Citation Nr: 1228675 Decision Date: 08/21/12 Archive Date: 08/30/12 DOCKET NO. 09-30 138 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUES 1. Entitlement to a rating in excess of 10 percent for traumatic arthritis of the right wrist with navicular nonunion. 2. Entitlement to a rating in excess of 10 percent for residuals of a fractured left wrist. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and his wife ATTORNEY FOR THE BOARD J Fussell INTRODUCTION The Veteran served on active duty from November 1973 to June 1975. These matters come before the Board of Veterans' Appeals (Board) on appeal from a June 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Huntington, West Virginia. A review of the Virtual VA paperless claims processing system does not reveal any additional documents pertinent to the present appeal. In November 2010, the Veteran and his wife testified at a Travel Board hearing before the undersigned Veterans Law Judge (VLJ). A transcript of this hearing is associated with the claims file. When the Board remanded the case in February 2011, it was noted that the Veteran had initiated an appeal of a February 2003 rating decision that denied service connection for hepatitis C but that he had not perfected an appeal after a December 2003 Statement of the Case (SOC) was issued. The Board remanded the case for an up-to-date VA rating examination. That examination was conducted in March 2011. The case has now been returned to the Board. FINDINGS OF FACT 1. The Veteran is right handed. 2. The service-connected right wrist disability is manifested by traumatic arthritis, navicular nonunion, an unhealed fracture of the ulnar styloid, radial deviation deformity, limitation of motion, and significant residual functional impairment including pain and weakness. 3. The residuals of a fractured left wrist are manifested by well healed bony injury and satisfactory postoperative status with painful and limited motion but no giving way, instability, incoordination, dislocation, subluxation, locking or effusion. CONCLUSIONS OF LAW 1. The criteria for a rating of no more than 30 percent for traumatic arthritis of the right wrist with navicular nonunion are met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.321(b)(1), 4.2, 4.7, 4.10, 4.20, 4.21, 4.27, 4.40, 4.41, 4.45, 4.59, 4.68, 4.69, 4.71a, Diagnostic Code 5003, 5010, 5214 (2011). 2. The criteria for a rating in excess of 10 percent for residuals of a fractured left wrist are not met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.321(b)(1), 4.2, 4.7, 4.10, 4.20, 4.21, 4.27, 4.40, 4.41, 4.45, 4.59, 4.68, 4.69, 4.71a, Diagnostic Code 5299 and 5215 (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA describes VA's duties to notify and to assist claimants in substantiating VA claims. See 38 U.S.C.A. §§ 5103, 5103A and 38 C.F.R § 3.159. Duty to Notify VA will notify the claimant of: (1) any information and medical or lay evidence needed for claim substantiation, and (2) what portion thereof VA will obtain, and (3) what portion the claimant is to provide. 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b); see Shinseki v. Sanders, 129 S. Ct. 1696 (2009). The VCAA notice was intended to be provided before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The RO provided the Veteran with pre-adjudication VCAA notice by letter, dated in December 2007, prior to the initial adjudication of the claims in June 2008. The notice included the type of evidence needed to substantiate the claims for increase, namely, evidence of an increase in severity and notice that VA would obtain VA and other Federal agency records and that private medical records could be submitted or VA could be authorized to obtain them. The notice included information as to determinations of effective dates and determinations of disability ratings, e.g., the nature, severity, and duration of symptoms in relation to a rating schedule as well as possible extraschedular evaluation. That letter also included notification that to substantiate an increased rating claim the claimant should provide or ask VA to obtain medical or lay evidence demonstrating a worsening or increase in a disability's severity and the effect thereof on the claimant's employment. Vazquez-Flores v. Shinseki, 24 Vet. App. 94 (2010). See also Vazquez-Flores v. Peake, 22 Vet. App. App. 37 (2008), affm'd in part by Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). Further, the Veteran's statements, and the testimony of he and his wife, as to the severity of each of his wrists indicates an awareness on the part of himself and his representative of the information of the effects of his disabilities which is necessary to substantiate the increased rating claims. See Dalton v. Nicholson, 21 Vet. App. 23, 30-31 (2007). Duty to Assist Under 38 U.S.C.A. § 5103A, VA must make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim. The Veteran service treatment records (STRs) are on file, as are the Veteran's VA records, and a report of an April 2007 private X-ray of his right wrist. The Veteran and his wife testified in support of the claims at a November 2010 travel Board hearing. Moreover, he has been afforded VA examinations for the increased rating claims in January 2008 and, after allegations of a worsening of his disabilities, again in March 2011. McLendon v. Nicholson, 20 Vet. App. 79 (2006); Wells v. Principi, 326 F.3d 1381 (Fed. Cir. 2003). 38 U.S.C.A. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4)(i). The adequacy of the VA rating examinations has not been challenged. The Board is entitled to assume the competence of a VA examiner and the adequacy of a VA medical examiner's findings or opinion unless either is challenged. See Sickels v. Shinseki, 643 F.3d 1362, 1366 (Fed. Cir. 2011); Bastien v. Shinseki, 599 F.3d 1301, 1307 (Fed.Cir. 2010); Rizzo v. Shinseki, 580 F.3d 1288, 1290-91 (Fed. Cir. 2009); and Cox v. Nicholson, 20 Vet. App. 563, 569 (2007); and Hilkert v. West, 12 Vet. App. 145, 151 (1999). As there is no indication of the existence of additional evidence to substantiate the claims for increase, the Board concludes that there has been compliance with the VCAA duty-to-assist provisions. Background STRs show that in April 1974, due to injuries in a motorcycle accident, the Veteran underwent open reduction of a peri-lunar dislocation of the left wrist and open reduction of the scaphoid with screw fixation, and a styloidecomy of the distal radius. The final diagnosis was a transcaphoid peri-lunar dislocation. X-rays on VA examination in 1975 revealed no demonstrable residuals of a right wrist fracture. There was a fracture of the navicular bone of the left wrist and the fragments were united by means of a screw, and the union was solid. There was no evidence of arthritis of either wrist. On VA examination in 1977 it was noted that the Veteran was right handed. An X-ray revealed what appeared to be a metallic small screw in the carpal-navicular which might have been used to hold a fracture fragment. There was about 1.8 centimeters (cms.) in length. It appeared to have been inserted through the infero-lateral aspect of the navicular bone and the tip of the screw appeared to have extended upward medially. The tip of the screw appeared to be confined to the bony structure. On a lateral view, there was an oblique, little, transcluent shadow which was about 0.7 cms. in the medial surface of the middle pole of the navicular bone which could represent a prior fracture line. There was no definite evidence of non-union or avascular necrosis of the bone. X-rays of the right wrist revealed no abnormality. On VA orthopedic examination in February 2003 the Veteran complained of pain in both wrists which limited his ability to do some work when using a ratchet or a screw driver but he had accommodated himself to this. He was right handed. He occasionally got swelling in the right wrist and had problems extending and flexing that wrist, as well as in ulnar and radial deviation. Because of pain he applied dry heat and took Tylenol to help relieve discomfort. Work involving twisting or "torquing" the wrist aggravated his discomfort, as did cold weather. He occasionally had to use an elastic support for his right wrist to stabilize the wrist and help control discomfort. Occasionally, the more he used the wrist the more discomfort he had in the wrist in the evening. It was reported that X-rays revealed a healed navicular fracture of the left wrist with a Herbert screw in place. There were arthritic changes of the articulating surface of the carpals on the radius. There was also evidence of a loose body at the tip of the navicular. X-rays of the right wrist revealed an un-united fracture of the navicular. On examination, in gross comparison of the wrists, there was slight radial deviation of the right wrist compared to the left. There was slight swelling of the dorsum of the right wrist over the radial aspect, compared to the left. There was a well healed 7 cms. transverse scar on the dorsum of the left wrist, to the metacarpophalangeal joint. Motion of the right wrist in extension was from 0 degrees to 25 degrees with pain and from 0 degrees to 45 degrees in the left. Flexion of the right wrist was from 0 degrees to 40 degrees with pain to the dorsum of the wrist and from 0 degrees to 50 degrees in the left wrist with pain to the dorsum of the left wrist. Radial deviation of the right wrist was to 15 degrees with pain and that motion was to 20 degrees in the left wrist without pain. Ulnar deviation was to 35 degrees in the right wrist with pain and to 35 degrees in the left wrist. The diagnosis was status post bilateral fracture of the navicular, postoperative open reduction and internal fixation of the left wrist; and painful traumatic arthritis of the right wrist; and nonunion of the right navicular. The report of the February 2003 VA X-rays of both wrists revealed, as to the right wrist, an old comminuted fracture of the right navicular, and an old detached unhealed fracture of the ulnar styloid. As to the left wrist, there was a metallic fixation of a prior fracture of the left navicular with alignment good and with bony healing appearing to be fairly firm. The radiological impressions were a prior fracture of the navicular of the right wrist, not healed; an old fracture of the right ulnar styloid, not healed; and a prior fracture of the left carpal navicular, metallically fixed and healed. Following the February 2003 VA examination, a rating decision later in February 2003 granted service connection for traumatic arthritis of the right wrist with nonunion of the navicular (previously denied as residuals of a right wrist injury) and assigned an initial 10 percent rating, under 38 C.F.R. § 4.71a, DC 5215, both effective April 5, 2002 (date of receipt of claim). The Veteran's claim for increased ratings for his service-connected disabilities of the wrists was received on November 27, 2007. Received thereafter was a report of private X-rays of the Veteran's right wrist in April 2007 which revealed an un-united fracture of the proximal aspect of the scaphoid. There were cystic irregularities of the scaphoid, distal radius, capitates and surfaces of several of the carpal bones which were degenerative in appearance and were not evidence of aseptic necrosis. These were most likely due to post-traumatic arthritis. On VA examination in January 2008 the Veteran's medical records were reviewed. The Veteran related having increased pain in both wrists, especially the right wrist. He reported dropping things, especially due to the right wrist. He was an underground coal miner, which often required that he be on "all fours." This had become increasingly difficult for him because of his bilateral wrist pain. He used braces on both wrists and took Tylenol as well as Darvon for pain. He did not have any constitutional symptoms of arthritis. He had no incapacitating episodes due to his disabilities of the wrists. On physical examination the Veteran had some deformity of the right wrist. He had no instability of the right wrist but reported having giving way of the right wrist, as well as pain, stiffness, and weakness in both wrists. He had not had episodes of dislocation, subluxation, locking or effusion of either wrist. He complained of limitation of motion of each wrist. As to his right wrist, during flare-ups he was very limited in use of the wrist, having trouble opening jars, driving, and working. The flare-ups lasted 3 to 7 days and he would have warmth and redness of the right wrist. There was no joint ankylosis. As to motion of the right wrist, the Veteran had 20 degrees of active motion in ulnar deviation against gravity with pain beginning at 15 degrees and ending at 0 degrees. Passively in that plane of motion he had motion to 20 degrees with pain beginning at 15 degrees and ending at 0 degrees. There was no additional limitation of motion of repetitive use. As to right wrist radial deviation the Veteran had 10 degrees of active motion against gravity with pain beginning at 10 degrees and ending at 0 degrees. Passively in that plane of motion he had motion to 10 degrees with pain beginning at 10 degrees and ending at 0 degrees. There was no additional limitation of motion of repetitive use. As to right wrist extension the Veteran had 40 degrees of active motion against gravity with pain beginning at 30 degrees and ending at 0 degrees. Passively in that plane of motion he had motion to 40 degrees with pain beginning at 30 degrees and ending at 0 degrees. There was no additional limitation of motion of repetitive use. As to right wrist flexion the Veteran had 40 degrees of active motion against gravity with pain beginning at 40 degrees and ending at 0 degrees. Passively in that plane of motion he had motion to 40 degrees with pain beginning at 40 degrees and ending at 0 degrees. There was no additional limitation of motion of repetitive use. As to left wrist ulnar deviation the Veteran had 30 degrees of active as well as passive motion in ulnar deviation against gravity without pain. He had 15 degrees of radial deviation of that wrist against gravity and passively without pain. He had 55 degrees of extension of that wrist against gravity and passively without pain. He had 60 degrees of flexion of that wrist against gravity and passively without pain. There was no additional limitation of motion of repetitive use in any of these planes of motion. The examiner reported that as to the Veteran's right wrist he had crepitus, edema, tenderness, painful motion, abnormality of motion, and guarding of motion. As to the Veteran's left wrist he had crepitus, edema, and painful motion but the examiner indicated (contrary to the other findings in the examination report) that left wrist flexion was to 40 degrees of active motion against gravity with pain beginning at 40 degrees and ending at 0 degrees and that passively in that plane of motion the Veteran had motion to 40 degrees with pain beginning at 40 degrees and ending at 0 degrees. There was no additional limitation of motion of repetitive use. X-rays in January 2008 were compared to X-rays of February 2003. The January 2008 X-rays revealed, as to the left wrist, an old scaphoid fracture which was transfixed with a small carpal screw, and mild surrounding degenerative changes but no definite additional fracture seen. There was a mild nonspecific stable irregularity about the ulnar styloid. As to the right wrist, there was a small dense ossicle incidentally noted adjacent to the ulnar styloid. There was an apparent old, non-healed scaphoid fracture with abnormal sclerosis of the scaphoid and apparent cyst formation. Degenerative changes of at least moderate extent were seen about the articulations of the scaphoid with the lunate and radius, with somewhat milder degenerative changes at the scaphotrapezial articulation. There was a probable small capitate cyst. Avascular necrosis was suspected. The January 2008 VA examiner commented that the Veteran had been seen by an orthopedist in Princeton who had recommended possible surgery on the Veteran's right wrist. It was reported that if the Veteran decided to have this procedure he would be applying for temporary unemployability since he would not be able to work during that time. The diagnoses were an unhealed fracture of the right wrist; degenerative joint disease (DJD) of the right wrist; and DJD of the left wrist. The examiner reported that these disabilities caused significant