Citation Nr: 1825014 Decision Date: 04/25/18 Archive Date: 05/03/18 DOCKET NO. 09-38 291 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUES 1. Entitlement to an initial disability rating in excess of 10 percent for residuals of a fracture of the metacarpal neck of the right index and long fingers. 2. Entitlement to an initial compensable rating for residuals of a fracture to include limitation of motion of the right ring and little fingers. 3. Entitlement to a total disability rating based upon individual unemployability (TDIU). REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD T. Minot, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Navy from June 1984 to June 1989. The Veteran also had a period of dishonorable service from February 1991 and July 1993 These matters come before the Board of Veterans' Appeals (Board) on appeal from a February 2008 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. In that decision, the RO granted service connection for residuals of a fracture of the metacarpal neck of the second to fifth metacarpals and assigned a 10-percent initial rating, effective April 21, 2006. New and material evidence was subsequently received within one year of that decision, and in accordance with 38 C.F.R. § 3.156(b), the RO issued rating decisions in January 2009 and February 2009 which reconsidered the initial rating assigned and determined that it should be continued. The Veteran filed a timely notice of disagreement in March 2009. Thus, the matter is appropriately considered an initial rating claim stemming from the Veteran's original claim for service connection. See Fenderson v. West, 12 Vet. App. 119 (1999). The Veteran requested a Board Central Office hearing in his September 2009 substantive appeal. Such a hearing was scheduled for May 2012; however, the Veteran failed to appear at the hearing, and has not provided good cause for his absence. The hearing request is considered withdrawn. See 38 C.F.R. § 20.704(d) (2017). In June 2012 and again in June 2017, the Board remanded the case to the RO for evidentiary development. During the pendency of the appeal, a May 2014 rating decision granted a separate, noncompensable rating for residuals of a fracture of the right ring and little fingers to include limitation of motion, pursuant to Diagnostic Code (DC) 5230, effective October 17, 2008. As this decision did not constitute a full grant of the benefits sought, the claim for a higher initial rating remains on appeal. See AB v. Brown, 6 Vet. App. 35, 39 (1993). The issue of entitlement to a TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran's residuals of a fracture of the metacarpal neck of the right index and long fingers have been manifested by pain, weakness, flare-ups, loss of grip, decreased dexterity, and limitation of motion; muscle impairment in the right hand has not been shown to be more than moderate in degree, and there is no evidence of ankylosis of any of the involved fingers. 2. The Veteran's residuals of a fracture of the right ring and little fingers have been manifested by pain, weakness, flare-ups, loss of grip, decreased dexterity, and limitation of motion; there is no evidence of ankylosis of any of the involved fingers. CONCLUSIONS OF LAW 1. The criteria for an initial disability rating in excess of 10 percent for residuals of a fracture of the metacarpal neck of the right index and long fingers have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.56, 4.59, 4.71(a), 4.73, DC 5299-5309 (2017). 2. The criteria for an initial compensable rating for residuals of a fracture of the right ring and little fingers have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.71(a), DC 5230 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran contends that the symptoms associated with the residuals of a fracture of the right index, long, ring, and little fingers warrant increased initial ratings. For the following reasons, the Board finds that the criteria for increased ratings have not been met. Applicable Laws and Regulations In general, disability ratings are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. The veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). "Staged" ratings are appropriate when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). When assessing the severity of a musculoskeletal disability that is rated on the basis of limitation of motion, VA must, in addition to applying schedular criteria, also consider evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss in light of 38 C.F.R. § 4.40, which requires VA to regard as "seriously disabled" any part of the musculoskeletal system that becomes painful on use. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 204-207 (1995). The provisions of 38 C.F.R. §§ 4.40 and 4.45 should only be considered in conjunction with the DCs predicated on limitation of motion. See Johnson v. Brown, 9 Vet. App. 7 (1996). Here, the Veteran's residuals of a fracture of the metacarpal neck of the right index, and long fingers are currently evaluated as 10-percent disabling under DC 5299-5309, which applies to muscle group injuries. See 38 C.F.R. § 4.73. He is also in receipt of a separate, noncompensable rating for residuals of a fracture of the metacarpal neck of the right ring and little fingers under DC 5230, which applies to limitation of motion of individual digits of the hand. See 38 C.F.R. § 4.71(a). An overview of the relevant legal principles applicable to disabilities of the fingers and hand is provided below. Rating Criteria for Muscle Group Injuries DC 5309 governs Group IX muscle injuries. Group IX governs function of the forearm muscles which act in strong grasping movements and are supplemented by the intrinsic muscles in delicate manipulative movements. Intrinsic muscles of hand include: thenar eminence; short flexor, opponens, abductor and adductor of thumb; hypothenar eminence; short flexor, opponens and abductor of little finger; 4 lumbricales; 4 dorsal and 3 palmar interossei. A note to DC 5309 states that the hand is so compact a structure that isolated muscle injuries are rare, being nearly always complicated with injuries of bones, joints, tendons, etc. DC 5309 provides that Group IX muscle injuries should be rated based on limitation of motion (the criteria for which is discussed below), with a minimum 10-percent rating. See 38 C.F.R. § 4.73. Alternatively, DCs 5307 and 5308 govern, respectively, Group VII and VIII muscle injuries, which also involve the muscles of the forearm and hand. Group VII involves the muscles of flexion of the wrist and fingers and muscles arising from the internal condyle of the humerus: flexors of the carpus and long flexors of fingers and thumb; pronator. For the dominant extremity, a noncompensable (0 percent) rating is assigned for slight impairment of muscle function; a 10-percent rating is assigned for moderate impairment; a 30-percent rating is assigned for moderately severe impairment; and a 40-percent rating is assigned for severe impairment. See id. at DC 5307. Group VIII involves the muscles of extension of the wrist, fingers, and thumb; abduction of the thumb; and muscles arising mainly from the external condyle of humerus: extensors of carpus, fingers, and thumb; supinator. For the dominant extremity, a noncompensable rating is assigned for slight impairment of muscle function; a 10-percent rating is assigned for moderate impairment; a 20-percent rating is assigned for moderately severe impairment; and a 30-percent rating is assigned for severe impairment. See id. at DC 5308. The classifications of slight, moderate, moderately severe, or severe under DCs 5307-5308 are described in 38 C.F.R. § 4.56(d). Slight impairment of muscles stems from a simple wound of a muscle without debridement or infection. It heals with good functional results, is superficial, results in minimal scarring, and shows no impairment of function or retained metallic fragments in the muscle tissue. There are no cardinal signs of muscle disability. See also 38 C.F.R. § 4.56(c) (for VA rating purposes, the cardinal signs and symptoms of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination, and uncertainty of movement). For moderate impairment, the type of injury is "through and through" or a deep penetrating wound of short track from a single bullet, small shell or shrapnel fragment, without explosive effect of high velocity missile, residual debridement or prolonged infection. The record of moderate muscle impairment would show consistent complaint of one or more of the cardinal signs and symptoms of muscle disability; particularly lowered threshold of fatigue after average use, affecting the particular functions controlled by the injured muscles. Objective findings are entrance and (if present) exit scars, small or linear, indicating short track of missile through muscle tissue; some loss of deep fascia or muscle substance; or impairment of muscle tonus and loss of power or lowered threshold of fatigue when compared to the sound side. 38 C.F.R. § 4.56(d)(2). Characteristics of moderately severe impairment include: through and through or deep penetrating wound by small high velocity missile or large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring. History and complaints would include evidence showing hospitalization for a prolonged treatment for wound; record of consistent complaint of cardinal signs and symptoms of muscle disability; and evidence of inability to keep up with work requirements. Objective findings include entrance and (if present) exit scars through one or more muscle groups; indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with sound side; and impacted strength and endurance. 38 C.F.R. § 4.56(d)(3). Characteristics of severe muscle impairment include all of the above, plus: evidence of wounds due to large or multiple missiles; shattering bone fracture or open comminuted fracture with extensive debridement, prolonged infection, or sloughing of soft parts; intermuscular binding and scarring; consistent complaints of cardinal signs and symptoms of muscle disability, worse than those shown for moderately severe injuries; ragged, depressed, and adherent scars indicating wide damage to muscle groups; loss of deep fascia on palpation, loss of muscle substance, or soft, flabby muscles in wound area; muscles swell and harden abnormally in contraction; severe impairment of strength, endurance, or coordinated movements. If present, the following are also signs of severe muscle disability: X-ray evidence of multiple scattered foreign bodies; adhesion of scars; diminished muscle excitability to pulsed electrical current; atrophy; adaptive contraction of an opposing group of muscles; atrophy of muscle groups not in the track of the missile; or induration or atrophy of an entire muscle following simple piercing by a projectile. 38 C.F.R. § 4.56(d)(4). Rating Criteria for Limitation of Motion Under 38 C.F.R. § 4.71(a), for the index, long, ring, and little fingers, zero degrees of flexion represents the fingers fully extended, making a straight line with the rest of the hand. The position of function of the hand is with the wrist dorsiflexed 20 to 30 degrees, the metacarpophalangeal and proximal interphalangeal joints flexed to 30 degrees, and the thumb abducted and rotated so that the thumb pad faces the finger pads. Only joints in these positions are considered to be in favorable position. For the index, long, ring, and little fingers, the metacarpophalangeal joint has a range of zero to 90 degrees of flexion, the proximal interphalangeal joint has a range of zero to 100 degrees of flexion, and the distal (terminal) interphalangeal joint has a range of zero to 70 or 80 degrees of flexion. 38 C.F.R. § 4.71(a), Evaluation of Ankylosis or Limitation of Motion of Single or Multiple Digits of the Hand. When two or more digits of the same hand are affected by any combination of amputation, ankylosis, or limitation of motion that is not otherwise specified in the rating schedule, the evaluation level assigned will be that which best represents the overall disability (i.e., amputation, unfavorable or favorable ankylosis, or limitation of motion), assigning the higher level of evaluation when the level of disability is equally balanced between one level and the next higher level. Id. If there is limitation of motion of two or more digits, evaluate each digit separately and combine the evaluations. Id. Under DC 5230, a noncompensable rating is assignable for any limitation of motion of the ring or little finger. No higher disability ratings are available. Id. at DC 5230. DC 5229 provides that a noncompensable rating is assignable for limitation of motion of the index or long fingers with a gap of less than one inch (2.5 cm) between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, and; extension is limited by no more than 30 degrees. A 10-percent rating is assignable for limitation of motion of the index or long finger with a gap of one inch (2.5 cm) or more between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, or; with extension limited by more than 30 degrees. Id. at DC 5229. DCs 5224-5227 provide evaluations for unfavorable or favorable ankylosis of individual digits. Id. at DCs 5224-5227. A Note to DCs 5224-5227 instructs the rater to consider whether evaluation as amputation is warranted in such cases, and whether an additional evaluation is warranted for resulting limitation of motion of other digits or interference with overall function of the hand. 38 C.F.R. § 4.71(a), DCs 5224-5227, Note. (DCs 5126-5156 governs amputation of individual and multiple fingers. Id. at DCs 5126-5156.) DCs 5220-5223 provide evaluations for favorable ankylosis of multiple digits of one hand, and DCs 5216-5219 provide evaluations for unfavorable ankylosis of multiple digits of one hand. Id. at DCs 5216-5223. A Note to DCs 5216-5219 instructs the rater to also consider whether evaluation as amputation is warranted. Id. Factual Background The Veteran filed an original claim for service connection for a right hand disability in April 2006. (The record shows that the Veteran is right-hand dominant.) The claim stemmed from an injury the Veteran sustained in service when his right hand was crushed by a hatch aboard the USS Trenton. On VA examination in November 2006, a history of right hand fracture was noted. The Veteran reported that he continued to have pain in his hand, and was unable to grip well. He reported weakness, stiffness, fatigability, lack of endurance, and flare-ups, which are precipitated by weather changes, with the average flare-up lasting 24 hours or more. He reported that during flare-ups he could not use his hand at all. On physical examination, there was tenderness to palpation and mild tremor, pain, and crepitus with movement. No ankylosis was noted. There was mild weakness of grip when compared to the left hand, as well as decreased strength for pulling and twisting (but normal strength for pushing). On VA examination in December 2008, the Veteran reported that his symptoms had worsened. He reported that he had always been a mechanic, but that he recently had to give that work up due to problems with his hand. He reported constant throbbing pain, worse in cold and wet weather. He reported that he dropped things after gripping them for longer than two or three minutes. He reported "popping and cracking" when making a fist, as well as occasional swelling. The examiner noted that there was an overall decrease in hand strength and dexterity. Range of motion testing was normal (though objective evidence of pain on motion was noted), with no gap between the index finger and proximal transverse crease of hand on maximal flexion of finger. No additional limitation of motion was noted after repetitive motion. No ankylosis was noted. In January 2009, a VA primary care consult note revealed hypertrophy and decreased grip, range of motion, and strength of the right hand. In his March 2009 notice of disagreement, the Veteran argued that his most recent VA examination was inadequate, as it "was only done on the bones and not the muscles and [tendons] in my right hand which show a much worse condition and should warranted a higher rating." In April 2009, a VA orthopedic surgery consult note revealed that the Veteran could not fully extend and flex the metacarpophalangeal and interphalangeal joints of his right hand. There was ligamentous popping at the long finger metacarpophalangeal joint. The examiner noted possible nerve impingement, i.e., carpal tunnel syndrome, citing the Veteran's reports of loss of grip. On VA examination in June 2009, it was noted that the Veteran did not have impaired strength or dexterity of his right hand. There was no indication of angulation or ankylosis. His grip strength was strong and equal, and no muscle atrophy was noted. Sensitivity was intact to all fingers. Nerve conduction studies (performed in May 2009) were all within normal limits, suggesting normal right median and ulnar nerve responses. The examiner noted that clinically there were no functional impairments of the Veteran's right hand. In August 2009, a VA orthopedic consult note revealed the Veteran's continued reports of pain, swelling, and numbness. On physical examination, there was mild flexion posture of the joint of the long finger, but flexion strength was normal. No intrinsic weakness was noted. Some subluxations were noted with repetitive flexion and extension. There was good strength in extension. The impression was right hand chronic pain and intermittent numbness, with no evidence of carpal tunnel syndrome or nerve impingement. In May 2011, another nerve conduction study was performed, revealing mild right ulnar neuropathy at the elbow; however, there was no evidence of neuropathy at the wrist. In July 2012, the Veteran underwent a VA hand and finger examination. Pain on movement was noted for the index, long, ring, and little fingers of his right hand; however, no objective limitation of motion was noted, and no gap was observed between any fingertips and the proximal transverse crease of the palm. There was no functional loss following repetitive-use testing, and no evidence of weakened movement, fatigability, incoordination, swelling, deformity, or atrophy. Muscle strength testing of the right hand was normal. No ankylosis was noted. It was observed that the Veteran had a scar on his right hand; however, the scar was not painful or unstable, and did not occupy a total area greater than 39 square cm (six square inches). X-rays of the right hand revealed no significant acute abnormality. The examiner remarked that testing of the functions of the Veteran's right hand were inconsistent, but that "distracting maneuvers" revealed more consistency, and "essentially normal functioning." Notably, the Veteran presented with a weak handshake grip, but had a "good strong strip" with alternating gripping maneuvers. The examiner further noted that the Veteran had prominent callouses on his right hand, larger than corresponding callouses on his left hand. In July 2012, the Veteran also underwent a VA peripheral nerves examination, which revealed no evidence of nerve damage in his right hand or wrist. In addition, a muscle injuries examination report noted no history of injuries to any of the muscle groups of the forearm or hand. There was no evidence that the Veteran exhibited any of the cardinal signs or symptoms of muscle injuries. Muscle strength testing of Groups VII and VIII were normal. No atrophy was noted. In February 2013, the Veteran submitted a letter, dated in January 2013, from his primary care physician, stating that the Veteran had "significant dysfunction and limitation of function and movement" of his right hand since he began treatment with the physician in January 2009. The physician stated, "Based on my clinical examination and review of records, [the Veteran] is totally and permanently disabled." On VA examination in April 2013, the Veteran reported having continued chronic pain in his right hand with increased numbness with hand use. He also reported increased weakness in his grip over the past several years. No range of motion testing was performed. The examiner noted that the Veteran's poor grip had a moderate impact on physical employment. In July 2017, the Veteran underwent another VA hand and finger examination. He reported loose grip, loss of strength, intermittent popping sensation, and loss of coordination. He reported flare-ups, and stated that upon using his right hand at all it "wrenches." He also reported the he struggled with writing because his hand would throb or wrench after a minute or two. On physical examination, range of motion was normal (including testing in weight bearing and non-weight bearing and in active versus passive range of motion), and there was no gap between the pad of the thumb and the fingers or between the finger and proximal transverse crease of the hand on maximal finger flexion. No objective evidence of pain on use was noted. No additional loss of function was noted after repetitive-use testing, and no additional contributing factors of disability were observed. Muscle strength testing revealed right hand grip strength at four out of five. No muscle atrophy was noted. No ankylosis was noted. The examiner observed that the Veteran had a five cm by 0.2 cm scar on his right hand dorsum third metacarpal bone; however, the scar was neither unstable nor painful. In terms of functional impact, the examiner noted that the Veteran may have difficulty with activities requiring extensive use of his hands and fine manipulation. In July 2017, the Veteran also underwent a VA peripheral nerve examination. No symptoms attributable to a peripheral nerve condition were noted. Muscle strength testing and reflexes were normal. The examiner indicated that there was no objective evidence to support a diagnosis of a peripheral nerve condition pertaining to the Veterans' right hand. In addition to the evidence discussed above, the Board has reviewed the Veteran's VA outpatient treatment notes, as well as his Social Security Administration (SSA) records (which reflect an ultimate determination that the Veteran is unable to work under the standards of that agency). These records show right hand symptomatology consistent with the evidence already discussed. Analysis After carefully reviewing the record, the Board finds that the Veteran's service-connected residuals of a fracture of the metacarpal neck of the right index, long, ring, and little fingers do not warrant increased ratings under the relevant criteria. As noted above, the Veteran's current 10-percent rating for residuals of fracture of the right index and long fingers, under DC 5299-5309, contemplates Group IX muscle impairment rated on the basis of limitation of motion. In this regard, his 10-percent rating is the maximum available rating under the DCs governing limitation of motion for fingers not involving the thumb. See 38 C.F.R. § 4.71(a), DCs 5229-5230. (There is no evidence of thumb involvement secondary to the Veteran's service-connected right hand disability.) Likewise, the Veteran's separate, noncompensable rating for limitation of motion of the right ring and little fingers, under DC 5230, represents the maximum rating available under that DC. See id. None of the evidence of record, lay or medical, demonstrates ankylosis of any of the digits of the Veterans' right hand. As such, a higher evaluation based upon DCs 5216-5227 is not warranted. See id. at DCs 5216-5227. The Board recognizes the Veteran's lay statements of pain, weakness, flare-ups, loss of grip, decreased dexterity, and limitation of motion in his right hand. See Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). However, as stated above, he is already in receipt of the maximum schedular disability ratings available for limitation of motion, and therefore there is no basis for a higher schedular evaluation under the applicable DCs. Accordingly, the Board finds that the current evaluations adequately compensate the Veteran for the pain and functional impairment caused by his service-connected right hand disability. See DeLuca, 8 Vet. App. at 204-207; 38 C.F.R. §§ 4.40, 4.45, 4.59. (To the extent the VA examination reports of record failed to comply with the holdings in Correia v. McDonald, 28 Vet. App. 158 (2016) or Sharp v. Shulkin, 29 Vet. App. 26 (2017), either individually or collectively, such non-compliance is harmless error. In this respect, the Court in Johnston v. Brown, 10 Vet. App. 80 (1997), indicated that where the Veteran is in receipt of the maximum schedular evaluation based on limitation of motion and a higher rating requires ankylosis, the cited regulations are not for application. Johnston, 10 Vet. App. at 84-85 (although the Secretary suggested remand because of the Board's failure to consider functional loss due to pain, remand was not appropriate because higher schedular rating required ankylosis). Thus, in this case, as the Veteran is in receipt of the maximum schedular rating based on limitation of motion and a higher rating requires ankylosis or other symptoms unrelated to limitation of motion, 38 C.F.R. §§ 4.40 and 4.45 are not for application.) The Board acknowledges that, with respect to the rating criteria governing muscle impairment, the Veteran's lay statements reflect that he has experienced some of the cardinal signs and symptoms of muscle disability, particularly loss of power, weakness, lowered threshold of fatigue, impairment of coordination, and uncertainty of movement. See 38 C.F.R. § 4.56(c). However, the evidence in this case demonstrates that the Veteran's residuals of a right hand fracture have been manifested by no worse than moderate muscle impairment. The Board reiterates that the criteria for moderately severe muscle disability-the requirement for an evaluation in excess of 10 percent under DCs 5307 and 5308-contemplates a "through and through" or deep penetrating wound, which is not applicable here. See 38 C.F.R. § 4.56(b). Moreover, there is no evidence that the Veteran's initial injury or subsequent surgical repair was productive of debridement, prolonged infection, sloughing of soft parts, or intermuscular scarring. In terms of objective findings, there is no evidence of loss of deep fascia, muscle substance, atrophy, or muscle firmness at any time during the appeal period. Rather, objective findings on examination, including most recently in July 2017, have revealed no fascial defects, muscle damage, atrophy, or flaccidity of the hand/finger flexors of the right forearm muscle group. See id. As noted above, the Board accepts the Veteran's lay reports regarding his right hand symptomatology. However, as there is simply no evidence, lay or medical, of muscle atrophy or damage to the extent contemplated under the criteria for a rating in excess of 10 percent, the Board finds that his lay statements, in light of the entire record, do not support a higher rating for muscle disability. See id. The Board has considered possible nerve involvement with respect to the Veteran's right hand symptomatology. However, 38 C.F.R. § 4.55(a) holds that muscle injuries will not be combined with a peripheral nerve paralysis rating of the same body part, unless the injuries affect entirely different functions. Thus, even assuming the Veteran's right hand and finger symptoms are a function of both nerve and muscle impairment, separate ratings cannot be assigned. Moreover, the Board notes that the July 2017 VA peripheral nerve examination report did not reflect any nerve damage to the right hand or fingers. Finally, the Board has considered whether a separate compensable rating is warranted for the Veteran's surgical scar. In this regard, the VA examination reports of record indicate that he has a scar on his right hand; however, there is no evidence to suggest (and the Veteran has never reported) that this scar is painful, tender, or unstable. As the evidence demonstrates a superficial, nonlinear scar that is neither painful nor unstable, and that is less than 929 square centimeters, a separate compensable rating under either DC 7804 or 7802 is not warranted. See 38 C.F.R. § 4.118. In sum, the Board finds that the criteria for increased ratings for symptomatology associated with the Veteran's residuals of a fracture of the right hand have not been demonstrated. Accordingly, the claim for an increased rating must be denied. Extra-schedular Consideration The Veteran's representative has contended that an extra-schedular rating is warranted in this case. See Informal Hearing Presentation (March 2018). To that end, the Board has considered the provisions of 38 C.F.R. § 3.321(b)(1) governing extra-schedular ratings. However, in this case, the evidence of record is against a finding that the disability on appeal is so exceptional or unusual as to warrant the assignment of an extra-schedular rating. See 38 C.F.R. § 3.321(b)(1). The threshold factor for extra-schedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular evaluation for the service-connected disability is inadequate. See Thun v. Peake, 22 Vet. App. 111 (2008). In this regard, there must be a comparison between the level of severity and symptomatology of the claimant's service- connected disability with the established criteria found in the rating schedule for those disabilities. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule and the assigned schedular evaluation is therefore adequate, and no extraschedular referral is required. Id.; see also VAOGCPREC 6-96 (Aug. 16, 1996). Otherwise, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, VA must determine whether the claimant's exceptional disability picture exhibits other related factors, such as those provided under 38 C.F.R. § 3.321(b)(1) as "governing norms"(including marked interference with employment and frequent periods of hospitalization). The evidence in this case does not show such an exceptional disability picture that renders inadequate the available schedular evaluation for the service-connected disability on appeal. A comparison between the level of severity and symptomatology of the Veteran's assigned rating with the established criteria found in the rating schedule shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. As discussed above, the Veteran's service-connected residuals of a fracture of the metacarpal neck of the right index, long, ring, and little fingers has been manifested by pain, weakness, flare-ups, loss of grip, decreased dexterity, and limitation of motion in his right hand. The ratings assigned for this disability fully contemplate this symptomatology-particularly functional limitation of motion and indications of one or more of the cardinal signs and symptoms of muscle disability. See 38 C.F.R. §§ 4.56(d), 4.71(a). As such, it cannot be said that the schedular evaluations for the disability on appeal are inadequate. The Board observes also that, even if the schedular evaluations for the disability at issue are inadequate (which they manifestly are not), the Veteran does not exhibit other related factors such as those provided by the regulation as "governing norms." There is no indication that the Veteran has required frequent periods of hospitalization, and although the record documents that his right hand symptomatology has a significant impact on his ability to work, the record does not indicate that this disability causes impairment with employment over and above that which is already contemplated in the assigned schedular ratings. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (noting that the disability rating itself is recognition that industrial capabilities are impaired). Based on the foregoing, the Board finds that the requirements for an extra-schedular rating for the Veteran's service-connected residuals of a fracture of the metacarpal neck of the right index, long, ring, and little fingers, under the provisions of 38 C.F.R. § 3.321(b)(1), have not been met. ORDER Entitlement to an initial disability rating in excess of 10 percent for residuals of a fracture of the metacarpal neck of the right index and long fingers is denied. Entitlement to an initial compensable rating for residuals of a fracture to include limitation of motion of the right ring and little fingers is denied. REMAND TDIU will be awarded when a Veteran is unable to secure or follow a substantially gainful occupation as a result of a service-connected disability or disabilities. 38 C.F.R. § 4.16(a); see Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993) ("[T]he central inquiry in determining whether a veteran is entitled to TDIU is whether the veteran's service-connected disabilities alone are of sufficient severity to produce unemployability."). When such unemployability is shown and the Veteran meets certain numeric evaluation requirements, the Board may award TDIU in the first instance. 38 C.F.R. § 4.16(a). Otherwise, the Board may only refer the case to the Director of Compensation Service (Director) for consideration of an extraschedular TDIU. 38 C.F.R. § 4.16(b); see also Cantrell v. Shulkin, 28 Vet. App. 382, 387 (2017). In this case, the Veteran is currently in receipt of service connection for right foot osteophyte, status post fracture of first metatarsal with right ankle strain (rated as 20-percent disabling); residuals of fracture metacarpal neck of right index and long fingers (10-percent disabling); residuals of fracture to include limitation of motion of the right ring and little fingers (noncompensable); and left fibula fracture (noncompensable). His combined disability rating is 30 percent. Thus, he does not meet the schedular requirements for TDIU pursuant to 38 C.F.R. § 4.16(a). Nevertheless, the Board finds that referral for consideration of an extraschedular TDIU is warranted. On review, the record contains plausible evidence suggesting that the Veteran's service-connected disabilities-in particular his right foot and right hand disabilities-have rendered him unemployable. This evidence includes a January 2013 letter from the Veteran's primary care physician stating that the Veteran is "totally and permanently disabled" due to his service-connected disabilities, as well as an SSA determination of disability in part due to his right foot and right hand disabilities. Moreover, the Veteran has asserted on multiple occasions that his service-connected symptomatology prevents him from working. See, e.g., Correspondence (April 2012) (asserting that he had to quit his job as a diesel mechanic because his right foot and right hand disabilities "would not allow me to stand for long periods of time . . . or hold and turn my wrenches and other necessary tools"). During his most recent VA examination, in July 2017, the examiner noted that the Veteran's right hand symptoms would cause "difficulty with activities requiring extensive use of hands and fine manipulation"-a description that appears to cover a wide range of occupations. In light of the above, the Board finds that there is sufficient evidence for referral under 38 C.F.R. § 4.16(b). The Board cannot award an extraschedular TDIU in the first instance. Accordingly, the case is REMANDED for the following action: 1. Secure any outstanding VA medical records pertaining to the Veteran from November 2013 to the present. 2. Refer the application for a TDIU to the Director of Compensation Service for a determination as to whether the Veteran is entitled to a TDIU on an extraschedular basis in accordance with the provisions of 38 C.F.R. § 4.16(b). A full statement as to the Veteran's service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue must be provided. 3. After completing all indicated development, readjudicate the issue of entitlement to a TDIU, to include on an extraschedular basis, in light of all the evidence of record. If the benefit sought on appeal remains denied, the RO should furnish to the Veteran and his representative a Supplemental Statement of the Case. The Veteran has the right to submit additional evidence and argument on the matter or 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 of Veterans' Appeals 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. §§ 5109B, 7112 (2012). (CONTINUED ON NEXT PAGE) ______________________________________________ YVETTE R. WHITE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs