Citation Nr: 21065650 Decision Date: 10/27/21 Archive Date: 10/27/21 DOCKET NO. 20-18 009 DATE: October 27, 2021 REMANDED Entitlement to service connection for a recurrent right upper extremity disability, to include forearm injury residuals, is remanded. REASONS FOR REMAND The Veteran had active service from December 1965 to January 1969. He served in the Republic of Vietnam. Entitlement to service connection for a recurrent right upper extremity disability, to include forearm injury residuals, is remanded. The Veteran asserts that service connection for a recurrent right upper extremity disability is warranted as he sustained in service right upper extremity trauma wherein his right arm was crushed. The service treatment records reflect that the Veteran was seen for a right forearm injury. Clinical documentation dated in September 1967 states that the Veteran reported sustaining a right forearm injury when he was attaching a chain to a clamshell and it shut on his hand. Treating medical personnel noted right forearm swelling with a hematoma and no nerve or vascular deficit. Contemporaneous X ray studies of the right upper extremity revealed no fractures. A September 1967 orthopedic evaluation conveys that the Veteran exhibited marked swelling on the right forearm flexor surface; distal median nerve numbness; and no motor deficits. The Veteran was diagnosed with a right forearm "flexer hematoma." The Veteran was hospitalized for observation for one day and discharged. Treatment records dated in October 1967 note that the Veteran sustained a right forearm contusion approximately one week before. Treating medical personnel observed a "massive hematoma" on the right forearm. The Veteran was instructed to exercise with a tennis ball or a hand ball. In a July 2015 written statement, the Veteran indicated that he experienced recurrent right arm pain and impairment following the in service trauma which had persisted until the present time. The Veteran has not been afforded a Department of Veterans Affairs (VA) examination which addresses the right upper extremity. VA's duty to assist includes, in appropriate cases, the duty to conduct a thorough and contemporaneous medical examination which is accurate and fully descriptive. McLendon v. Nicholson, 20 Vet. App. 79 (2006); Green v. Derwinski, 1 Vet. App. 121, 124 (1991). Clinical documentation dated after May 2020 is not of record. VA should obtain all relevant VA and private treatment records which could potentially be helpful in resolving the Veteran's claim. Murphy v. Derwinski, 1 Vet. App. 78 (1990); Bell v. Derwinski, 2 Vet. App. 611 (1992). The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for each private healthcare provider who has treated any right upper extremity disability. Make two requests for the authorized records from all identified healthcare providers unless it is clear after the first request that a second request would be futile. 2. Obtain any VA treatment records not of record, to include those pertaining to treatment after May 2020. 3. Schedule the Veteran for a VA upper extremity examination conducted by a medical doctor to assist in determining the nature and etiology of any identified recurrent right forearm disability and any relationship to active service. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The examiner should: (a) Diagnose all right upper extremity disabilities found. (b) Opine whether it is at least as likely as not (50 percent probability or greater) that any identified right upper extremity disability had its onset during active service or is related to any incident of service, including the documented in service right forearm trauma. J. T. HUTCHESON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Smith, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.