effects on the Veteran's general occupational activities due to decreased manual dexterity, problems lifting and carrying, weakness or fatigue, and pain. Resulting work problems were his having been assigned different duties and increased absenteeism. Also, it was reported that the Veteran had missed 3 months of work in the last year due to his right wrist. At work, he had been placed on restricted duty to accommodate his problems with his wrists. As to activities of daily living, there was a mild effect as to the Veteran's bathing, dressing, toileting, and grooming. There was a moderate effect as to his doing chores, exercising, recreation, traveling, and feeding. At travel Board hearing in November 2010 the Veteran's wife testified that his disabilities of the wrist had progressively worsened. He dropped things, particularly small objects. He had difficulty working when holding screws and had numbness. He had a lot of pain, for which he applied heat. He tried not to take medication to control his pain. Page 3 of that transcript. He was able to help somewhat around the house but had pain and discomfort. Page 4. The Veteran testified that cold weather affected his wrists a lot and caused his most severe attacks of pain, more so than during the summer. He sometimes had pain down the middle of his hands, especially his right hand. He had numbness every night when he slept. He would awaken at night, at which times his hands would be numb. Page 5. But after a little movement, the numbness went away. He had driven to the travel Board hearing but his disabilities affected his driving. He had to swap hands a lot when driving. His wife did most of the driving. He had problems holding screws when at work, and when handling smaller tools. After 10 to 15 minutes of such work he developed cramps. Page 6. He had limited mobility of his wrists, with more limited motion in the right wrist than the left. He had difficulty holding on to, and often dropped, things. To compensate at work he just had to concentrate more on whatever he was doing. Page 7. He was a mechanic at a coal mine and did electrical work and some maintenance work, and had to use many hand tools. Sometimes he had to crawl, using either his knuckles or fists when doing so. He had worked at this job for about 30 years. Page 8. He had not sought treatment. A few years ago he had hurt his hand just putting an air hose together, straining his right wrist. That was the only time he had sought treatment other than going to VA, which was just for an examination in 2003. He wore wrist braces. Page 9. The Veteran testified that his disabilities of the wrist caused him to take longer to do a job in his employment. Page 10. On VA examination in March 11, 2011 the Veteran's medical records and claims folder were reviewed. He reported having had decreased grip strength in both hands, worse in the right hand, for the last 8 years. He reported having daily episodes of sharp pain in both wrists with movement, which he rated as a 6 on a scale of 10, which lasted a few seconds. For the last 5 years he had had episodes of dull achy pain in both wrists, that he rated as a 5, which occurred 3 to 4 times weekly with the episodes lasting about 3 hours and which were worse in cold weather. He took non-steroidal anti-inflammatory medications and Motrin. He had also used braces and had applied hot pads and hot water, with a good response. He was right handed. A summary of the Veteran's joint symptoms were a deformity of the "left" wrist but not the "right" wrist. He had no giving way, instability, incoordination, dislocation, subluxation, locking or effusion of either wrist. He had pain, stiffness, weakness, and decreased speed of joint motion of each wrist. On physical examination the Veteran had crepitus of each wrist. There was objective evidence of painful motion of each wrist. Flexion of both wrists was from 0 to 60 degrees, extension was from 0 to 70 degrees, radial deviation was from 0 to 15 degrees, and ulnar deviation was from 0 to 30 degrees. There was no objective evidence of pain following repetitive motion of either wrist and no additional limitation of motion after three repetitions of motion. There was no joint ankylosis. An X-ray of the Veteran's left wrist, compared to X-rays of January 2008, revealed the open reduction and internal fixation of the left scaphoid. Limited surrounding degenerative changes appeared grossly stable. No acute fracture or dislocation was detected. As to the right wrist, there was a small ossicle adjacent to the ulnar styloid and severe abnormalities persisted around the scaphoid, to include apparent nonunion of a proximal pole fracture, with mixed cystic/sclerotic changes about the scaphoid, and with substantial associated regional degenerative disease. The radiological impression was severe abnormalities associated with the right scaphoid, presumably related to prior trauma, stable to minimally worsened in the interval. The examiner reported that the Veteran was an electrician and mechanic in an underground coal mine, where he had been employed for more than 20 years. He had loss less than 1 week of work in the last 12 months, having been off from work from January 2010 to January 2011 due to knee surgery. He had not missed work due to his service-connected disabilities of the wrists. The diagnoses were nonunion of a proximal pole fracture of the right wrist; and DJD of the right wrist and the left wrist. The associated problem was bilateral wrist pain. The effect on his usual occupation was significant. The Veteran had reported that he used hand tools in his work and had to vary his use due to wrist pain, and take breaks. He avoided air compression tools because of the vibration they produced. He had decreased manual dexterity, problems lifting and carrying, weakness or fatigue, decreased strength, and upper extremity pain. The effects on his activities of daily living were none with respect to dressing, feeding, bathing, and grooming; mild as to performing chores, shopping, and toileting; and moderate as to recreation, traveling, and driving; and he was unable to participate in sports. General Rating Principles Ratings for a service-connected disability are determined by comparing current symptoms with criteria set forth in VA's Schedule for Rating Disabilities, which is based as far as practical on average impairment in earning capacity. Separate diagnostic codes (DCs) identify the various disabilities. 38 U.S.C.A. § 1155. Disabilities are viewed, and examinations are interpreted, historically, in order to accurately reflect the elements of disability present. 38 C.F.R. § 4.1, 4.2. A higher rating is assigned if it more nearly approximates such rating. See 38 C.F.R. §§ 4.7, 4.21. Separate ratings may be assigned either initially or during any appeal for an increased rating for separate periods of time based on facts found, a practice known as "staged ratings." Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007) (staged ratings during the appeal of any increased rating claim). When evaluating musculoskeletal disabilities, VA may, in addition to applying the schedular criteria, consider granting a higher rating in cases in which a claimant experiences additional functional loss due to pain, weakness, excess fatigability, or incoordination, to include with repeated use during flare-ups, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). The provisions of 38 C.F.R. §§ 4.40 and 4.45 are to be considered in conjunction with the diagnostic codes predicated on limitation of motion (see Johnson v. Brown, 9 Vet. App. 7 (1996)). Traumatic arthritis is rated under DC 5010, which provides that it shall be rated based on limitation of motion of the affected part, as degenerative arthritis under 38 C.F.R. § 4.71a, DC 5003. 38 C.F.R. § 4.71a, DC 5010. Under DC 5003, degenerative arthritis, 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. However, when 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 major joint or groups of minor joints affected by limitation of motion, to be combined, not added under DC 5003. 38 C.F.R. § 4.71a; see also Degmetich v. Brown, 104 F.3d 1328, 1331 (Fed. Cir. 1997). Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. 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. A 20 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 and there are occasional incapacitating exacerbations. NOTE (2): The 20 percent and 10 percent ratings based on x-ray findings will not be utilized in rating conditions listed under DC 5013 to 5024, inclusive. 38 C.F.R. § 4.71a. The wrist is considered a major joint. 38 C.F.R. § 4.45(f). However, under DC 5214 and 5215, major refers to the dominant extremity and minor refers to the non-dominant. Here, the Veteran is right handed; therefore, his left wrist is the non-dominant or minor wrist for rating purposes and his right wrist is his dominant or major wrist for rating purposes. 38 C.F.R. § 4.69. Under 38 C.F.R. § 4.71, DC 5003, degenerative arthritis requires consideration of 38 C.F.R. §§ 4.40, 4.45, and 4.59. Also, functional loss and the impact of pain must be considered. VAOGCPREC 9-98. Normal range of motion of the wrist is: radial deviation from 0 to 20 degrees; ulnar deviation from 0 to 45 degrees; dorsiflexion from 0 to 70 degrees; and plantar flexion from 0 to 80 degrees. 38 C.F.R. § 4.71a, Plate I. The left wrist fracture residuals are rated analogously as limitation of motion. Under 38 C.F.R. § 4.20 it is permissible to rate an unlisted disorder as if it were a closely related disease or injury, when the functions affected, the anatomical localization, and symptomatology are closely analogous. See Lendenmann v. Principi, 3 Vet. App. 345, 351 (1992) (permitting analogous ratings on the basis of etiology rather than symptoms). Analogous ratings are accomplished under 38 C.F.R. § 4.27 by a 'built-up' DC with the first 2 digits being from the part of the schedule most closely identifying the bodily part or system and, followed by a hyphen, the last 2 digits being '99' to signify rating as an unlisted condition. Generally see Archer v. Principi, 3 Vet. App. 433 (1992). Under DC 5215 limitation of motion of the wrist of either the major extremity or the minor extremity with dorsiflexion of less than 15 degrees, or plamar flexion limited in line with the forearm, warrants a maximum 10 percent rating. Under DC 5214, pertaining to ankylosis of the minor wrist, a rating of 20 percent is warranted for favorable ankylosis of the minor wrist in 20 degrees to 30 degrees of dorsiflexion; 30 percent is warranted for ankylosis of the minor wrist in any other position, except favorable; and a maximum 40 percent rating is warranted for unfavorable ankylosis of the minor wrist in any degree of palmar flexion, or with ulnar or radial deviation. 38 C.F.R. § 4.71a, DC 5214. Under DC 5214, pertaining to ankylosis of the major wrist, a rating of 30 percent is warranted for favorable ankylosis of the major wrist in 20 degrees to 30 degrees of dorsiflexion; 40 percent is warranted for ankylosis of the major wrist in any other position, except favorable; and a maximum 50 percent rating is warranted for unfavorable ankylosis of the major wrist in any degree of palmar flexion, or with ulnar or radial deviation. 38 C.F.R. § 4.71a, DC 5214. Extremely unfavorable ankylosis will be rated as loss of use of hands under DC 5125. Loss of use of the hand of the minor extremity warrants a 60 percent rating and loss of use of the hand of the major extremity warrants a 70 percent rating. DC 5125 (and these rating establish entitlement to special monthly compensation). Under DC 5210 nonunion of the radius and ulna with flail false joint warrants a 40 percent rating when affecting the minor extremity and 50 percent when affecting the major extremity. Under DC 5211 malunion of an ulna with bad alignment warrants 10 percent when affecting the major or minor extremity. Twenty (20) percent is warranted when there is nonunion in the lower half of the ulna of the major or minor extremity. With nonunion in the upper half but without loss of bone substance or deformity 20 percent is warranted for the minor extremity and 30 percent for the major extremity. Nonunion in the upper half with loss of bone substance (1 inch (2.5 cms.) of more) and marked deformity 30 percent is warranted for the minor extremity and 40 percent for the major extremity. Under DC 5212 malunion of a radius with bad alignment warrants 10 percent when affecting the major or minor extremity. Twenty (20) percent is warranted when there is nonunion in the upper half of a radius of the major or minor extremity. With nonunion in the lower half of a radius but without loss of bone substance or deformity 20 percent is warranted for the minor extremity and 30 percent for the major extremity. Nonunion in the lower half of a radius with loss of bone substance (1 inch (2.5 cms.) of more) and marked deformity 30 percent is warranted for the minor extremity and 40 percent for the major extremity. DC 5213 provides that limitation of supination of a forearm to 30 degrees or less warrants a 10 percent rating for either the major or minor upper extremity. Limitation of pronation with motion lost beyond the last quarter of arc, and the hand does not approach full pronation, a 20 percent rating is warranted for the major or the minor extremity. With pronation lost beyond the middle of arc, a 20 percent rating is warranted for the minor extremity and 30 percent for the major extremity. A Note to DC 5213 provides that in all forearm and wrist injuries, DCs 5205 through 5213, multiple impaired finger movements due to tendon tie-up, muscle or nerve injury, are to be separately rated and combined not to exceed rating for loss of use of hand. Ankylosis is immobility and consolidation of a joint due to disease, injury or surgical procedure. Lewis v. Derwinski, 3 Vet. App. 259 (1992) (memorandum decision); Nix v. Brown, 4 Vet. App. 462, 465 (1993); and Shipwash v. Brown, 8 Vet. App. 218, 221 (1995). The "amputation rule" provides that the combined rating for disabilities of an extremity shall not exceed the rating for the amputation at that elective level, were amputation to be performed. 38 C.F.R. § 4.68. Amputation at the first elective site above the wrist (insertion of the pronator teres) for the minor wrist would warrant a 60 percent disability rating. See 38 C.F.R. § 4.71a, DC 5124. Moreover, loss of use of the hand for the minor wrist would also warrant a 60 percent disability rating. See 38 C.F.R. § 4.71a, DC 5125. Analysis Initially, the Board notes the contention that the Note to DC 5213, providing for wrist injuries separate ratings are warranted for impaired finger movement due to tendon tie-up, muscle or nerve injury. However, in this case, the evidence does not demonstrate that the initial injury caused any injury of the muscles of the wrists or nerves passing through either wrist. Likewise, there is no clinical evidence of tendon injury or any current tendon tie-up at the wrists, or forearms. While the Veteran has complained of some numbness or pain at times in his hands, his testimony makes it clear that this occurs only at night when sleeping and upon awakening and simply moving his wrists such symptoms immediately resolve. In other words, the symptoms of pain or numbness of his hands are no more, than at worse, fleeting and transitory in nature. Moreover, he has not testified that any particular finger, or groups of fingers, of either hand are specifically affected in any manner. Accordingly, separate additional disability ratings for impaired finger movements, pursuant to the Note to DC 5213 is not in order. The Board further notes that other than a maximum rating of 10 percent for limited motion of the wrist, of either the major or the minor extremity, the rating schedule does not set forth any other Diagnostic Code for the evaluation of a disability of the wrist except for ankylosis of the wrist. Traumatic Arthritis of the Right Wrist with navicular Nonunion - Rated 10 percent It is undisputed that the Veteran is right handed and, thus, the service-connected right wrist injury affects the dominant, or major, extremity. The X-ray evidence on file confirms the Veteran's testimony that he sustained a postservice injury of the right wrist, at some unspecified time. VA X-rays in 1975 found not demonstrable residuals of a right wrist fracture, and no arthritis. VA X-rays in 1977 found no right wrist abnormality. Whereas, all X-rays, both VA and private, beginning with VA X-rays in 2003 found significant bony abnormalities in the right wrist. X-rays at that time found an un-united fracture of the navicular (also called the scaphoid) and the diagnoses included an old, non-healed, fracture of the right ulnar styloid. However, neither X-rays nor VA examiners have been able to distinguish the residual functional impairment of the right wrist prior to and since the postservice injury, which the Veteran intimated at his hearing had occurred while on-the-job. Accordingly, the Board will not attempt to separate any prior or post injury impairment but, rather, will consider all impairment of the right wrist as being service-connected. The evidence shows that at least since this postservice injury the Veteran had had a deformity of the right wrist. Specifically, the 2003 VA examination found slight radial deviation of the wrist, when compared to the structural alignment of the left wrist. That deformity was noted, although not described, on the 2008 VA examination. It was again noted on the VA examination in 2011, although at that time it was described as affecting the "left" wrist. In view of all the evidence on file showing that the deformity is one that affects the right wrist and the absence of evidence of a similar, or any, deformity, of the left wrist, the Board concludes that the notation on the report of the 2011 VA examination that the deformity was of the left wrist is no more than a typographical error inasmuch as the evidence is otherwise overwhelming that there is residual structural deformity of the right but not the left wrist. The Veteran's statements and testimony, and the testimony of his wife, are convincing and credible as to the residual functional impairment of his right wrist. The testimony that he had flare-ups and keeps dropping things is consistent with the evidence of limited motion and weakness of the right wrist which would be expected from an unhealed bony injury of the right navicular (scaphoid) bone and the ulnar styloid. The VA examiners in both 2008 and 20101 found that the disabilities of both wrist, together, caused significant occupational impairment, particularly as to manual dexterity, lifting, carrying, weakness, and pain. However, it is clear that it is impairment due to the Veteran's right wrist that causes the majority of this overall functional impairment, as indicated by the 2008 VA examiner's report that the Veteran had missed three months of work due to his right wrist. Likewise, at the 2011 examination the Veteran reported that the decreased grip strength in his wrists was greater in the right wrist. VA X-rays in 2008 and 2011 are also in keeping with impairment which is significantly beyond that contemplated by only some, although compensable, degree of limited motion due to arthritis or other bony pathology. Overall, the Board is left with the clear impression that the 10 percent rating assigned is inadequate to compensate the Veteran for the degree of impairment shown by the evidence of record. In the judgment of the Board, his degree of impairment more closely approximates and equates to ankylosis of the wrist in a favorable position, i.e., between 20 degrees and 30 degrees of dorsiflexion, and, thus, warrants a 30 percent disability rating under 38 C.F.R. § 4.71a, Diagnostic Code 5214. However, a rating in excess of 30 percent is not warranted because the degree of remaining functional impairment does not equate with ankylosis of the right wrist in any position other than favorable. While the 2008 VA examiner noted that the Veteran had been re-assigned to more limited occupational duties and had had increased absenteeism, as to his activities of daily living there was only a mild adverse impact in bathing, dressing, toileting, and grooming; and only a moderate adverse effect in doing chores, exercising, recreation, traveling, and feeding. The 2011 VA examiner found that the Veteran was unable to participate in sports. On the other hand, there was no adverse impact as to dressing, feeding, bathing, and grooming; only mild impairment as to performing chores, shopping, and toileting; and moderate as to recreation, traveling, and driving. The 2011 VA examination found no giving way, instability, incoordination, dislocation, subluxation, locking or effusion of the right wrist. In fact, despite the residual deformity and significant impairment of the right wrist, he has remained employed at the same job for many years and that employment requires his continued use of tools. Moreover, he is still able to drive, having driven himself and his wife to the travel Board hearing. This does not, in the judgment of the Board, more closely approximate impairment equal to that stemming from ankylosis which is other than favorable, or unfavorable, ankylosis particularly in light of the absence of actual ankylosis in any degree of dorsiflexion, palmar flexion, ulnar deviation or radial deviation. Accordingly, and with the favorable resolution of all doubt in favor of the Veteran, a schedular rating of no more than 30 percent is warranted since the date of receipt of the claim for an increased rating on November 27, 2007. Residuals of a Fractured Left Wrist - Rated 10 percent Unlike the right wrist, the initial injury of the left wrist, following surgery, is now well healed. While radiological studies have confirmed the presence of arthritis, described as DJD, of the left wrist, and he has limited left wrist motion with pain and complaints of weakness and stiffness, all this is encompassed in the current 10 percent rating assigned. The 2011 VA examination found no giving way, instability, incoordination, dislocation, subluxation, locking or effusion of the left wrist. Overall, the evidence simply does not show that the Veteran now has the same level of impairment of the left wrist that he now has in his right wrist. That is, he is not shown to have such impairment in his left wrist, i.e., the wrist of his non-dominant extremity, as to warrant a rating in excess of the maximum rating now assigned on the basis of limited motion. His overall impairment of the left wrist is not shown to approximate or equate with impairment which would be expected from ankylosis, even in a favorable position. Accordingly, the preponderance of the evidence is against the claim for a rating in excess of 10 percent for the service-connected left wrist disability. Extraschedular Consideration The Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance but not from considering whether the case should be referred to the Director of VA's Compensation and Pension Service for an extraschedular rating. The threshold factor in this determination is whether there is such an exceptional disability picture that the available schedular ratings criteria are inadequate. This is done by comparing the level of severity and symptomatology of the service-connected disability with the established criteria. If the criteria reasonably encompass the assigned disability level and the symptomatology, then the disability picture is contemplated by the Rating Schedule, and the assigned schedular evaluation is, therefore, adequate and referral for an extraschedular rating is not required. Thun v. Peake, 22 Vet. App. 111, 115 (2008); aff'd Thun v. Peake, 572 F.3d 1366 (Fed.Cir. 2009). Significantly, since under 38 U.S.C.A. § 1155 provides that the basis of a disability rating is the "reduction in earning capacity," any compensable rating encompasses employment interference. Comparing the Veteran's current disability levels and symptomatologies to the Rating Schedule, the degree of disability for each disorder is contemplated by the Rating Schedule and the assigned schedule ratings are adequate. The symptoms shown are not exceptional or unusual for a musculoskeletal disability. Specifically, a wide range of signs and symptoms are contemplated in the applicable rating criteria, including pain, loss of motion, painful motion, muscle spasm, and other neurological findings as to strength and sensory function. In fact, 38 C.F.R. § 4.40 requires consideration of functional loss, including the ability to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance, pain, weakness, and atrophy. Likewise, 38 C.F.R. § 4.45 requires consideration of, in part, incoordination, impaired ability to execute skilled movements, painful motion, swelling, deformity, disuse atrophy, instability of station, disturbance of locomotion, interference with sitting, standing and weight-bearing. Also, 38 C.F.R. § 4.59 requires consideration of such matters as unstable or mal-aligned joints, and crepitation. The Veteran has significant limitation of motion as well as decreased strength but this functional impairment, including difficulty grasping, are expected and normally associated with a significant wrist condition. It was further noted that symptoms such as pain, stiffness, limited motion, and flare-ups are appropriately rated under the applicable DC and that some interference with employment is normally to be expected. Indeed, as noted, that is the purpose of VA disability compensation. Here, the recent examination particularly shows an absence of evidence of marked interference with documented significant loss of time from work or loss of wages. Rather, the most recent and significant loss of time from work was due to nonservice-connected knee surgery. Further, higher ratings could be assigned under either 38 C.F.R. § 4.71a, DC 5214 for ankylosis from 20 percent to 40 percent for the minor (left) wrist and 40 and 50 degrees for the major (right) wrist; or under 38 C.F.R. § 4.71a, DC 5125 for loss of use of a hand, i.e., 60 percent for the left wrist and 70 percent for the right wrist. However, the evidence in this case does not show that either service-connected wrist disabilities equates to loss of use of a hand. The medical evidence fails to demonstrate symptomatology productive of such extent or severity that application of the ratings schedule would not be appropriate. In sum, the symptomatology associated with the service-connected disability of each wrist, principally pain, limitation of motion, and weakness, are specifically contemplated under the appropriate rating criteria. Accordingly, the Board finds that the Veteran's disability pictures are sufficiently contemplated by the ratings schedule. Since the available schedular evaluation adequately contemplates the level of disability and symptomatology, the second and third questions posed by Thun become moot and referral for extraschedular consideration is not warranted. ORDER A rating of 30 percent for traumatic arthritis of the right wrist with navicular nonunion is granted subject to applicable laws and regulations governing the award of monetary benefits. A rating in excess of 10 percent for residuals of a fractured left wrist is denied. ____________________________________________ CHERYL L. MASON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs