Citation Nr: 1220196 Decision Date: 06/08/12 Archive Date: 06/20/12 DOCKET NO. 09-15 204 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, Kentucky THE ISSUES 1. Entitlement to a disability rating in excess of 10 percent for residuals, fracture of the left thumb. 2. Entitlement to service connection for a skin disorder, to include as due to an undiagnosed illness. 3. Entitlement to service connection for left wrist strain. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Heather J. Harter, Counsel INTRODUCTION The Veteran served on active duty from January 1982 to December 1992, to include service in Southwest Asia in support of the Persian Gulf War. This matter comes before the Board of Veterans' Appeals (Board) from a May 2008 RO decision. In May 2009, the Veteran withdrew his request for a hearing before a Veterans' Law Judge. This withdrawal is valid. 38 C.F.R. § 20.704(e). The issues of entitlement to service connection for a skin disorder, to include as due to an undiagnosed illness, and entitlement to service connection for left wrist strain are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDING OF FACT The Veteran's left thumb fracture residuals include arthritis, decreased grip ability, decreased dexterity, and pain; however, there is no amputation, ankylosis, and he is able to close the thumb to the fingers with no gap. CONCLUSION OF LAW A disability rating in excess of 10 percent is not warranted for fracture residuals of the left thumb. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.10, 4.40, 4.59, 4.71a, Diagnostic Codes 5003, 5010, 5228 (2011). REASONS AND BASES FOR FINDING AND CONCLUSION Duties to notify and assist When an application for benefits is received, VA has certain notice and assistance requirements under the law. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). First, proper notice must be provided to a claimant before the initial VA decision on a claim for benefits and must: (1) inform the claimant about the information and evidence not of record necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. The VA is also required to inform the Veteran of how the VA assigns disability ratings and effective dates. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Review of the claims file shows that the Veteran was informed of these elements with regard to his claim in letters of January 2007 and August 2007, prior to the initial adjudication of the claim. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As set forth in greater detail below, the Board finds that the VA examinations obtained in this case are adequate with regard to the issue decided herein. The examination reports relied upon herein were predicated on a review of the claims folder and the relevant medical records contained therein; contain a description of the history of the disability(ies) at issue; document and consider the Veteran's complaints and symptoms. The examiners considered all of the available pertinent evidence of record, and provided a rationale for the opinions rendered, relying on and citing to the records reviewed. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issue on appeal has been met. 38 C.F.R. § 3.159(c)(4). VA medical records reflecting treatment provided from 2002 through 2009, service treatment records, some private medical records, VA examination reports, and VA medical opinions have been obtained and reviewed in support of the Veteran's claims. The Veteran has presented written statements in support of his claim. All relevant records and contentions have been carefully reviewed. The Board therefore concludes that the VA's duties to notify and assist have been met with regard to the matter decided herein. Standard of review Once the evidence has been assembled, it is the Board's responsibility to evaluate the record. 38 U.S.C.A. § 7104(a). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States Court of Appeals for Veterans Claims (Court) stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. The Board must consider all the evidence of record and discuss in its decision all "potentially applicable" provisions of law and regulation. See 38 U.S.C. § 7104(a); Schafrath v. Derwinski, 1 Vet. App. 589, 592-93 (1991). The Board is also required to provide a statement of reasons or bases for its determination, adequate to enable an appellant to understand the precise basis for its decision, as well as to facilitate further appellate review. See 38 U.S.C. § 7104(d)(1); Allday v. Brown, 7 Vet. App. 517, 527 (1995); Gilbert, 56 (1990). To comply with this requirement, the Board must analyze the credibility and probative value of the evidence, account for the evidence it finds persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). A disability rating in excess of 10 percent for left thumb disability Disability evaluations are assigned to reflect levels of current disability. The appropriate rating is determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When 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 approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. If there is disagreement with the initial rating assigned following a grant of service connection, separate ratings can be assigned for separate periods of time, based on the facts found. Fenderson v. West, 12 Vet. App. 119, 126 (1999). See AB v. Brown, 6 Vet. App. 35, 38 (1993) (on a claim for an original or an increased rating, it is presumed that the veteran seeks the maximum benefit allowed by law and regulation, and it follows that such a claim remains in controversy when less than the maximum available benefit is awarded). Reasonable doubt as to the degree of disability will be resolved in the veteran's favor. 38 C.F.R. § 4.3. Because the level of a veteran's disability may fluctuate over time, VA is required to consider the level of the Veteran's impairment throughout the entire period, from November 2005, one year prior to when the Veteran filed the instant claim for an increased disability rating. In this respect, staged ratings are a sensible mechanism for allowing the assignment of the most precise disability rating-one that accounts for the possible dynamic nature of a disability while the claim works its way through the adjudication process. O'Connell v. Nicholson, 21 Vet. App. 89 (2007). In another relevant precedent, the Court noted that staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. In reaching this conclusion, the Court observed that when a claim for an increased rating is granted, the effective date assigned may be up to one year prior to the date that the application for increase was received if it is factually ascertainable that an increase in disability had occurred within that timeframe. 38 U.S.C.A. § 5110; Hart v. Mansfield, 21 Vet. App. 505 (2007). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the veteran, as well as the entire history of the veteran's disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). In evaluating claims for increased ratings, we must evaluate the veteran's condition with a critical eye toward the lack of usefulness of the body or system in question. 38 C.F.R. § 4.10. A disability of the musculoskeletal system is measured by the effect on ability to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. Weakness is as important as limitation of motion in assigning the most accurate disability rating. 38 C.F.R. § 4.40. Although § 4.40 does not require a separate rating for pain, it does provide guidance for determining ratings under other diagnostic codes assessing musculoskeletal function. The Board has a special obligation to provide a statement of reasons or bases pertaining to § 4.40 in rating cases involving pain. Spurgeon v. Brown, 10 Vet. App. 194 (1997). Disability of the joints, including the spine, is measured by abnormalities of motion, such as limitation of motion or hypermobility, instability, pain on motion, or the inability to perform skilled motions smoothly. 38 C.F.R. § 4.45. Painful motion with joint or periarticular pathology and unstable joints due to healed injury are recognized as productive of disability entitled to at least a minimal compensable rating for the joint. 38 C.F.R. § 4.59. Under section 4.59, painful motion is considered limited motion even though a range of motion is possible beyond the point when pain sets in. Hicks v Brown, 8 Vet. App. 417, 421 (1995). Diagnostic Code 5010 provides that arthritis due to trauma, and confirmed by X-ray findings, should be rated as degenerative arthritis. The criteria for rating degenerative arthritis provide that when established by X-ray findings, degenerative arthritis 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. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Additionally, a rating based on X-ray findings will not be combined with ratings based on limitation of motion. Historically, the Veteran fractured his left thumb during service. Service connection was granted effective upon his discharge from service and a noncompensable (0 percent) disability rating was assigned on the basis that a VA examination showed no residual disability and complete left thumb function. The Veteran filed the instant claim for an increase in November 2006, claiming increased pain in his left wrist. The RO assigned a 10 percent disability rating for painful motion in the joint in light of the moderate to serious effects upon the Veteran's occupational tasks and his daily functioning. The Veteran continues to assert that a higher disability rating is warranted. A request for an increased rating must be viewed in light of the entire relevant medical history. 38 C.F.R. § 4.1. However, the Court has held that, where, as here, entitlement to compensation has already been established, and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Veteran is right-hand dominant. His VA medical records reflect that he has complaints of left hand pain and a diagnosis of arthritis, for which he takes pain medication. He underwent a VA examination pertinent to his left hand in February 2007. At that time, he reported that he had fallen and fractured the base of his left thumb in 1989, and then after getting into a fight, had the area re-casted. He reported that his left hand grip was decreased. He reported that he would experience a flare-up in left thumb pain, when he gripped and twisted or turned something, that the pain was alleviated when he ceased the activity and that he experienced such flare-ups weekly. Upon clinical examination, the examiner noted a slight boney joint enlargement and tenderness of the left first metacarpal. There was no gap between the thumb pad and tips of the fingers on attempted opposition of the thumb to the fingers. The examiner noted that the strength of the affected muscles was normal, but the mild to moderate pain the Veteran experiences at the first metacarpal and first metacarpal phalangeal joint with activities such as twisting or turning mostly likely would result in mild guarding and have an effect on speed and endurance for gripping, twisting, and turning. The examiner noted that the mild to moderate pain at the first metacarpal and first metacarpal phalangeal joint would also have a mild effect on dexterity, especially twisting, turning, touching, and expression. Upon range of motion testing, there was no pain on active or passive motion, and no additional loss of motion on repetitive use of the joint. There was less range of motion in the left thumb than in the right thumb, with the left thumb manifesting flexion from 0 to 75 degrees and the right thumb manifesting flexion from 0 to 95 degrees. An X-ray study was interpreted as showing an irregularity at the base of the first metacarpal with some boney thickening, apparently representing an old healed fracture. The examiner opined that the fracture residuals had significant effects upon the Veteran's usual occupation due to decreased manual dexterity, problems with lifting and carrying, and pain. With regard to the Veteran's daily activities, the examiner opinioned the disability would have a moderate effect with regard to his chores, a severe effect upon exercise and sports, and a moderate effect upon recreation and travelling. During a Gulf War examination in April 2008, the Veteran stated he still had pain in the left hand/wrist, with no real change since the 2007 examination. He reported continuing to experience difficulty opening things, turning, gripping, with severe pain during a flare-up. He also reported experiencing joint pains like arthritis in his knees, hips and his right wrist as well. Upon examination, the examiner noted an overall decrease in strength and dexterity of the hand with flare-ups upon use, and problems with gripping and twisting. The examiner also described a scar at the base of the left thumb, 2mm by 2cm. However, the examiner declined to render a diagnosis of a thumb disorder, and noted that there was no angulation, ankylosis, or deformity involving the thumb. Electromyograph testing was performed in May 2008, and was interpreted as showing no peripheral neuropathy or carpal tunnel syndrome in the left upper extremity. Upon review of this testing and the 2007 X-ray studies, the examiner noted the Veteran's similar right wrist complaints and opined that the most likely diagnosis was of bilateral intermittent wrist strains related to overuse, with no evidence of relation to service. The examiner then rendered the diagnostic assessments of arthritis of both hands, and "previous left thumb fracture with continued pain." In October 2008, the Veteran's girlfriend submitted a statement to the effect that the Veteran complained of left thumb pain all the time. She noted that he was required to use his left thumb frequently, especially on the job, where he did plumbing and heavy lifting. She noted that he had problems opening a jar of pickles and problems gripping anything that was as big as a baseball. She also noted that he often just holds and rubs his left thumb because of the pain. The Veteran's left thumb fracture residuals are rated under the provisions of 38 C.F.R. § 4.71a, Diagnostic Code 5228 in conjunction with the provisions of Diagnostic Codes 5003 and 5010. When the minor thumb has limitation of motion which causes a gap of more than two inches (5.1cm) between the thumb and the fingers, with the thumb attempting to oppose the fingers, a 20 percent disability rating is assigned. When the minor thumb has limitation of motion which causes a gap of one to two inches (2.5 to 5.1cm) between the thumb and the fingers, with the thumb attempting to oppose the fingers, a 10 percent disability rating is assigned. When the gap is less than one inch (2.5cm) a noncompensable, or 0 percent disability rating is assigned. Other Diagnostic Codes provide rating criteria for the evaluation of ankylosis of the thumb or amputation of the thumb. Ankylosis is defined as immobility and consolidation of a joint due to disease, injury or surgical procedure. Lewis v. Derwinski, 3 Vet. App. 259 (1992). However, as the Veteran has neither of these impairments, they are not for application here. Upon review, the Board holds that the currently-assigned 10 percent disability rating more nearly approximates the Veteran's level of impairment due to his service-connected left thumb fracture residuals. In so concluding the Board notes that he does not technically meet the criteria for a compensable disability rating under Diagnostic Code 5228, as he is able to close the gap between his left thumb and fingers completely. Furthermore, no actual decrease in grip strength was observed upon examination. Rather, the examiner explained that the Veteran's thumb joint pain likely caused a functional decrease in grip strength. However, as the fracture residuals are shown on X-ray, which is one of the factors enumerated under Diagnostic Code 5003, and as the VA examiner concluded the Veteran has decreased grip and decreased manual dexterity due to pain in the left thumb, and the moderate to serious effects upon the Veteran's occupational tasks and his daily functioning, the 10 percent disability rating is supported by the evidence of record. However, no basis whatsoever is shown for the assignment of a disability rating in excess of 10 percent. There is also no basis for consideration of a staged disability rating based upon fluctuation of the disability over time; rather it would appear that the pain and functional impairment related to his left thumb fracture residuals have remained stable throughout the appeal period. O'Connell. The preponderance of the evidence is thus against the claim. In reaching this conclusion, the Board observes that the statement of the Veteran's girlfriend is helpful to the Board's understanding of the impact of the Veteran's left thumb impairment upon his daily life. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991). Lay evidence is one type of evidence that must be considered and competent lay evidence can be sufficient in and of itself. The Board, however, retains the discretion to make credibility determinations and otherwise weigh the evidence submitted, including lay evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006). Generally, lay persons ostensibly untrained in medicine can provide personal accounts of symptomatology, but cannot provide evidence constituting a medical conclusion, such as an opinion as to the medical characteristics of symptoms or the etiology of a disease. For the most part, medical testimony must be provided by someone qualified as an expert by knowledge, skill, experience, training, or education. Thus, as a lay person, the Veteran is not competent to opine as to medical etiology or render medical opinions. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Grover v. West, 12 Vet. App. 109, 112 (1999); Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). Extra-schedular consideration Generally, evaluating a disability using either the corresponding or analogous Diagnostic Codes contained in the rating schedule is sufficient. See 38 C.F.R. § 4.20, 4.27. For exceptional cases, VA has authorized the assignment of extraschedular ratings and provided the following guidance for awarding such ratings: To accord justice, therefore, to the exceptional case where the schedular evaluations are found to be inadequate, the Under Secretary for Benefits or the Director, [C & P], upon field station submission, is authorized to approve on the basis of the criteria set forth in this paragraph an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. The governing norm in these exceptional cases is: 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 as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b). As the Court recently explained in Thun, a "determination of whether a claimant is entitled to an extraschedular rating under § 3.321(b) is a three-step inquiry." Thun v. Peake, 22 Vet. App. 111, 115 (2008). If the RO or Board determines that (1) the schedular evaluation does not contemplate the claimant's level of disability and symptomatology, and (2) the disability picture exhibits other related factors such as marked interference with employment or frequent periods of hospitalization, then (3) the case must be referred to an authorized official to determine whether, to accord justice, an extraschedular rating is warranted. Neither the RO nor the Board is permitted to assign an extraschedular rating in the first instance; rather the matter must initially be referred to those officials who possess the delegated authority to assign such a rating. See Floyd v. Brown, 9 Vet. App. 88, 95 (1996). Anderson v. Shinseki, 22 Vet. App. 423 (2009). In this case, there is no indication that the schedular criteria fail to contemplate the Veteran's level of disability or symptomatology; as such there is no basis for referring this case for consideration of an extra-schedular rating. In summary, the preponderance of the evidence is against a higher disability rating for the Veteran's left thumb fracture residuals. The appeal is denied. ORDER A disability rating in excess of 10 percent for residuals of a fracture of the left thumb is denied. REMAND Skin disorder The Veteran contends that he has had a skin condition since service. He asserts that service connection is warranted either on a direct basis or under the liberalizing provisions for undiagnosed illnesses related to his service in the Southwest Asia Theater of operations during the Persian Gulf War. The Veteran's service treatment records do not reflect any skin problems during service. He was discharged from service in December 1992. That same month he submitted an application for VA compensation for compensation for various disabilities. He did not claim any disorder involving his skin at that time, however. Pursuant to the December 1992 claim, he underwent a VA general medical examination in February 1993. The report of this examination reflects that his skin was deemed to have been normal. He filed another claim in February 1995, but again did not claim any disorder involving his skin. In fact, the earliest evidence of the existence of a skin disorder contained in the claims file is the Veteran's February 2002 claim for service connection. At that time, the veteran simply noted that he wanted to open a claim for an "aggravated skin condition." His VA treatment records (the earliest available) reflect that as of February 2002, the Veteran was being treated for follicular dermatitis with a skin wash and lotrisone cream. The clinical description was of scattered papules on shoulders, back, abdomen, and chest in various stages of eruption and healing. A November 2002 VA treatment report shows that the Veteran requested a dermatological consultation for a rash he reported having had for twelve years. Another November notation reflects that the dermatological consultation was ordered. There is no record reflecting the report of the consultation available for review in his claims file, however. In a February 2007 statement, the Veteran reported having sought medical care from "every VA near where I have lived," since his discharge from service. He also reported receiving medical care for "spots" at the William Beaumont Army Medical Center from 1992 to 1993. He listed three VA Medical Centers in particular: in Shreveport, Louisiana; Houston, Texas; and Louisville, Kentucky. Records from Louisville are contained in the claims file. Records from Shreveport consist of VA examination reports only, although a certification from the archival facility where older Shreveport medical records are filed attests that they did not find any records pertaining to the Veteran between 1993 and 2000. The VA Medical Center in Houston has certified that they have no records pertaining to the Veteran in their file system, to include in their retired-records archive. Given the Veteran's contention that he has had a skin disorder since his discharge from service, any medical records reflecting the presence of the disability between 1992, when he was discharged, and 2002, when the disability is first documented in the claims file, would be highly relevant to his claim. Governing regulation provides that VA will make as many requests as are necessary to obtain relevant records from a Federal department or agency, such as a VA medical center. VA will end its efforts to obtain such records only if VA concludes that the records sought do not exist or that further efforts to obtain them would be futile. 38 C.F.R. § 3.159(c). Upon review of the efforts undertaken by the VA to search for records pertaining to the Veteran at the VA Medical Center in Houston, and the VA Medical Center in Shreveport, the Board is satisfied that no such records exist. However, the Board is not satisfied that adequate efforts have been undertaken to ensure that no other relevant records exist. In particular, while 1992 records from the William Beaumont Army Medical Center are contained in the Veteran's service treatment records, there are no 1993 treatment records from the William Beaumont Army Medical Center contained in the claims file, and it does not appear that such records have been requested. Therefore, upon remand, the RO should ascertain whether the Veteran received any post-service medical care at the William Beaumont Army Medical Center in 1993, and if so, these records should be obtained for review. Lastly, there is the matter of the missing 2002 or 2003 dermatological consultation report. The RO should therefore make a special request for this report. Left wrist strain As noted above, the Veteran's Gulf War examination yielded a diagnosis of "bilateral intermittent wrist strains related to overuse, with no evidence of relation to service." The RO raised, adjudicated and denied service connection for bilateral wrist strain in May 2008, providing notice of the denial in a letter dated the same month. The Veteran did not mention his wrists in the notice of disagreement which he filed in August 2008. However, in his April 2009 substantive appeal, he stated, "the pain in my left thumb. . . is continuous and results in my favoring it at work and consequently has caused trauma in my left wrist that is also painful." The Board finds that this April 2009 statement constitutes a notice of disagreement with the May 2008 decision as to the left wrist, because it was filed within the requisite time period and it indicates dissatisfaction and a desire to contest the denial. See 38 C.F.R. §§ 20.201, 20.302. The RO has not yet issued a statement of the case, however. After a notice of disagreement has been filed in any claim, the RO is required to issue a statement of the case containing a summary of the evidence, the applicable laws and regulations, and an explanation as to the decision previously reached, unless the Veteran has withdrawn the notice of disagreement. 38 C.F.R. §§ 19.26, 19.29. Technically, when there has been an initial RO adjudication of a claim and a notice of disagreement has been filed as to its denial, thereby initiating the appellate process, a remand is required for procedural reasons. Manlincon v. West, 12 Vet. App. 238 (1999). Thus, the Board accepts limited jurisdiction over this issue, for the sole purpose of remanding to order issuance of a statement of the case along with information about the process for perfecting an appeal as to this claim, if the Veteran so desires. Accordingly, the case is REMANDED for the following action: 1. The RO should request any post-service 1993 treatment records reflecting medical care provided to the Veteran at the William Beaumont Army Medical Center through official channels. The request(s) and all responses should be fully-documented in the claims file to facilitate appellate review. 2. The RO should request a copy of the dermatologic consultation report pertaining to the Veteran which was conducted after November 2002 at the Louisville VA Medical Center, or any related clinic. If no such consultation was performed, this should be fully-documented for appellate review. 3. IF and only if any new records pertaining to the Veteran's skin are obtained pursuant to the above requests, the Veteran should be afforded a VA dermatologic examination to identify whether it is more, less, or equally likely that the any skin disorder present between February 2002 and the present (the appeal period) had its inception during service or is otherwise related to service. The claims folder, including the newly-obtained records must be made available to the examiner for review before the examination. All tests and studies deemed helpful by the examiner should be conducted in conjunction with the examination. The complete rationale for all opinions expressed should be fully explained. 4. After the development requested above has been completed to the extent possible, the RO should again review the record. If the benefit sought on appeal remains denied, the Veteran and his representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto. 5. The RO should furnish the Veteran with a Statement of the Case pertaining to the issue of entitlement to service connection for left wrist strain, to include as secondary to his service-connected left thumb fracture residuals. This claim will not be returned to the Board unless the Veteran perfects an appeal by filing a timely substantive appeal. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2011). ____________________________________________ S. L. Kennedy Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs