over the median nerve distribution of the right hand. There was pain over the lateral epicondyle of the right elbow and he had flexion to 100 degrees of active and 115 degrees of passive flexion and extension was only to 30 degrees. Supination and pronation were each limited to 40 degrees and with significant pain. There was evidence of fatigue, weakness, and lack of endurance with repetitive motion of the right elbow, but no incoordination. The examiner opined that the Veteran had a moderate limitation of functioning of the right elbow. Contemporaneous x-rays showed degenerative arthritis of the right elbow. As to the left wrist, from 2007 the Veteran had experienced increased pain and numbness in the left hand. There was noted pain and muscle weakness of the biceps, triceps, grip muscles, and supination muscles, as well as slight weakness of intrinsic muscles. Range of motion of the wrist was 50 degrees of extension, 60 degrees of flexion, 10 degrees of ulnar deviation, and 15 degrees of radial deviation. Median nerve compression and Tinel's tests were positive. There also was marked clonus with the brachioradialis and biceps. Contemporaneous x-rays showed degenerative changes. The examiner diagnosed right elbow posttraumatic arthralgia with ankylosis due to the in-service injury and left wrist arthritis due to his in-service injury, but hyperreflexia, clonus, and other neurological symptoms likely unrelated to the in-service injury. In a January 2010 addendum, the examiner noted that on repetition the Veteran reported some discomfort and weakness in the left wrist and no significant limitation of the right elbow due to pain, fatigue, or lack of endurance on repetition, but that that he had considerably more limited motion and weakness compared to the contralateral side. A February 2010 addendum clarified that the January 2010 VA examination reports notation of ankylosis of the right elbow was due to the overall limitation of the Veteran's flexion, extension, pronation, and supination, but that there was no significant loss of range of motion on repetition. The RO felt that the January 2010 VA examination and addenda were inadequate and scheduled the Veteran for another VA examination in April 2010. The examiner noted review of the claims file. The Veteran showed up to the examination using a rolling walker. As to the right elbow, there was pain in the lateral and medial epicondyle. Range of motion of the right elbow was between 30 degrees and 100 degrees of extension/flexion, supination to 80 degrees, and pronation to 40 degrees, with pain throughout the ranges of motion. On repetition, the Veteran was able to complete only two of three repetitions due to pain, with additional evidence of fatigability, weakness, and lack of endurance, but no incoordination. Supination and pronation in particular caused severe pain. Reflexes of the right elbow were normal. The examiner noted that there was moderate restriction of motion of the right elbow. As to the left wrist, there was tenderness to palpation and his range of motion was dorsiflexion to 30 degrees, plantar flexion to 60 degrees, radial deviation to 15 degrees, and ulnar deviation to 40 degrees. As with the right elbow, the Veteran was able to perform only two of the three requested repetitions of motion of the left wrist due to pain, with additional evidence of weakness, fatigability, and lack of endurance, but no incoordination. His grip strength was 3 out of 5. Reflex testing was somewhat abnormal and there was decreased sensation to light touch throughout the medial nerve distribution. Right Elbow As will be discussed in greater detail below, the Board finds that a 30 percent rating is warranted based on the Veteran's complaints, including those of pain and limitation of motion, as well as increased weakness, fatigability, lack of endurance, and pain on repetitive motion. The evidence of record shows that the Veteran is right-handed. Therefore, for rating purposes, his left wrist is considered his minor or non-dominant extremity. See 38 C.F.R. § 4.69 (2010). Limitation of flexion of the dominant forearm warrants a 10 percent rating if flexion is limited to 100 degrees, a 20 percent rating if limited to 90 degrees, a 30 percent rating if limited to 70 degrees, and a 40 percent rating if limited to 55 degrees. 38 C.F.R. § 4.71a, DC 5206. Limitation of extension of the dominant forearm warrants a 10 percent rating if limited to 45 to 60 degrees, a 20 percent rating if limited to 75 degrees, a 30 percent rating if limited to 90 degrees, and a 40 percent rating if limited to 100 degrees. 38 C.F.R. § 4.71a, DC 5207. A 20 percent rating is warranted if flexion is limited to 100 degrees and extension is limited to 45 degrees. 38 C.F.R. § 4.71a, DC 5208. For the dominant forearm, limitation of supination to 30 degrees or less warrants a 10 percent rating. Limitation of pronation when motion is lost beyond the last quarter of the arc and the hand does not approach full pronation warrants a 20 percent rating, and motion lost beyond the middle of arc warrants a 30 percent rating. A 40 percent rating is available when the hand is fixed in supination or hyperpronation. 38 C.F.R. § 4.71a, DC 5213. As there is no medical evidence of ankylosis, fracture malunion, or nonunion of the major bone structures, these criteria do not apply. 38 C.F.R. § 4.71a. DCs 5205, 5210-5212. Degenerative arthritis established by x-ray findings are rated on the basis of limitation of motion under the appropriate DCs for the specific joint or joints involved. 38 C.F.R. § 4.71a, DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm or satisfactory evidence of painful motion. When the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate DCs, an evaluation of 10 percent is applied for each major joint or group of minor joints affected by limitation of motion. In the absence of limitation of motion, a 10 percent evaluation will be assigned where there is x-ray evidence of involvement of two or more major joints or two or more minor joint groups. Initially, the Board notes that the rating schedule provides a separate rating for the combination of limitation of elbow extension and flexion (DC 5208). The fact that the rating schedule provides such separate rating for the combination of limitation of motion indicates that the schedule does not envision providing separate ratings for limitations of flexion, extension, supination, or pronation. 38 C.F.R. § 4.59 (2010) (providing that functional impairment is expected to be evaluated as at least the minimal compensable level); Cf. VAOPGCPREC 9-2004; 69 Fed. Reg. 59,990 (2004); VAOPGCPREC 9-98 (1998); 63 Fed. Reg. 56,704 (1998); VAOPGCPREC 23-97; 62 Fed. Reg. 63,604 (1997) (holding that separate ratings can be assigned for limitation of knee extension, flexion, and instability, where the rating schedule did not provide a DC for rating the combination of these disabilities in a single rating). In this case, the Board concludes that the highest possible rating for the Veteran's decreased range of motion and other symptoms of the right elbow is a 30 percent rating available under 38 C.F.R. § 4.71a, DC 5213 for the Veteran's limitation of pronation. As such, the Board finds that a rating under DC 5213 is warranted, rather than DC 5206. See Butts v. Brown, 5 Vet. App. 532, 538 (1993); Pernorio v. Derwinski, 2 Vet. App. 625 (1992). As noted above, several examinations found pronation limited to 40 degrees. As normal pronation is from 0 to 80 degrees, these records show pronation lost beyond the middle of the arc, which warrants a 30 percent rating for the major extremity. A higher rating under DC 5213 is not available because the Veteran's hand is not fixed in supination or hyperpronation. A higher rating is not available under a separate DC. A higher rating is not available under DCs 5206 or 5207 as flexion is not limited to 55 degrees or less or extension to 100 degrees or more. There is no evidence of an ununited or unhealed joint fracture or impairment of the flail joint. There is no evidence of nonunion of the radius and ulna with the flail joint or nonunion of the ulna or radius with loss of bone substance to afford a higher or separate rating under DCs 5210-5212. Separate disability ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not "duplicative of or overlapping with the symptomatology" of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 262 (1994). In this case, a separate rating for the Veteran's symptomatology is not warranted. There is no additional neurological disability that has been attributed to the Veteran's right elbow disability. As such, separate ratings under DCs 8510 and 8511 are not warranted. See 38 C.F.R. § 4.124a (2010). The Board notes that functional loss as contemplated by the Court's holding in DeLuca v. Brown was also considered. The Board recognizes that the medical evidence and the Veteran's testimony show some functional impairment of right elbow function. In general, evaluation of a service-connected disability involving a joint requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions of 38 C.F.R. § 4.40 state that disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence of part, or all, of the necessary bones, joints and muscles, or associated structures. It may also be due to pain supported by adequate pathology and evidenced by visible behavior of the Veteran undertaking the motion. See 38 C.F.R. § 4.40. The factors of disability affecting joints are reduction of normal excursion of movements in different planes, weakened movement, excess fatigability, swelling and pain on movement. See 38 C.F.R. § 4.45. In this case, a higher rating based on functional loss is not warranted. The Veteran clearly has complaints of chronic pain, weakness, fatigue, lack of endurance, and difficulty performing daily tasks. The Board recognizes that during several VA examinations the Veteran reported pain throughout the range of motion and an inability to complete more than two repetitions of motion due to weakness, fatigability, and lack of endurance. However, the Board notes that the 30 percent rating assigned under the criteria of DC 5213 contemplate significant problems with pain and decreased movement. Moreover, the rating is comparable to ratings assigned for fixation and complete inability to use certain joints. In that regard, a 30 percent rating or less is assigned under DC 5213 for fixation of the hand in full pronation or in moderate pronation. Thus, the 30 percent rating assigned is comparable to and contemplates significant loss of function. Moreover, the Veteran appeared at one of his VA examinations using a walker to assist his ambulation, which shows that he is able to use his right elbow sufficiently to maneuver the walker as necessary over an extended period of time. In addition, during his October 2009 Board hearing the Veteran reported that because of his wife's physical condition he was required to perform all household tasks and chores. While he noted some problems on certain days, he stated that on others he was able to complete the activities of daily living, shopping, driving, and similar tasks. Significantly, the Veteran indicated that his primary limitation in performing these tasks was his left wrist rather than his right elbow. As such, while the Board sympathizes with the Veteran's difficulties, the Board notes that some degree of impairment on his ability to perform daily activities is contemplated in the current 30 percent rating. Therefore, the Board concludes that the greater weight of evidence establishes that the Veteran's right elbow has suffered no significant or additional functional loss beyond that contemplated by the 30 percent rating assigned herein. As shown above, and as required by Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991), the Board has considered all potentially applicable provisions of 38 C.F.R. Parts 3 and 4, whether or not they have been raised by the Veteran. In this case, the Board finds no provision upon which to assign a rating greater than 30 percent for the Veteran's right elbow disability. As discussed, the symptoms throughout the appellate time period are substantially consistent. For this reason, staged ratings are not applicable. See Fenderson, 12 Vet. App. at 119. Left Wrist As will be discussed in greater detail below, the Board finds that a 20 percent rating is warranted based on the Veteran's complaints, including those of pain and limitation of motion, as well as increased weakness, fatigability, lack of endurance, and pain on repetitive motion. Consequently, the Board finds that a rating under DCs 5214-5010 is warranted, rather than DCs 5215-5010. See Butts v. Brown, 5 Vet. App. 532, 538 (1993); Pernorio v. Derwinski, 2 Vet. App. 625 (1992). The evidence of record shows that the Veteran is right-handed. Therefore, for rating purposes, his left wrist is considered his minor or non-dominant extremity. See 38 C.F.R. § 4.69 (2010). The Board notes that there are several DCs under which the Veteran's wrist disability must be evaluated. DC 5010 provides the rating criteria for arthritis due to trauma, substantiated by x-ray findings, and directs that it be rated as degenerative arthritis under DC 5003. That rating code indicates that degenerative arthritis established by x-ray evidence will be rated on the basis of limitation of motion under the appropriate DCs for the specific joint or joints involved. When the limitation of motion is noncompensable under the appropriate DC a 10 percent rating is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a. DC 5215, in turn, governs limitation of motion of the wrist. An evaluation of 10 percent is warranted for the major and minor joints for palmar flexion limited in line with the forearm and for dorsiflexion less than 15 degrees. See 38 C.F.R. § 4.71a, DC 5215. Normal range of motion for the wrist is 70 degrees of dorsiflexion (extension); 80 degrees of palmar flexion; 45 degrees of ulnar deviation; and 20 degrees of radial deviation. See 38 C.F.R. § 4.71, Plate I. Under DC 5214, favorable ankylosis in 20 to 30 degrees dorsiflexion warrants a 20 percent disability evaluation in the minor wrist and a 30 percent evaluation in the major wrist. Ankylosis in any other position except favorable warrants a 30 percent disability evaluation for the minor wrist and a 40 percent evaluation for the major wrist. Unfavorable ankylosis in any degree of palmar flexion, or with ulnar or radial deviation warrants a 40 percent rating for the minor wrist and 50 percent rating for the major wrist. 38 U.S.C.A. § 4.71a, DC 5214. The Board concludes the objective medical evidence and the Veteran's statements regarding his symptomatology show disability that more nearly approximates that which warrants the assignment of a 20 percent disability rating. See 38 C.F.R. § 4.7 (2010). As noted above, a 10 percent rating is the highest rating available for DCs pertinent to arthritis (DC 5010) and limitation of motion (DC 5215) and that the Veteran does have limitation of motion of the left wrist that meets the requirements for such a rating under DC 5215. However, given the Veteran's decreased range of motion in his left wrist and the VA examiners' statements that the joint function of his left wrist involved pain throughout his range of motion with concurrent evidence of fatigue, weakness, and lack of endurance on repetitive motion, the Board finds that the criteria for a 20 percent rating based on additional functional limitation is warranted pursuant to the holding in DeLuca v. Brown, 8 Vet. App. 202 (1995). See also 38 C.F.R. §§ 4.40, 4.45, 4.59 (2010). However, a rating in excess of 20 percent for additional limitation of function is not warranted as the evidence does not show symptoms consistent with ankylosis of the left wrist. In that regard, ankylosis is "immobility and consolidation of a joint due to disease, injury, surgical procedure." Lewis v. Derwinski, 3 Vet. App. 259 (1992) (citing Saunders Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health at 68 (4th ed. 1987)). While the Veteran certainly has some limitation of motion of the left wrist, daily pain, and fatigue, weakness, and lack of endurance on repetitive motion, these symptoms are not consistent with unfavorable ankylosis. In that regard, during his October 2009 Board hearing and his VA examinations the Veteran indicated that he is able to perform light household chores, depending on the day, and he is otherwise able to use a walker to assist ambulation, which evidences an ability to use his left wrist for certain physically demanding tasks. Therefore, the Board finds that the Veteran's service-connected left wrist disorder is entitled to a 20 rating pursuant to DCs 5214-5010 and the DeLuca criteria enumerated above, but no more. No higher rating under a different DC can be applied. Analogous ratings for impairment of the wrist are either not applicable to the Veteran's case or do not offer a higher disability rating. To that end, in the absence of impairment of the radius or ulna or impairment of supination and pronation, DCs 5212 and 5213 are not for application and, to the extent that any limitation exists it has not been attributed to the Veteran's left wrist disability. The Board has also considered the Veteran's neurological problems, including carpal tunnel syndrome and clonus. In that regard, the Board notes the Court's decision in Mittleider v. West, 11 Vet. App. 181 (1998), which held, in pertinent part, that when it is not possible to separate the effects of the service-connected condition from a nonservice-connected condition, 38 C.F.R. § 3.102 requires that reasonable doubt on any issue be resolved in the Veteran's favor, and that such signs and symptoms be attributed to the service-connected condition. In this case, however, as discussed above, there are multiple competent medical opinions that explicitly found that the Veteran's carpal tunnel syndrome and other neurological problems were unrelated to his in-service accident and subsequent treatment. As such, a higher rating is not warranted under DCs 8515 or 8516 for paralysis of the median or ulnar nerves. Similarly, a separate or higher rating is not warranted for the Veteran's post-operative scar for carpal tunnel release and left thumb arthroplasty, as such conditions are not related to the service-connected disorder. As shown above, and as required by Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991), the Board has considered all potentially applicable provisions of 38 C.F.R. Parts 3 and 4, whether or not they have been raised by the Veteran. In this case, the Board finds no provision upon which to assign a rating greater than 20 percent for the Veteran's left wrist disability. As discussed, the symptoms throughout the appellate time period are substantially consistent. For this reason, staged ratings are not applicable. See Fenderson, 12 Vet. App. at 119. Extraschedular Considerations The Board also has considered whether the Veteran is entitled to a greater level of compensation on an extraschedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2010). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). 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 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 evaluations for the service-connected left wrist and right elbow are inadequate. A comparison between the level of severity and symptomatology of the Veteran's left wrist and right elbow with the established criteria shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. Specifically, the Veteran reports pain, decreased motion, weakness, fatigability, and lack of endurance of the left wrist and right elbow. As discussed above, the Veteran's ratings take into account all these symptoms for both the left wrist and right elbow. Thus, the Veteran's current schedular ratings under DCs 5206 and 5214-5010 are adequate to fully compensate him for his disabilities on appeal. In short, the rating criteria reasonably describe the Veteran's disability level and symptomatology. The Board, therefore, has determined that referral of this case for extraschedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted. ORDER Entitlement to an increased rating of 30 percent for residuals of right elbow (major) fracture is granted, subject to the laws and regulations controlling the award of monetary benefits. Entitlement to an increased rating of 20 percent for residuals of left wrist (minor) fracture is granted, subject to the laws and regulations controlling the award of monetary benefits. ____________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs