Citation NR: 9734780 Decision Date: 10/15/97 Archive Date: 10/24/97 DOCKET NO. 96-29 483 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Oakland, California THE ISSUES 1. Entitlement to service connection for a left foot disorder. 2. Entitlement to an increased evaluation for scar, residual of forehead laceration, currently evaluated as 10 percent disabling. 3. Entitlement to an increased (compensable) evaluation for fracture, left acetabulum and pubis. 4. Entitlement to an increased (compensable) evaluation for fracture, right femur. 5. Entitlement to an increased (compensable) evaluation for fractures, left tibia and fibula, distal third. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Alice A. Booher, Counsel INTRODUCTION The veteran had active service from April 1962 to April 1965. The veteran filed her initial claim in 1995. This appeal to the Board of Veterans’ Appeals (the Board) is from rating actions by the Department of Veterans Affairs (VA) Regional Office (RO) in Oakland. In a rating in February 1997, the RO increased the rating for the veteran’s facial (forehead) scar from noncompensable to 10 percent, stated that this was a full grant of the requested benefits, and held that the issue has been withdrawn from appellate consideration. On the contrary, since the 10 percent rating is not the maximum available, and absent specific indication on the part of the veteran in that regard, pursuant to AB v. Brown, 6 Vet. App. 35 (1993), the issue remains in appellate status. The Board notes that service records show multiple lacerations in service, and multiple residual scars at separation. Service connection is in effect for the herein concerned forehead scar. The issues with regard to any other scars [other than with regard to the action in part taken herein with regard to issue #5] are not presently on appeal but are called to the attention of the RO for whatever action is required. Although the RO has included a number of inapplicable regulations in the Statements of the Case, the RO has not fully addressed, nor has the veteran specifically or inferentially raised, the issue of entitlement to extraschedular evaluations for her service-connected disabilities, and in keeping with numerous judicial holdings, that issue is not part of the current appellate review. CONTENTIONS OF APPELLANT ON APPEAL In substance, it is argued that the veteran has significant problems with residuals from her in-service accident, including involving the left foot to which she has not had intercurrent injury, and that additional compensation is warranted. She has argued that some of her injuries were similar in impact to that caused by gunshot wounds and should be rated accordingly. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991 & Supp. 1997), has reviewed and considered all of the evidence and material of record in the veteran's claims file. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the veteran’s claim for service connection for a left foot disorder is not well grounded. It is further the decision of the Board that the evidence is against entitlement to increased evaluations for a forehead laceration scar, residuals of a fractured left acetabulum and pubis, and a fracture of the right femur; and that the evidence is in favor of increased ratings of 10 percent for residuals of fracture of the left tibia and fibula, distal third, and for a separate 10 percent rating for tender left thigh laceration scar with calcified bulge comparable to recurrent ulceration. FINDINGS OF FACT 1. The claim for service connection for a left foot disorder is not supported by cognizable evidence showing that the claim is plausible or capable of substantiation. 2. A forehead scar is of slight cosmetic impact and causes no functional impairment, is not significantly discolored or otherwise no more than moderately disfiguring. 3. Residuals of left hip injury involving fractures of the left acetabulum and pubis cause no current measurable functional impairment, limitation of motion or pain. 4. The right femur fracture is well healed without deformity and causes no pain or limitation of motion. 5. Left tibia and fibula fracture residuals are manifested in minimal osseous deformity with a slightly crooked/bowed and mildly shorter left leg than the right, which causes slight but no more than moderate knee impairment. 6. The veteran’s scar on the left thigh, a separate disability entity from the fracture injury, was also caused by the initial in-service accident as well as subsequent hematoma removal; it is currently painful and the calcified bulge is comparable to recurrent ulceration. CONCLUSIONS OF LAW 1. The claim for service connection for a left foot disorder is not well grounded. 38 U.S.C.A. § 5107 (West 1991 & Supp. 1997). 2. The criteria for an increased evaluations for scar residuals of a forehead laceration, fracture of the left acetabulum and pubis, and fracture of the right femur, rated as 10, zero, and zero percent disabling, respectively, are not met. 38 U.S.C.A. §§ 1155, 5107 (West 1991 & Supp. 1997); 38 C.F.R. §§ 4.2, 4.7, 4.31, 4.40, 4.45, 4.59, 4.71(a), 4.118, Diagnostic Codes 5003, 5251, 5255, 5262, 7800 (1996). 3. The criteria for a 10 percent rating for fractures of the left tibia and fibula, distal third; and a separate 10 percent for tender scar, residuals of left thigh laceration with repeated ulceration, are met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 4.2, 4.7, 4.40, 4.45, 4.59, 4.71(a), 4.118, Diagnostic Codes 5003-5262, 7803-4 (1996). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Factual Background: in-service Service clinical records show that the veteran was involved in an accident, wherein while on a weekend pass to visit her family, she was a pedestrian walking in a crosswalk and was hit by a car. This took place just outside Ft. Ord where she received her initial 90 days of treatment. Hospital reports describe her injuries as involving a displaced fracture in the mid-shaft of the right femur, open fractures of the left fibula and tibia, distal third, and displaced fractures of the left inferior ramus of the pubis and left acetabulum. There were no neurovascular injuries or deficits. The veteran also had multiple lacerations including involving the lateral aspect of the lower half of the left fibula. The left lower extremity underwent debridement and the wound was primarily closed. An elliptical laceration about 3 cms. above the lateral malleolus on the left lower extremity, extending 7 cms. in length, was irrigated and sutured. A closed reduction was done on the left fibula and tibia and she was placed in a long leg cast on the left. A Steinmann pin was introduced into the right tibia cubical and she was placed in balanced suspension traction. Three weeks after the initial injury, she was again taken to surgery where an intramedullary fixation of the right femur was performed from which she had a benign postoperative course and she was started on physical therapy. Callus formation was shown on X-rays of the fracture site. After changing the cast on the left lower extremity, there was still some overriding of the fragments, but the general alignment of the leg was good. There was no infection. At the time of her transfer to Letterman Army Medical Center (AMC) in February 1964 for follow-up care and rehabilitation prior to reassignment, the appellant was partially weight bearing with the right lower extremity on crutches and weight bearing on the left leg was soon anticipated. On admission, X-rays showed comminuted fractures of the left tibia and fibula at the junction of the middle and distal thirds of both. In the lateral projection, there were approximately a 5-degrees angulation of the distal tibial fragment and 0.5 cm. of anterior displacement, overriding of the distal fibular fragment. In the anterior-posterior projection, there was medial displacement of approximately 2 cm. of overriding of the distal fibular fragment, and slight lateral displacement of the tibial fragment with a small fragment which was angled medically above the fracture site. The anterior posterior view of the pelvis showed a fracture of the left acetabulum, healing in normal position. X-rays of the right femur showed a mid-shaft fracture of the right femur, healing with exuberant callus, stable fixation achieved with a Kuntscher nail. Follow-up films of the left leg on three occasions showed progressive healing of the tibial fracture with unchanged position and alignment. She was started on a rehabilitation program and worked into left leg weight bearing without marked difficulty. She was discharged from Letterman AMC in July 1964 to her new duty station with the injuries healed or healing and improved. At the time of her separation examination in March 1965, she was noted to have minor swelling in the left ankle as a result of the 1963 accident, with limited plantar flexion of the left ankle. She was also unable to completely flex at the knees. Several scars were described. Factual background: post service In the veteran’s initial claim, filed in 1995, she referred only to having been seen by a Dr. James for arthritis in 1983. Clinical records were received from Paul James, M.D., concerning care of the veteran. Care for conditions unrelated to this claim, including of a gynecological nature, show no history or complaints referable to the pertinent injuries herein concerned. In May 1988, the veteran was seen with complaints of having been struck in the left anterolateral knee by her 75 pound dog. Immediate lateral joint line pain was acknowledged with difficulty extending the terminal 30 degrees. There was an associated popping sensation. Symptoms did not respond, and after extensive testing, it was concluded that she had a tear of the posterior horn lateral meniscus. She indicated that she had manifested a valgus deformity of the left knee since age 21 and recognized that surgery might not bring complete restoration of the knee to normal. She underwent surgery for the diagnosed internal derangement of the left knee with chronic valgus deformity. During surgery, it was determined that in addition to the torn mid medial and anterolateral meniscus, she also had severe chondromalacia of the left patella involving the articular surfaces of the medial and lateral femoral condyles and tibial plateaus. In August 1993, the claimant saw Dr. James with complaints of having sustained an inversion injury to the left ankle and forefoot two days previously. She had been hobbled by it ever since then and had had some problems bearing weight. She said she had sustained a similar injury several weeks before but had not then sought treatment. On examination, Dr. James found an ecchymotic, tender soft tissue swelling over the anterolateral proximal forefoot. The bimalleolar compression was nontender, and the proximal leg was negative as was the distal foot. Distal neurovascular and tendon functions were intact. X-rays showed mild osseous porosis but no fracture. She was placed in a 4” ace wrap and was told to use the crutches she already had at home as necessary. Diagnosis was subacute sprain, left forefoot. She was next seen again by Dr. James in November 1993 after having experienced lumbar back pain after moving a chair with her grandson the day before. Diagnosis was lumbar strain. In March 1995, the appellant complained to Dr. James of left foot pain, dorsal to medial mid foot and ankle for the past 3 weeks, gradually increasing in severity, and better with rest and ace wrap. She had a history of fractures in both lower leg bones 20-30 years before. Examination showed a non- compliant left subtalar joint, tender posterior tibial tendon, left foot shoes “too many toes sign”, and deformity of the distal tibia at the site of the previous fracture. X- rays showed bilateral feet osteoarthritis, and left talonavicular. Diagnosis was left foot talonavicular joint osteoarthritis. Suggested recommendations were for her to use a higher arch and heel, and there was discussion of possible fusing operation in the future should simple conservative measures not ease the pain. The veteran returned to see Dr. James in June 1995 with complaint of painful left leg, and foreign body at the site of old trauma with associated small mass formation 1/3 proximal lateral thigh. There was a probable crepitant loose body in the soft tissue. X-rays showed a smooth walled calcific mass suggestive of old calcified hematoma, well encapsulated. It was incidentally noted that there had been no change in supportive footwear but there was some improvement. In October 1995, the veteran saw Dr. James with new right anterior lateral knee joint line pain and swelling. The prior Saturday, she had had sudden swelling and giving way while she was involved in increased coaching/crouching while she was supervising play in the school yard where she worked. There was no other history of a single accident of twist strain. Examination showed tender sessile mass anterior lateral joint line right knee, tenderness increased with lateral Mcmurray maneuver, with 0-90 degrees passive range of motion and no laxity. Impression was synovitis/effusion, possible torn meniscus right knee. A trial injection of cortisone and Marcaine was to be undertaken, and if not successful in 10 days, a magnetic resonance imaging (MRI) was to be done. An MRI was done later in November which showed a degenerated torn lateral meniscus throughout without definite evidence of medial meniscus tears. There was a small joint effusion without Baker’s cyst. There was degenerative spurring laterally and an increased signal on T-2 weighing in the tibia was felt to be associated with degenerative changes or related to trauma. Noting that she had not done well with prior treatment, she underwent arthroscopic right knee surgery. On VA examination in May 1996, the veteran said that if she walked a lot, the pain would become severe enough that she would have to quit walking. She had no pain when sitting or standing but did have some pain when in bed at night. She was taking no pain medications. She said her left foot would hurt excruciatingly if it was bumped. On examination, she was walking with a limp which the examiner felt was due to the stiffness of her left foot. There was also noted to be a left calf deformity at the location of the healing of the fractured tibia. There was also a large muscular bulge in the left lateral posterior thigh, and a surgical incision there which was felt to have been related to the hematoma. There was another 29 cm. surgical scar on the right lateral thigh going from the greater trochanter to above the knee. The examiner stated “I would suspect this patient has orthopedic disabilities from the development of degenerative joint disease secondary to the multiple pelvis and lower extremity fractures she sustained. In addition, her left foot in the healing process she has limited mobility of the foot. Her left leg is crooked and slightly shorter than the right leg and would seem to bow at the knees.” The reports of the multiple X-rays show the following: (1) healed fracture of the right proximal femoral diaphysis (which was incompletely visualized) with evidence of prior right femoral intramedullary rod, and heterotopic ossification in the lateral aspect of the left proximal thigh; (2) mild narrowing of the left hip joint space; (3) osteitis pubis, of doubtful significance (usually seen after pregnancy); (4) healed fracture deformity of the left distal tibia and fibula at the diaphysis with satisfactory alignment; (5) osteoarthrosis of the left knee joint (incompletely visualized); (6) bony irregularity and hypertrophy at the dorsal aspect of the left foot, incongruence and suggestion of narrowing of the left talonavicular joint with possible subchondral cyst which might be post-traumatic; (7) diffuse mild osteopenia in both feet, and no other significant bone or joint abnormality. The examiner found that these showed multiple abnormalities mostly secondary to trauma. On the 1996 VA examination, the veteran reported that at the time of the in-service accident, she had also experienced severe lacerations to her face around her eye and to the left side of her nose. Colored photographs were taken of her face which are in the file. Service connection Criteria In Boeck v. Brown, 6 Vet. App. 14 (1993), the United States Court of Veterans Appeals (Court) held that A(n appellant) claiming entitlement to Department of Veterans Affairs (VA) benefits has the burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim is well grounded. See 38 U.S.C.A. § 5107, and see Tirpak v. Derwinski, 2 Vet. App. 609, 610-11 (l992). If an appellant has not presented a well-grounded claim, then the appeal must fail and there is no duty to assist him/her further in the development of the claim. 38 U.S.C.A. § 5107(a); Murphy v. Derwinski, 1 Vet. App. 78 (1992). Case law provides that although a claim need not be conclusive to be well-grounded, it must be accompanied by evidence. A claimant must submit supporting evidence that justifies a belief by a fair and impartial individual that the claim is plausible. See Dixon v. Derwinski, 3 Vet. App. 261, 262 (1992). The quality and quantity of the evidence required to meet this statutory burden of necessity will depend upon the issue presented by the claim. Where the issue is factual in nature, such as whether an incident or injury occurred in service, competent lay testimony, including an appellant’s testimony, may constitute sufficient evidence to establish a well-grounded claim under 38 U.S.C.A. § 5107(a). See Cartright v. Derwinski, 2 Vet. App. 24 (1991). However, where the determinative issue involves medical causation or a medical diagnosis, competent medical evidence to the effect that the claim is "plausible" or "possible" is required. See Murphy, op. cit. at 81 (1990). A claimant would not meet this burden imposed by section 5107(a) merely by presenting lay testimony because lay persons are not competent to offer medical opinions. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). Consequently, lay assertions of medical causation cannot constitute evidence to render a claim well-grounded under section 5107(a). If the claim is not well-grounded, the claimant cannot invoke VA's duty to assist in the development of the claim. See 38 U.S.C.A. § 5107(a); Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992). It has also been determined that a well-grounded claim requires three elements: (1) medical evidence of a current disability; (2) lay or medical evidence of a disease or injury in service; and (3) medical evidence of a link between the current disability and the in-service injury or disease. Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may be established for a disability incurred in or aggravated by active service. 38 U.S.C.A. § 1110 (West 1991). Moreover, it remains the duty of the Board as the fact finder to determine credibility of the testimony and other lay evidence. See Culver v. Derwinski, 3 Vet. App. 292, 297 (1992). Application of the criteria under 38 U.S.C.A. § 1154(b) (West 1991) with regard to circumstances of service, etc., does not absolve a claimant from submitting a well-grounded claim for service connection. See Beausoleil v. Brown, 8 Vet. App. 459, 464 (1996). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Lay persons are not competent to render testimony concerning medical causation. See Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). Service connection may be established through competent lay evidence, not medical records alone. Horowitz, op. cit. But a lay witness is not capable of offering evidence requiring medical knowledge. Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). The Board has the duty to assess the credibility and weight to be given the evidence. Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992) (quoting Wood v. Derwinski, 1 Vet. App. 190, 193 (1991), reconsideration denied per curiam, 1 Vet. App. 406 (1991)). Finally, the Court has made it clear that the Board is precluded from making a medical judgment absent an expert opinion in that regard. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). Analysis A review of the veteran’s service records following the accident in 1963, discloses no complaint or evidence of any left foot injury, nor of any residuals of such at the time of her separation from service. Moreover, there is no evidence submitted to show that the veteran has had residuals of a left foot injury in almost three intervening decades after service. Although the appellant alleges that she had no intercurrent left foot problems after service, the private clinical records clearly demonstrate that when she saw Dr. James in August 1993, she reported having injured the left ankle and forefoot two days before, and even once before that, several weeks before. She has been seen on a recurrent basis since then for complaints with regard to her left foot. However, there is no evidence or medical opinion to associate any current left foot problems with incident or disease of service origin, including but not limited to any injury or service-connected residuals of any injury of service origin. Even assuming for argument’s sake that the veteran experienced an in-service incident which had any impact on her left foot (which is not shown), the evidence shows the absence of any clinical chronic residuals and no further symptoms until recently. In the total absence of any evidence to sustain that the appellant has any current disability or a nexus of any current disability to service, a well grounded claim as to a left foot disorder has not been presented, and there is no further duty to assist in the development of the evidence. In light of the implausibility of the appellant’s claims and the failure to meet her initial burden in the adjudication process, the Board concludes that she has not been prejudiced by the decision to deny her appeal. Bernard v. Brown, 4 Vet. App. 384 (1993). The Court has held that, pursuant to 38 U.S.C.A. § 5103(a) (West 1991 & Supp. 1997), the Secretary has a duty to notify the claimant of the evidence needed to make the claims well grounded if the application is incomplete and VA is on notice of the existence of evidence that would make the claims well grounded. Beausoleil v. Brown, 8 Vet. App. 459 (1996); Epps v. Brown, 9 Vet. App. 341 (1996). The veteran has not identified any evidence which would make her claim well grounded. The facts and circumstances of this case are such that no further action is warranted. Increased Ratings General Criteria Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board has also considered all regulatory provisions which are potentially applicable through the assertions and issues raised in the evidence of record as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). 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. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). In each case when the schedule does not provide for a noncompensable rating, a noncompensable rating will be assigned when the requirements for a compensable rating are not met pursuant to 38 C.F.R. § 4.31 (1996). The Court has held that when a diagnostic code provides for compensation based solely upon limitation of motion, the provisions of 38 C.F.R. §§ 4.40, 4.45 must be considered. The examinations upon which the rating decisions are based must adequately portray the extent of functional loss due to pain “on use or due to flare-ups.” DeLuca v. Brown, 8 Vet. App. 206 (1995). The Court also held in Hicks v. Brown, 8 Vet. App. 417 (1995) that once degenerative arthritis is established by X-ray evidence, there are three circumstances under which compensation may be available for service-connected degenerative changes: (1) where limitation of motion of a joint or joints is objectively confirmed by findings such as swelling, muscle spasm or satisfactory evidence of painful motion, and that limitation of motion meets the criteria in the diagnostic code or codes applicable to the joint or joints involved, the corresponding rating will be assigned thereunder; (2) where the objectively confirmed limitation of motion is not of sufficient degree to warrant a compensable rating under the code or codes applicable to the joint or joints involved, a rating of 10 percent will be assigned for each major joint or joints affected “to be combined, not added”; and (3) where there is no limitation of motion, a rating of 10 percent or 20 percent, depending upon the degree of incapacity, may still be assigned if there is X-ray evidence of the involvement of 2 or more major joints or 2 or more minor joint groups. In addition, Diagnostic Code 5003 is to be read in conjunction with 38 C.F.R. § 4.59, and it is complemented by a separate regulation, 38 C.F.R. § 4.40, which relates to pain in the musculoskeletal system. Finally, the Court noted that “Diagnostic Code 5003 and 38 C.F.R. § 4.59 deem painful motion of a major joint or groups caused by degenerative arthritis that is established by X-ray evidence to be limited motion even though range of motion may be possible beyond the point when pain sets in”. Scar, residual of facial laceration Special Criteria 38 C.F.R. § 4.118 (1996) provides that scars of the head, face or neck which are disfiguring, may be rated as noncompensably disabling when slight; 10 percent disabling when moderately disfiguring; 30 percent when severe, especially if producing a marked and unsightly deformity of the eyelids, lips or auricles; or at 50 percent disabling if there is complete or exceptionally repugnant deformity of one side of the face or marked or repugnant bilateral disfiguration under Diagnostic Code 7800. Increases may be given for such involvement when there is marked discoloration, color contrast or the like in addition to tissue loss or scarring. Other ratings are assignable under Diagnostic Codes 7801-2 for scars which are a result of burns (in which case the rating is primarily based on the degree of the burn and the amount of area involved as a residual); or when superficial and poorly nourished with repeated ulcerations, or superficial, tender and painful on objective demonstration, a 10 percent rating may be assigned under Diagnostic Code 7803-7804. Otherwise, scars are ratable on the basis of limitation of function under Diagnostic Code 7805. Analysis In this case, the veteran has service connection for a single scar over the left eyebrow. Colored unretouched photos of the area taken by VA in 1996 show some evidence of the scar which caused relatively minimal disfiguration. Observation of those photos leads the Board to conclude that the scarring is moderate at most, does not show severe disfigurement, any functional impairment or other symptoms, and an evaluation in excess of 10 percent is not warranted regardless of the schedular provisions under which it may be rated. Residuals, fracture left acetabulum and pubis Special criteria Various criteria are set forth for rating disability involving portions of the hip including acetabulum and os pubis. For instance, when there is ankylosis of the hip, ratings range from 60 to 90 percent under Diagnostic Code 5250. When extension of the thigh limited to 5 degrees, 10 percent is warranted under Diagnostic Code 5251. When there is limitation of flexion of the thigh to 45 degrees, 10 percent is warranted; when limited to 30 degrees, 20 percent is warranted; when limited to 20 degrees, 30 percent is warranted; and when limited to 10 degrees, 40 percent is warranted under Diagnostic Code 5252. When there is impairment of the thigh involving limitation of rotation, i.e., cannot toe-out more than 15 degrees in the affected leg; or limitation of adduction so that one cannot cross legs, 10 percent is warranted; or when there is limitation of abduction lost beyond 10 degrees, 20 percent is warranted under Diagnostic Code 5253. Impairment of the femur, with malunion, and slight knee or hip disability, 10 percent is assignable; with moderate hip or knee disability, 20 percent is assignable; or with marked knee or hip disability, 30 percent is assignable under Diagnostic Code 5255. Under that same code, when there is fracture of the surgical neck of the femur with false joint, 60 percent is assignable, and higher ratings are available when there is fracture at the anatomical neck of the femur or at the shaft. Analysis In this case, the in-service fractures of the left inferior ramus of the pubis and left acetabulum were without nerve or vascular involvement, and healed remarkably well and without significant demonstrable functional impairment including pain. It is not shown that the veteran currently has such residuals of either fractures as to warrant a compensable rating under what appears to probably be the most appropriate Diagnostic Code 5251, or any others as cited above for that matter. Specifically, it is not shown that she has such slight hip impairment as would warrant a 10 or more percent rating under Diagnostic Code 5255 or any of the other possible pertinent regulations cited above. Residuals, Right femur fracture Analysis Although the right femur fracture required a stabilizing rod from the start, after that rod was eventually removed, there has been relatively no functional impairment as a result of the fracture. On the other hand, a review of the recent private clinical evidence clearly shows that the veteran injured her right knee in the Fall of 1995 while crouching apparently while coaching at her work at a school playground, and required subsequent right knee surgical and other intervention. However, there is nothing to indicate that the service problems were in any way responsible for that exacerbation, nor that she has any current right femur fracture residuals which cause even slight (or greater) knee impairment under Diagnostic Code 5255 or any of the other pertinent regulations. Residuals, injury to the left tibia and fibula, distal third, with fractures Special criteria Under Diagnostic Code 5256, provided for knee ankylosis, if extremely unfavorable, in flexion at an angle of 45 degrees or more, 60 percent is assignable; if in flexion between 20 degrees and 45 degrees, 50 percent is assignable; if in flexion between 10 degrees and 20 degrees, 40 percent is assignable. When at a favorable angle in full extension, or in slight flexion between 0 degrees and 10 degrees, 30 percent is assignable. Under Diagnostic Code 5257 provided for other knee impairment, when there is recurrent subluxation or lateral instability which is severe, 30 percent is assignable; when moderate, 20 percent is assignable; or when slight, 10 percent is assignable. When there is cartilage, semilunar, dislocated, with frequent episodes of "locking," pain, and effusion into the joint, 20 percent is assignable under Diagnostic Code 5258. When there is cartilage, semilunar, removal of, symptomatic, 10 percent is assignable under Diagnostic Code 5259. Under Diagnostic Code 5260, when there is limitation of flexion to 15 degrees, 30 percent is warranted. When flexion is limited to 30 degrees, 20 percent is warranted. When flexion is limited to 45 degrees, 10 percent is warranted. When flexion is limited to 60 degrees, zero percent is warranted. Under Diagnostic Code 5261, when there is limitation of leg extension to 45 degrees, 50 percent is warranted. When extension is limited to 30 degrees, 40 percent is warranted. When extension is limited to 20 degrees, 30 percent is warranted. When extension is limited to 15 degrees, 20 percent is warranted. When extension is limited to 10 degrees, 10 percent is warranted. When extension is limited to 5 degrees, zero percent is warranted. Under Diagnostic Code 5262 provided for impairment of the tibia and fibula, when there is nonunion with loose motion, requiring brace, 40 percent is warranted. When there is malunion with marked knee or ankle disability, 30 percent is warranted. With moderate knee or ankle disability, 20 percent is warranted. With slight knee or ankle disability, 10 percent is warranted. Under Diagnostic Code 5263, when there is genu recurvatum (acquired, traumatic, with weakness and insecurity in weight- bearing objectively demonstrated), 10 percent is warranted. Under 38 C.F.R. § 4.71, Plate II, normal range of knee motion is identified as flexion and extension of 140 degrees to 0 degrees. Analysis From the start, the veteran has had a somewhat more convoluted problem with her left lower extremity. She initially required more prolonged care for the left lower extremity open fractures involving the tibia and fibula. In addition, it is noted that the in-service injury clearly caused a laceration on the lateral malleolus as well. In the healing of the left leg fractures, there was some initial overriding of the fragments, but this improved with extended casting, etc. At the time of service separation, she still had some left ankle discomfort and swelling, although it appears that that particular residual abated with time. A review of more recent clinical records shows that the appellant has indeed reinjured her left lower extremity, including when bashed by her big dog in May 1988 which caused a torn meniscus which required surgery. Whatever disability she has from this or any other nonservice-connected cause is not considered in rating her service-connected disability. However, it is significant to note that at the time of 20+ years post-service surgery, the claimant was found not only to have meniscus tearing, which is clearly attributable to the acute and recent 1988 injury, but the discovery was made that she had an underlying widespread chondromalacia of the patella involving multiple articular surfaces. This, according to the VA examiner, was probably not due to the (recent acute) knee trauma, and thus must alternatively be attributed to her service-connected condition. In March 1995, again the appellant developed some problems with her left foot, ankle and tendon which were unrelated to the service-connected injury; however, examination showed, among other findings, the residual deformity at the distal tibia, site of the earlier fracture. When seen in June 1995, the appellant complained of left leg pain which was found to be due to a foreign body at the site of her 1960’s trauma with an associated small mass formation in the proximal lateral thigh, described on X-ray as a well encapsulated calcification. On VA examination in 1996, the veteran had continued evidence of deformity at the location of the healed fractured tibia, as well as what was described as a large muscular bulge in the left lateral posterior thigh and surgical incision there felt to be related to the hematoma. Accordingly, there appear to be two separate residual problems as a result of the in-service injury to the left leg, i.e., one involving hematoma and muscle bulging, and that other impairment, of a bony nature. While this is not, as the appellant has suggested, tantamount to the same sort of injury one might have from a gunshot wound, it does in fact involve both bone and muscle, and to the extent that this reflects two distinct types of impairment and functional incapacitations, and not mere pyramiding under 38 C.F.R. § 4.14 (1996), she is entitled to be compensated accordingly. First, from an objective evaluative prospective, while the claimant may have technically “satisfactory osseous alignment” of the left distal tibia and fibula, nonetheless there is residual deformity, with what the recent VA examiner has described as a slightly “crooked” left leg, which is slightly shorter and more bowed than the right leg. The Board finds that this might conceivably be compared to an acquired genu varum (which would also warrant no more than 10 percent under Code 5263); it is probably even more accurately comparable to malunion which is ratable under Diagnostic Code 5262. Since it causes slight (and no greater) knee disability, a 10 percent rating is warranted under that Diagnostic Code. She is not now shown to have such moderate knee impairment or other symptoms as to warrant an evaluation in excess thereof under that or other codes reflecting bony injury residuals. However, on the other hand, the appellant also exhibits what looks to a casual observer as “muscle bulging” in the area of the originally closed laceration scar. When this area recently exacerbated with considerable pain, it underwent closer assessment, by both VA and private physicians, and was identified as a heterotypic ossification which is clearly the result of hardened left thigh hematoma at the area of the laceration caused by the original in-service injury. The Board finds that this is probably most aptly rated as residual scarring, since the laceration was what precipitated the current problem. Although it superficially might seem to be a muscle injury it is more accurately a hematoma ossification. Absent significant functional (movement) limitations, it seems preferable to evaluate it based on the underlying cause as reflected in other symptomatic manifestations, i.e., pain, rather than under any motion- activated muscle-dominated schedular criteria. Recent clinical records show that this has caused the claimant additional problems with pain. Accordingly, the Board finds that it may be rated by comparison to a superficial scar which has had repeated ulcerations, or is tender and painful on objective demonstration, and a 10 percent rating may be assigned under Diagnostic Codes 7803- 7804. However, she does not exhibit such additional symptomatology such as objectively confirmed functional impairment, limitation of motion, etc. as would permit an evaluation in excess of 10 percent under that or any other pertinent regulations. ORDER The veteran not having submitted a well grounded claim for service connection for a left foot disorder, the appeal in that regard is denied. Entitlement to increased evaluations for a facial scar, residuals of a left acetabulum and pubis fracture and a right femur fracture, are denied. Entitlement to increased evaluations to include a 10 percent rating for residuals of fractures, left tibia and fibula; and a separate 10 percent rating for painful and tender and ulcerated/bulging scar of the left thigh, are granted, subject to the regulatory criteria pertinent to the payment of monetary awards. RONALD R. BOSCH Member, Board of Veterans' Appeals NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991 & Supp. 1997), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402, 102 Stat. 4105, 4122 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals. - 2 -