Citation Nr: 1418252 Decision Date: 04/23/14 Archive Date: 05/02/14 DOCKET NO. 09-21 048 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUE Entitlement to a disability rating in excess of 10 percent for residuals of a fracture of the right thumb with traumatic arthritis. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD VanValkenburg, A., Associate Counsel INTRODUCTION The Veteran served on active duty from July 1982 to December 1982 and subsequently served in the National Guard. This matter comes before the Board of Veterans'Appeals (Board) on appeal from a July 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in North Little Rock, Arkansas. In January 2010, the Veteran provided testimony at a videoconference hearing before the undersigned Veterans Law Judge. A transcript of the hearing is in the claims folder. The Board has not only reviewed the Veteran's physical claims file but also the electronic records maintained in the Virtual VA and VBMS systems to ensure complete review of the evidence of record. FINDING OF FACT The Veteran's residuals of a fracture of the right thumb with traumatic arthritis most closely equates to right thumb amputation at the metacarpophalangeal joint or through the proximal phalanx. CONCLUSION OF LAW Resolving reasonable doubt in the Veteran's favor, for the entire rating period, the criteria for a rating of 30 percent, and no higher, for residuals of a fracture of the right thumb with traumatic arthritis, have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. § 4.71a, Diagnostic Codes 5152, 5224 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION Duties to Notify and Assist VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326. A June 2008 satisfied the duty to notify provisions. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The letter also notified the Veteran of regulations pertinent to the establishment of an effective date and of the disability rating. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Finally, the Veteran was informed of the need to show the impact of disabilities on daily life and occupational functioning. Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), rev'd in part sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The claim was subsequently readjudicated, most recently in the October 2012 supplemental statement of the case (SSOC). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). As noted above, the Veteran also was afforded a hearing before the undersigned Veterans Law Judge (VLJ) during which he presented oral argument in support of his claims. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) requires that the VLJ/DRO who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, the VLJ fully explained the issues on appeal during the hearing and specifically discussed the basis of the prior determination, the element(s) of the claims that were lacking to substantiate the claims for benefits, and suggested the submission of evidence that would be beneficial to the Veteran's claims. Significantly, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has he identified any prejudice in the conduct of the Board hearing. By contrast, the hearing focused on the elements necessary to substantiate the claims, and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claims. As such, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). VA has met its duty to assist the Veteran in the development of the claim. The Veteran's service treatment records, VA treatment records and VA examinations are in the file. 38 U.S.C.A § 5103A, 38 C.F.R. § 3.159. The Veteran has not identified relevant private treatment records. The record does not indicate nor has the Veteran asserted he is in receipt of Social Security Administration (SSA) benefits. 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). The Veteran has been afforded a VA examination most recently in March 2012. A medical examination is adequate "where it is based upon consideration of the Veteran's prior medical history and examination and also describes the disability, if any, in sufficient detail so that the Board's evaluation of the claimed disability will be a fully informed one." Stefl v. Nicholson, 21 Vet App. 120, 123 (2007). The VA examiner considered the Veteran's description and history of his symptoms, reviewed the claim file, conducted a thorough examination and provided a detailed report of the Veteran's condition. There is no indication of any additional relevant evidence or information that has not already been obtained. The Board finds the examination report contains sufficient bases and findings for the Board to render a decision in this appeal. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman, 19 Vet. App. at 486; Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009). Legal Criteria Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule), found in 38 C.F.R. Part 4. The Board attempts to determine the extent to which the Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.10. Where 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. 38 C.F.R. §§ 4.1, 4.2; see also Francisco v. Brown, 7 Vet. App. 55 (1994). In Hart v. Mansfield, 21 Vet. App. 505 (2007), however, the Court held 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 this case the Board has concluded that the disability has not significantly changed and that a uniform evaluation is warranted for the period considered. 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). This includes the analysis of additional functional impairment above and beyond the limitation of motion objectively demonstrated involving such factors as painful motion, weakness, incoordination, and fatigability, etc., particularly during times when these symptoms "flare up," such as during prolonged use, and assuming these factors are not already contemplated in the governing rating criteria. Id. See also 38 C.F.R. §§ 4.40, 4.45 and 4.59. In this regard, manifestation of pain alone does not equate with functional loss under 38 C.F.R. §§ 4.40 and 4.45 but may cause functional loss if affecting some aspect of the normal working movements of the body such as excursion, strength, speed, coordination, and endurance. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). The evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14. 38 C.F.R. § 4.14 does not preclude the assignment of separate evaluations for separate and distinct symptomatology where none of the symptomatology justifying an evaluation under one diagnostic code is duplicative of or overlapping with the symptomatology justifying an evaluation under another diagnostic code. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). Traumatic arthritis will be rated as degenerative arthritis. 38 C.F.R. § 4.71a, DC 5010. Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate Diagnostic Code (DC) for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate DC, a 10 percent evaluation is assignable each such major joint or group of minor joints affected by limitation of motion, to be combined, not added, under DC 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, DC 5003. The Veteran's service connected residuals of a right thumb fracture with traumatic arthritis (minor) is currently rated under DC 5010-5228 with a 10 percent rating. (A hyphenated DC is used when a rating under one DC requires use of an additional DC to identify the basis for the evaluation assigned.). For purposes for applying the criteria the Veteran's right hand has been evaluated as a minor digit. However, the March 2012 VA examiner found the Veteran was ambidextrous, so the Board will consider the Veteran's hand as a major digit for rating purposes. Disability of the thumb may be rated under DC 5152, 5224, or 5228 of 38 C.F.R. § 4.71a. Evaluations of 10, 20, 30, and 40 percent are authorized for disorders such as amputation, favorable ankylosis, unfavorable ankylosis, and limitation of motion. As the Veteran's disorder has been rated as 10 percent disabled during the length of the appeal period, the Board will limit its analysis of the rating criteria to whether a 20, 30, or 40 percent rating would be authorized under these DCs. DC 5228 provides for limitation of motion of the thumb. Under these criteria, the dominant thumb with a gap less than one inch (2.5 cm) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers is noncompensable. If there is a gap between one to two inches (2.5 to 5.1 cm), then a 10 percent rating is warranted, and if there is a gap more than two inches (5.1 cm), a 20 percent rating is warranted. Ankylosis in the thumb is evaluated under DC 5224, which distinguishes between favorable and unfavorable ankylosis. Ankylosis is the "[s]tiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint." See Dinsay v. Brown, 9 Vet. App. 79, 81 (1996) (citing Stedman's Medical Dictionary). A 20 percent rating is warranted for findings of unfavorable ankylosis. Under DC 5224, it is provided that, in cases involving certain degrees of unfavorable ankylosis, rating a thumb disorder as amputated may be warranted. The code provides the following guidance when determining whether a thumb should be deemed unfavorably ankylosed, and/or should be rated as effectively amputated due to the severity of the ankylosis: (i) If both the carpometacarpal and interphalangeal joints are ankylosed, and either is in extension or full flexion, or there is rotation or angulation of a bone, evaluate as amputation at metatarsophalangeal joint or through proximal phalanx; (ii) If both the carpometacarpal and interphalangeal joints are ankylosed, evaluate as unfavorable ankylosis, even if each joint is individually fixed in a favorable position; (iii) If only the carpometacarpal or interphalangeal joint is ankylosed, and there is a gap of more than two inches (5.1 cm.) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers, evaluate as unfavorable ankylosis; (iv) If only the carpometacarpal or interphalangeal joint is ankylosed, and there is a gap of two inches (5.1 cm.) or less between the thumb pad and the fingers, with the thumb attempting to oppose the fingers, evaluate as favorable ankylosis. 38 C.F.R. § 4.71a, Evaluation of Ankylosis or Limitation of Motion of Single or Multiple Digits of the Hand. In the event a thumb is amputated, or is to be rated as amputated, DC 5152 provides (for the major hand) a 40 percent rating with a metacarpal resection, a 30 percent rating with a resection at metatarsophalangeal joint or through proximal phalanx, and a 20 percent rating with a resection at the distal joint or through the distal phalanx. 38 C.F.R. § 4.71a, DC 5152. The evidence detailed below will demonstrate that the Veteran's service-connected thumb disability is on his major hand, and will demonstrate that that thumb has not been amputated. The question before the Board is whether a 20 percent or 30 percent rating would be warranted at any time during the appeal period - i.e., a 20 percent rating for unfavorable ankylosis or for an inability to oppose the thumb to the fingers; or a 30 percent rating for ankylosed carpometacarpal and interphalangeal joints, in extension or full flexion, or where there is rotation or angulation of a bone. The Veteran contends he is entitled to a rating in excess of 10 percent for residuals of a fracture of the right thumb with traumatic arthritis. Nevertheless, for reasons explained below, the severity of the Veteran's right thumb disability is the functional equivalent of an amputation. The July 2008 VA examiner diagnosed the Veteran with a right thumb fracture, post operation with traumatic degenerative joint disease. The Veteran reported a fracture of his right thumb during service which required two surgeries to repair. He complained of chronic pain at the base of his right thumb with tenderness to palpation to the scar. The surgical scar measured 4 cm and was intact, slightly tender and nonadherent to underlying tissue. It occasionally broke down. The thumb did not lock or swell. The Veteran had trouble with gripping and lifting activities. There was weakness in the thumb during flare ups without additional loss of motion. On examination the right hand revealed moderate degenerative joint disease at the base of the right thumb. The thumb and remaining fingers had normal alignment. The Veteran could fully flex all the fingers across the palmar crease without difficulty. He could oppose the thumb to the second, third, and fourth fingers. He could not oppose the thumb to the short finger on the right hand. He had excellent grip strength in the second, third, fourth and fifth fingers of the right hand. He had some weakness noted with attempts at gripping with the thumb of the right hand. The lateral four fingers revealed full range of motion without restricted range of motion or pain on range of motion. The 2008 VA examiner specifically examined the right thumb and it was tender to palpation at the base. The metacarpophalangeal joint range of motion revealed extension to thirty degrees with pain at thirty degrees; flexion to sixty degrees with pain at sixty degrees. The interphalangeal joint extension was to thirty degrees without pain and flexion was to thirty degrees with pain at thirty degrees. Pain was noted at extreme range of motions in all directions described. There was no appreciable laxity on stressing the right thumb in all directions. There was no additional weakness, fatigability, discoordination, additional restricted range of motion or functional impairment following repetitive stress testing involving the right thumb and fingers of the right hand. The Veteran testified most recently during his January 2010 Board hearing regarding his right thumb. He reported because of his right thumb he had little to no grip strength, constant pain and twitching. Cold weather and hot water bothered his hand. His scar tore easily. He wrote with his left hand but did everything else with his right. He was unable to continue his job as a cook because he couldn't hold the pans but worked at a grocery store. On examination in March 2012 the Veteran had a diagnosis of a right fracture, degenerative joint disease and a crush injury. The Veteran reported his right hand was stiff, painful and weak with flare ups caused by active use. He was ambidextrous. Upon physical examination in March 2012, the Veteran had limitation of motion in all digits of his right hand. There was more than a two inch gap between the Veteran's thumb pad and the fingers on the right. Pain began at a gap of more than two inches on the right side. Finger flexion resulted in more than a one inch gap between the right fingertips and the proximal transverse crease of the palm or evidence of painful motion in attempting to touch the palm with fingertips. Painful motion began at the gap of one inch. Finger extension was limited by no more than 30 degrees (unable to extend finger fully, extension limited to between zero and 30 degrees of flexion) for the right index finger and long finger. There was no objective evidence of painful motion. There was no additional limitation of motion for any fingers upon repetitive use testing. All of the Veteran's right hand digits had functional loss as less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling and deformity without change upon repetitive use. The Veteran had tenderness or pain to palpation for joints or soft tissue on the right side, including the thumb and fingers. Hand grip was 0/5 in the right and 5/5 in the left. The Veteran had degenerative or traumatic arthritis confirmed by imaging studies in the right hand. The 2013 VA examiner noted the Veteran had ankylosis of the thumb and/or fingers. The right thumb had carpometacarpal joint ankylosis which was abducted and rotated so that the thumb pad faced the finger pads. There was a gap of two inches or less between the right thumb pad and the fingers, with the thumb attempting to oppose the fingers. The left thumb had carpometacarpal joint ankylosis and interphalangeal joint ankylosis in extension. There was a gap of more than two inches between the thumb pad and the fingers with the thumb attempting to oppose the fingers. The ankylosis condition resulted in interference with overall function of the hand by preventing the right hand from making a fist. The Veteran had a non-painful and stable scar less than 6 inches which was related to the Veteran's diagnosis. No other pertinent physical findings, complications, condition, signs and/or symptoms were noted. The Veteran regularly used a brace on his right hand. Significantly, the VA examiner noted that functioning was so diminished that amputation with prosthesis would equally serve the Veteran. That is, the examiner equated the level of severity of the right thumb to a level of disability that would be expected if there was amputation of the digit. Further, the examiner observed that the Veteran's thumb impacted the Veteran's ability to work because there was no real functional use of the right thumb. Analysis As noted above, residuals of a fracture of the right thumb with traumatic arthritis is rated 10 percent under DCs 5010-5228. The assigned 10 percent rating is the minimum compensable rating for a thumb disability. 38 C.F.R. § 4.59; see Burton v. Shinseki, 25 Vet. App. 1 (2011) (painful motion under 38 C.F.R. § 4.59 requires the minimum rating for the joint). After a review of the evidence, giving the Veteran the benefit of the doubt, the Board finds the Veteran is entitled to a rating of 30 percent for his service connected residuals of a fracture of the right thumb with traumatic arthritis under 5152. The maximum rating under DC 5228 and DC 5224 is 20 percent. DC 5224 explicitly states that other rating codes such as those for amputation of the thumb or overall use of the hand are to be considered. The Board acknowledges that, in order for the Veteran's disability to be evaluated as an amputation at the metacarpophalangeal joint or through the proximal phalanx, there must be ankylosis of both the carpometacarpal and interphalangeal joints, and either is in extension or full flexion, or with rotation or angulations of a bone. Note 4 of 38 C.F.R. § 4.71a, evaluation of ankylosis or limitation of motion of single or multiple digits of the hand. Clinical findings are consistent with the criteria, as discussed below. The evidence shows that the ankylosis findings regarding the Veteran's right thumb were erroneously reported as "left" thumb findings. The 2013 VA examiner indicated the left thumb had an anklyosed carpometacarpal joint and an interphalangeal joint in extension, as detailed above. However, the Board finds the report of an ankylosed "left" thumb is wholly inconsistent with all the other findings and measures by the same VA examiner and with the record as a whole, so this recording was in error. When asked to describe the effect of the ankylosis condition on the overall function of the hand, the VA examiner noted the ankylosis of the thumb kept the right hand from making a fist, which supports the ankylosis findings were related to his right thumb. Further, the VA examiner consistently referred to findings regarding the Veteran's right hand and thumb. In addition, the 2013 VA examination report revealed that the Veteran's functioning in his right thumb was so diminished that amputation with prosthesis would equally serve the Veteran. Traumatic degenerative arthritis of his right thumb has been documented as well. The Board observes that, during the entire increased rating period under appeal, the Veteran has asserted problems with his right hand, not his left. Functional limitations impacting gripping with the right hand have been documented. For these reasons, the Board finds the Veteran actually exhibited an ankylosed carpometacarpal joint and an interphalangeal joint on the right side, not left. The Board finds clinical evidence reflects that the carpometacarpal joint of the right thumb is ankylosed and the interphalangeal joint is ankylosed in extension. Given the evidence of ankylosis (immobility and/or consolidation of a joint) in both joints, the VA physicians indication that there is no real functional use of the right thumb and the Veteran's credible testimony (also supported by clinical findings) regarding limitations of function and motion of the right thumb due to pain, and resolving any reasonable doubt in the Veteran's favor, the Board finds that the symptomatology manifested by the Veteran's right thumb disability more closely equates to amputation of right thumb at the metatarsophalangeal joint or through the proximal phalanx, warranting a 30 percent evaluation for the entire appeal period. See 38 C.F.R. § 4.71a, DC 5152; DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995); Mitchell v. Shinseki, 25 Vet. App. 32 (2011). In order for the Veteran to receive an evaluation in excess of 30 percent for his right thumb disability at any point during the period under appeal, the evidence must show that a disability as the equivalent of an amputation with metacarpal resection; favorable or unfavorable ankylosis of thumb and any finger on the right hand; or a disability as the equivalent of loss of use of the hand. 38 C.F.R. § 4.71a, DCs 5125, 5152, 5216 to 5223. Here, the evidence of record does not show an equivalent of amputation of right thumb with metacarpal resection. See 38 C.F.R. § 4.71a, DC 5152. The objective medical evidence does not show that the Veteran's disability is so severe as to equate to thumb amputation with metacarpal resection, as the VA examiners have not indicated there have been symptoms or findings involving the metacarpal joint. Therefore, under the provisions of DC 5152, the Veteran's disability does not warrant a higher, 40 percent evaluation, as an amputation with metacarpal resection. See 38 C.F.R. § 4.71a. The Board has also considered whether the Veteran could be assigned a higher or separate evaluation under other DCs. As discussed above, during the 2013 VA examination, the examiner specifically determined there was no ankylosis in any other joint of the right hand other than thumb carpometacarpal and interphalangeal joints or any other fingers. Accordingly, there is no basis for assigning separate or increased ratings for any conditions affecting the right hand, wrist or fingers (aside from the right thumb), under code 5125 (loss of use of the hand); or codes 5216 to 5223 (ankylosis of multiple digits). Also for consideration is whether a higher rating is warranted for the Veteran's currently service connected right thumb scar evaluated at 10 percent under DC 7804. The next higher rating of 20 percent under DC 7804 requires three or four scars, which has not been shown. The Board has also considered whether an additional 10 percent is warranted pursuant to Note (2) of the rating criteria for a scar that is both unstable and painful. Although the Veteran' reported his scar was tender, painful and tore easily; it was not shown to be unstable during the 2013 VA examination. The Board has also considered whether the Veteran is entitled to a higher rating under other diagnostic codes used to evaluate scars under DCs 7800, 7801, 7802, 7803 and 7805. As DC 7800 evaluates scars and disfigurement of the head, face or neck, it is not applicable to evaluate the Veteran's right hand. A 20 percent rating under DC 7801 is warranted for scars not of the head, face or neck that are deep and nonlinear consisting of an area or areas of at least 12 square inches (77 sq. cm.) but less than 72 square inches (465 sq. cm.). In this case, the evidence does not show that the Veteran's scar covers an area of at least 12 square inches but less than 72 square inches. Only a 10 percent rating is available under DC 7802. DC 7805 provides for a rating for disabling effect(s) not considered in a rating provided under diagnostic codes 7800-04 under an appropriate diagnostic code. Here, no disabling effects have been shown on examination or in the Veteran's treatment records. The March 2013 examination report specifically reflects that the scar had no other pertinent physical findings or symptoms to be reported. Therefore, the Board concludes that a rating in excess of 10 percent under other diagnostic codes used to evaluate scars is not warranted under DCs 7800, 7801, 7802, 7805. Upon reviewing the record in this case, the Board finds that a 30 percent rating, but no higher, is warranted for residuals of a fracture of the right thumb with traumatic arthritis, for the portion of the entirety of appeal period extending from September 30, 2004 forward, and the claim is granted to that extent. See Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2008). In reaching this conclusion, the Board has considered the benefit-of-the-doubt doctrine as applicable. Gilbert, 1 Vet. App. 49, 53-56 (1990); See 38 U.S.C.A. § 5107(b). Extraschedular Consideration 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). 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 residuals of a fracture of the right thumb with traumatic arthritis are inadequate. A comparison between the level of severity and symptomatology of the Veteran's residuals of a fracture of the right thumb with traumatic arthritis with the established criteria shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. The schedular rating criteria, as demonstrated above, evaluate disabilities involving the thumb based on limitation of motion (DC 5228), ankylosis (DC 5224), and amputation (DC 5152), all of which were considered in this case as well as consideration of motion and function limited by factors such as pain and weakness, pursuant to 38 C.F.R. §§ 4.40, 4.45, and 4.59. 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. (CONTINUED ON NEXT PAGE) ORDER Entitlement to an evaluation of 30 percent and no higher, for residuals of a fracture of the right thumb with traumatic arthritis, is granted. ____________________________________________ DAVID L. WIGHT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs