Decision Date: 07/21/95 Archive Date: 07/25/95 DOCKET NO. 93-17 070 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in No. Little Rock, Arkansas THE ISSUES 1. Entitlement to service connection for fungus of both feet. 2. Entitlement to service connection for arthritis of the left hand and wrist, secondary to the veteran's service- connected residuals of the left hand. 3. Entitlement to service connection for amputation of the right arm, secondary to the veteran's service-connected residuals of the left hand and right wrist. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Brian W. Lemoine, Associate Counsel INTRODUCTION The veteran had active military service from September 1959 to August 1962 and from April 1964 to November 1974. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 1991 rating decision of the No. Little Rock, Arkansas Regional Office (RO) of the Department of Veterans Affairs (VA), which denied the veteran's claims seeking entitlement to service connection for fungus of both feet; for arthritis of the left hand and wrist, secondary to the veteran's service-connected residuals of the left hand; and for amputation of the right arm, secondary to the veteran's service-connected residuals of the left hand laceration with tendon and nerve involvement and traumatic arthritis of the right wrist. A February 1993 rating decision of the RO denied the veteran's claim for service connection for arthritis of the spine. However, the issue of service connection for arthritis of the spine has not been developed for appellate review inasmuch as, according to the records before the Board, the veteran has not filed a notice of disagreement, has not been provided with a supplemental statement of the case, and has not filed a substantive appeal. Accordingly, that issue is not before the Board at this time. CONTENTIONS OF APPELLANT ON APPEAL The veteran and his representative contend, in effect, that service connection is warranted for fungus of both feet; for arthritis of the left hand and wrist, secondary to the veteran's service-connected residuals of his left hand injury; and for amputation of the right arm, secondary to the veteran's service-connected left hand and right wrist disorders. They contend that the veteran had treatment in service for bilateral foot fungus and the veteran continues to suffer from chronic foot fungus. The veteran's representative notes that the veteran is presently service- connected for residuals of the left hand from a laceration injury with tendon and nerve involvement; and for residuals of traumatic arthritis to the right wrist, secondary to malunion. The representative contends that the veteran has developed left hand and wrist arthritis, and suffered an amputation of the right arm secondary to these service- connected disabilities. They further contend that as a result of his weakened left hand and arthritic right wrist, when the veteran's jacket became caught in a mechanical auger, the veteran was unable to push away with his left hand and was unable to pull his right wrist out of the jacket and, as a result, the veteran suffered an amputation of his right arm. Consequently, the veteran's representative requests that the case be favorably decided under the provisions of 38 C.F.R. § 3.310 (1994). DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), 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 preponderance of the evidence is against the veteran's claims for service connection for fungus of both feet; and for arthritis of the left hand and wrist, secondary to the service-connected residuals of his left hand injury. It is the decision of the Board that the record supports a claim for service connection for amputation of the right arm, secondary to the service-connected residuals of the veteran's left hand and right wrist disorders. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the veteran's appeal has been obtained by the RO. 2. The veteran's foot fungus disorder in service was acute and transitory, resolving without chronic disability. 3. Service connection is currently in effect for residuals to the left hand from a laceration injury with tendon and nerve involvement; and for residuals of traumatic arthritis to the right wrist, secondary to malunion. 4. The veteran is not shown to have arthritis of the left hand and wrist, that is causally related to the service- connected residuals of the left hand laceration injury with tendon and nerve involvement. 5. The veteran's amputation injury to the right arm is causally related to his service-connected residuals to the left hand from a laceration injury with tendon and nerve involvement; and to his residuals of degenerative arthritis to the right wrist, secondary to malunion. CONCLUSION OF LAW 1. The veteran does not have a foot fungus disorder that was incurred in or aggravated by the veteran's active service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 1991); 38 C.F.R. § 3.303 (b) (1994). 2. The veteran does not have arthritis of the left hand and wrist that is proximately due to or the result of the service-connected disability of the left hand from a laceration injury with tendon and nerve involvement. 38 U.S.C.A. § 5107 (West 1991); 38 C.F.R. § 3.310(a) (1994) 3. Amputation of the right arm is proximately due to or the result of the service-connected disabilities of the left hand from a laceration injury with tendon and nerve involvement and residuals of degenerative arthritis to the right wrist, secondary to malunion. 38 U.S.C.A. § 5107 (West 1991); 38 C.F.R. § 3.310(a) (1994) REASONS AND BASES FOR FINDINGS AND CONCLUSION Factual Background Service Records Review of the veteran's service medical records reveals a normal entrance physical examination in September 1959. Clinical records indicate the veteran was seen for a fungus infection of the left foot in March 1960. Desenex was prescribed. In March 1961, the veteran was again seen for athlete's foot of the left foot between the 4th and 5th toes. In December 1961, the veteran was seen with complaints of a painful left foot. Dermatophytosis with abrasion between the toes was noted. The examiner prescribed Desenex and wearing white socks. The veteran's separation examination in June 1962 was unremarkable. At that time, the feet were described as normal and there was no indication of a continuing foot fungus problem. The veteran reenlisted in service in April 1964 and his entrance physical examination was unremarkable. At that time, the veteran's feet were described as normal. Clinical notes indicate that the veteran suffered a trauma to his left hand in July 1965, with damage to the tendons of the second and third fingers. The admission report indicates the veteran was hospitalized in August 1965, to have a surgical tendon graft of the left long finger and a neurolysis of the left index finger. The November 1965 surgical summary report gives a history of the veteran being injured on duty, when an aircraft target intercept computer was dropped and fell on his left hand. The summary report states that at the time of injury the wound was closed without an attempt to repair the nerve or tendon damage. The report further notes that admission examination revealed that the flexor digitorum profundus and flexor digitorum sublimus of the long finger were both severed. There was also absent sensation of the radial aspect of the index finger. The summary report describes a surgical tendon graft on the left long finger using the flexor digitorum sublimus tendon and a neurolysis of the left index finger, performed in September 1965. The veteran was discharged from the hospital in November 1965 and at that time, he had 10 degrees of flexion in each of the interphalangeal joints of the long finger and a return of sensation to the radial aspect of the index finger. A February 1966 report of a medical board indicated that upon examination, of the left hand the veteran had 10 degrees of flexion of the distal interphalangeal joint of the long finger and 35 degrees of flexion at both the metacarpophalangeal and the proximal interphalangeal joints. There was no flexion of the distal interphalangeal joint of the ring finger. The veteran was right handed. The Board recommended that the veteran be returned for six months to limited duties, not requiring precise movement of both hands. A medical board was held to reexamine the veteran and issued a report in December 1966. That report indicates that a tenodesis and temporary arthrodesis of the distal interphalangeal joint of the left ring finger was performed in August 1966. The arthrodesis included inserting two K- wires for joint stability. The wires were removed in September 1966 and closure was attempted, but the skin graft did not take. In October 1966, a local pedicle flap was raised and used to cover the exposed bone and a split thickness skin graft was used to cover the base of the pedicle flap. The December 1966 report indicates that healing occurred , however, the majority of flexion that was desired at the distal interphalangeal joint was lost and some bony deviation of the distal phalanx occurred toward the ulnar side. The veteran was again returned to six months of limited duty. Further review of service medical records reveals a June 1967 medical board report finding the veteran fit to return to full duty. Examination of his left hand revealed normal sensation to pin prick over the entire hand. The DIP joint of the middle finger was fused at 75 degrees flexion, lacking 2 cm. of reaching the palm. The DIP joint of the ring finger was fused at 0 degrees flexion with 30 degrees ulnar deviation and a 10 percent soft tissue loss on the ulnar side was described. X-ray of the left hand revealed destructive changes present in the distal portion of the middle phalanx of the forth digit which was felt to be old post traumatic changes. It was felt the veteran could perform the duties of his rate. However, clinical notes reveal that in July 1967, the veteran suffered a fracture of the distal right radius, in addition to other injuries, as a result of an automobile accident. A closed reduction of the fracture of his distal right radius was performed. Radiological studies of the veteran's hands in July 1967, indicated some impaction of the distal right radial fracture in otherwise near anatomic position; and on the left hand, an old traumatic injury to the fourth finger was identified, with partial absence of the bone of the distal portion of the second phalanx and some resulting deformity. A February 1968 medical board report noted that the veteran had suffered radial shortening and subluxation at the distal radial ulnar joint as a result of the fracture to his right radius. The report described no pain but decreased motion of the right wrist and slight loss of grip in the right hand. The report recommended that the veteran be returned to full duty. Subsequent service medical records indicate the veteran was again hospitalized in July 1974 with a diagnosis of residuals of injury to the left hand, namely malunion of an osteotomy of the left ring finger, distal joint, and failure of an attempted arthrodesis of the long finger, distal joint. A September 1974 medical board report notes that upon examination in July 1974, the left ring finger had fused at the distal join in a position of ulnar deviation and extension, rendering the finger functionless and cumbersome in that it prevented normal use of the adjacent fingers. The veteran had complaints of poor sensation in the left index, middle and ring fingers and of pain in the right wrist, aggravated by activity and climatic conditions. The examination of the right wrist noted a prominence of the ulnar styloid. Forearm rotation was limited with supination at 60 degrees and pronation at 70 degrees. Flexion was reported as full and extension at 25 degrees. Radial deviation was normal and ulnar deviation was essentially zero. Modest tenderness in the region of the ulnar styloid was noted, especially on radial ulnar compression. Regarding the left hand and wrist, the examination found some mild dystrophic skin changes in the ulnar aspect of the ring finger. The long finger demonstrated a flail distal joint which had approximately 60 percent of its normal range of motion passively. The ring finger was fused in a position of 5 degrees extension and 15 of ulnar deviation at the distal joint with dystrophic skin changes noted on the ulnar border and ischemic changes noted in the pad and nail. Except for the middle and ring fingers, he had intact motor tendon units to all fingers. X-ray studies of the right wrist indicated a malunion of the distal radial fracture with a marked loss of length of the radius. Prominence of the ulnar styloid with hypertrophic degenerative changes were noted at the radial volar lip. X-ray studies of the left hand indicated the described deformity of the ring finger at the distal joint. Otherwise, no abnormalities were noted. The report describes the veteran undergoing surgery in July 1974, for an arthrodesis of the distal joint of the left long finger with K-wire stabilization and an osteotomy of the distal joint of the left ring finger with K-wire stabilization. The medical board report notes that although the surgery improved the functional position of the fingers of the left hand, there was still a loss of normal sensation in the left index, middle, and ring fingers. The veteran's right wrist was described as having persistent pain and loss of motion with a prognosis of further deterioration. The final diagnoses of the medical board was malunion fracture, right distal radius, status post injury; arthrofibrosis of the right wrist, secondary to the malunion fracture; degenerative arthritis of the right wrist, secondary to the malunion fracture; and residuals of laceration of the left index, middle and ring fingers with bone, tendon, and nerve involvement. The September 1974 medical board recommended that the veteran be medically discharged from further service. Postservice Records Based upon the above service medical records, a January 1975 rating decision granted the veteran service connection, effective from November 1974, for residuals of laceration of the left index, middle and ring fingers with bone tendon and nerve involvement, evaluated as 20 percent disabling; and for residuals of degenerative arthritis of the right wrist, secondary to malunion, evaluated as 10 percent disabling. Review of subsequent medical evidence reveals Department of Defense outpatient clinical notes from February 1986, which indicate the veteran complained of osteoarthritis in both hands since 1972. The examiner observed scars on the left hand and tenderness. The assessment was traumatic arthritis of the left hand. Private medical records from G. Peter Dingeldein, M.D., indicate that the veteran was first seen in March 1989 with complaints of weakness in the left hand and dropping things. The veteran also complained of increasing numbness over the last two or three years, in the index finger along the radial border of the left hand. Examination revealed no sublimus function in the left index or long finger and there was fusion of the distal interphalangeal of the left long and ring fingers. There was a grip strength deficit of 50 percent in the left hand as compared to the right hand. Dr. Dingeldein felt that surgery would not improve the sensation or function of the injured fingers so the veteran was placed on a physical therapy program. The veteran did increase his grip strength more than three times and was released from further treatment in May 1989, when it was felt he had reached his maximum benefit. It was then felt that the veteran still had mild to moderate problems with his grip strength although both hands were roughly comparable. The January 27, 1991 private hospital admission notes indicate that the veteran suffered a traumatic amputation of the right arm at the shoulder. The history, taken at that time, indicates the veteran's coat and right arm were caught by a post auger. At the scene, there was a complete amputation of the right arm at the shoulder level. Hospital records indicate that the veteran underwent ligation of the axillary artery and debridement dressing of the wound. He began to stabilize after approximately 24 hours. Further hospital records reveal that numerous X-ray studies of the veteran were completed, including images of the left hand. The X-ray studies of the veteran's left hand indicated no fractures, dislocations, or other significant bone or joint abnormalities, with a negative impression. On February 11, 1991, the veteran underwent surgical closure with grafting of the stump. A portion of the clavicle was amputated at that time to allow skin closure. The veteran was discharged from the hospital on February 18, 1991. An August 1991 private rehabilitation examination of the veteran listed the amputation of the right arm as the major disabling condition, and nerve and tendon damage to the left hand as a secondary disabling condition. The most recent VA examination of the veteran, in August 1991, diagnosed the traumatic disarticulation of the right arm at the shoulder. Regarding the veteran's foot disorder, examination by a dermatologist indicated that the veteran had no problem with his feet for the last three or four years and there was no problem at present. The veteran's left wrist and hand were not examined during this VA examination. In September 1992, the veteran, accompanied by his representative, appeared and presented testimony at a hearing on appeal before a VA hearing officer. The veteran testified that he was treated for a foot fungus condition in the early 1960s while in service. He testified that heat and humidity, or getting his feet wet will cause the condition to flare up, but as long as he keeps the feet clean and changes socks regularly, he does not have any trouble. Regarding his left hand, the veteran testified that he had a limited range of motion ever since his service-connected injury to the left hand. The veteran cited Dr. Dingeldein's report as supporting his claim. Regarding the amputation of his right arm, the veteran testified that his coat sleeve became caught by a post auger and he was pulled into the machine, which amputated his right arm. The veteran maintained that because of his service-connected disabilities, he could not twist and pull his right hand out of his coat to get loose from the auger and then because of left hand weakness he could not grip with his left hand to push or pull away from the auger. A complete transcript of the testimony is of record. Analysis Initially, we note that we have found that the appellant's claims are well-grounded within the meaning of 38 U.S.C.A. § 5107(a). That is, we find that he has presented claims which are not inherently implausible. Furthermore, after reviewing the record, we are satisfied that all relevant facts have been properly developed. The record is devoid of any indication that there are other records available which might pertain to the issues on appeal. No further assistance to the veteran is required to comply with the duty to assist him, as mandated by 38 U.S.C.A. § 5107(a). In order to establish service connection for a disability, there must be objective evidence that establishes that such disability either began in or was aggravated by service. 38 U.S.C.A. §§ 1110, 1131. If a disability is not shown to be chronic during service, service connection may nevertheless be granted when there is continuity of symptomatology post- service. 38 C.F.R. § 3.303(b). "A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service." Watson v. Brown, 4 Vet.App. 309, 314 (1993). A disability which is proximately due to or the result of a service-connected disease or injury shall be service- connected. 38 C.F.R. § 3.310. I. Fungus of both feet. Upon review of the entire record, the Board concludes that service connection for a chronic bilateral foot fungus condition is not warranted by the preponderance of the evidence. Instead, we find that the symptoms in service were acute and transitory in nature and resolved without a chronic disability. The veteran was treated in service in 1960 and 1961 for a fungus infection of the left foot. After 1961, service medical records are completely negative for any complaints or indications of a foot fungus disorder. The veteran's separation examination in June 1962 and his reentry examination in April 1964 describe the feet as normal. The August 1991 VA dermatological examination of the veteran indicated no problem with the veteran's feet for the last 3 or 4 years. At his hearing on appeal, the veteran testified that he does not have any foot trouble as long as he keeps his feet clean and changes socks. Therefore, we find no medical evidence of a chronic foot fungus disability which may be related to service and this claim is denied. II. Arthritis of the left hand and wrist, secondary to service-connected residuals of the left hand. We note that at the time of his separation from service, the September 1974 medical board diagnosed the veteran with residuals of laceration of the left index, middle and ring fingers with bone, tendon, and nerve involvement. X-ray studies taken at that time revealed degenerative arthritis of the right wrist but not of the left hand or wrist. The X-ray studies of the left hand indicated a deformity of the ring finger, but otherwise, there were no abnormalities. We conclude that at the time of separation from service, the veteran did not have arthritis of the left hand or wrist. Department of Defense outpatient clinical notes from February 1986, indicate the veteran complained of osteoarthritis in both hands, and the examiner made an assessment of traumatic arthritis in the left hand. We note that this assessment was based on physical examination without accompanying X-ray studies. We consider the conclusion of this examiner to be of less weight and reliability than other examinations conducted with X-ray studies. During his testimony, at his hearing on appeal, the veteran cited the reports of Dr. Dingeldein as proof that he had arthritis of the left hand and wrist. We have carefully reviewed Dr. Dingeldein's notes and report and they make no diagnosis of arthritis and therefore, do not support the veteran's claim. Dr. Dingeldein's report notes weakness and numbness of the veteran's left hand, resulting from the service-connected left hand injury. A prescribed physical therapy program did improve the veteran's grip strength and Dr. Dingeldein felt that surgery would not improve the sensation or function of the injured fingers further so the veteran was discharged. The most recent X-ray studies of the veteran's left hand were in January 1991, and they indicated no fractures, dislocations, or other significant bone or joint abnormalities, with a negative impression. Based on this recent examination of the veteran, we find that the veteran does not presently have arthritis of the left hand or wrist. We have carefully considered the veteran's testimony and it is clear that the veteran is sincere in his belief that he has arthritis of the left hand and wrist, as a result of his service-connected left hand injury. However, the medical evidence does not support the veteran's assertion, and inasmuch as the veteran is offering his own medical opinion, we would note that the record does not indicate that the veteran has any medical expertise. See Espiritu v. Derwinski, 2 Vet.App. 492 (1992). Therefore, upon review of the entire record, the Board concludes that service connection for arthritis of the left hand and wrist, secondary to the veteran's service-connected residuals of the left hand, is not warranted by the preponderance of the evidence and this claim is denied. III. Amputation of the right arm, secondary to service- connected residuals of the left hand and right wrist. At the time of his medical board in September 1974, the veteran was diagnosed with a malunion fracture of the right distal radius; arthrofibrosis of the right wrist, secondary to the malunion fracture; degenerative arthritis of the right wrist, secondary to the malunion fracture; and residuals of laceration of the left index, middle and ring fingers with bone, tendon, and nerve involvement. The medical board report noted that the veteran had a loss of normal sensation in the left index, middle, and ring fingers and the right wrist was described as having persistent pain and loss of motion with a prognosis of further deterioration. The veteran was service-connected, effective from November 1974, for residuals of laceration of the left index, middle and ring fingers with bone tendon and nerve involvement, evaluated as 20 percent disabling; and for residuals of traumatic arthritis of the right wrist, secondary to malunion, evaluated as 10 percent disabling. Accordingly, we find that the veteran clearly had some limitation of strength and mobility in the right wrist and in the left hand. There was no VA examination of the veteran's service- connected disabilities prior to the January 1991 amputation of his right arm. However, there is no medical evidence that the veteran's service-connected disabilities improved after his 1975 disability rating. At his September 1992 hearing on appeal, the veteran testified that his coat sleeve became caught by a post auger and he was pulled into the machine, which amputated his right arm. The veteran maintained that because of his service-connected disabilities, he could not twist and pull his right hand out of his coat to get loose from the auger and then he could not grip with his left hand to push or pull away from the auger. We have carefully considered the veteran's testimony on this issue. While, it is possible that the amputation of the veteran's right arm would have occurred regardless of his service-connected disabilities, this can not be determined with certainty from the evidence before us. We find the veteran's testimony under oath to be plausible and there is no other evidence to contradict the veteran's description of his accident. Accordingly, the Board, based on its review of the relevant evidence in this matter, finds that the evidence is in equipoise as to the merits of this claim. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. 38 C.F.R. § 3.102. In light of the foregoing, and granting the veteran the benefit of any doubt, the Board concludes that the amputation of the veteran's right arm is causally related to his service-connected disabilities of the left hand and right wrist. Service connection for this claim is warranted. 38 C.F.R. § 3.310(a). ORDER Service connection for fungus of both feet is denied. Service connection for arthritis of the left hand and wrist, secondary to service-connected residuals of the left hand is denied. Service connection for amputation of the right arm, secondary to service-connected residuals of the left hand and right wrist is granted. S. L. COHN Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991), 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 (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 -