[Federal Register Volume 66, Number 213 (Friday, November 2, 2001)]
[Proposed Rules]
[Pages 55614-55617]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 01-27426]


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DEPARTMENT OF VETERANS AFFAIRS

38 CFR Part 4

RIN 2900-AI44


Ankylosis and Limitation of Motion of Digits of the Hands

AGENCY: Department of Veterans Affairs.

ACTION: Proposed rule.

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SUMMARY: This document proposes to amend the Department of Veterans 
Affairs (VA) Schedule for Rating Disabilities by revising the 
evaluation criteria for ankylosis and limitation of motion of the 
fingers and thumb. This change is necessary to ensure that veterans 
diagnosed with these conditions receive consistent evaluations.

DATES: Comments must be received by VA on or before January 2, 2002.

ADDRESSES: Mail or hand deliver written comments to: Director, Office 
of Regulations Management (02D), Department of Veterans Affairs, 810 
Vermont Ave., NW., Room 1154, Washington, DC 20420; or fax comments to 
(202) 273-9289; or e-mail comments to [email protected]. 
Comments should indicate that they are in response to ``RIN 2900-
AI44.'' All written comments received will be available for public 
inspection at the above address in the Office of Regulations 
Management, Room 1158, between the hours of 8 a.m. and 4:30 p.m., 
Monday through Friday (except holidays).

FOR FURTHER INFORMATION CONTACT: Caroll McBrine, M.D., Consultant, 
Regulations Staff (211A), Compensation and Pension Service, Veterans 
Benefits Administration, Department of Veterans Affairs, 810 Vermont 
Ave., NW., Washington, DC 20420, (202) 273-7230.

SUPPLEMENTARY INFORMATION: This document proposes to amend the 
Department of Veterans Affairs (VA) Schedule for Rating Disabilities by 
clarifying the method of evaluation for ankylosis and limitation of 
motion of the digits of the hands.
    Current diagnostic codes (DC's) 5216 through 5227 represent 
ankylosis of individual digits or combinations of digits, and they are 
grouped in the following way: DC's 5216 through 5219 represent 
unfavorable ankylosis of multiple digits; DC's 5220 through 5223 
represent favorable ankylosis of multiple digits; and DC's 5224 through 
5227 represent ankylosis of individual digits. Explanatory notes 
preceding DC 5216, following DC 5219, preceding DC 5220, following DC 
5223, and following DC 5227 give specific directions on evaluating 
limitation of motion or ankylosis of single and multiple digits, 
determining whether ankylosis is favorable or unfavorable, and 
evaluating combinations of digit amputations at various levels or any 
combination of digit amputation, ankylosis, or limitation of motion of 
the digits.
    The United States Court of Veterans Appeals (now the Court of 
Appeals for Veterans Claims), in Hill v. Principi, 3 Vet. App. 540, 541 
(1992), noted that ``[n]either the format of the code pertaining to 
finger injuries nor its interpretive notes are a model of clarity.'' We 
therefore propose to clarify the method of evaluation of ankylosis

[[Page 55615]]

and limitation of motion of single and multiple digits by revising and 
reorganizing the diagnostic codes and explanatory notes that address 
the evaluation of these conditions. The intent of this revision is to 
assure fair and consistent evaluations of these disabilities by 
clarifying existing evaluation criteria.
    We propose to relocate the interpretive notes regarding evaluations 
of ankylosis and limitation of motion of the digits of the hands into a 
single set of instructions preceding DC 5216 and to delete current 
notes (1), (2), (3), and (4) preceding DC 5216; notes (a), (b), and (c) 
following DC 5219; notes (1), (2), (3) and (4) preceding DC 5220; notes 
(a) and (b) following DC 5223; and the note following DC 5227. We 
propose to incorporate the content of these notes into the proposed 
instructions preceding DC 5216, with modifications as discussed below.
    We propose to change the term used for the third digit from 
``middle finger'' to ``long finger,'' the currently preferred 
terminology. We also propose to add descriptions of the position of 
function of the hand, and of the normal range of motion of the index, 
long, ring, and little fingers, in order to assist the rating agency in 
assessing impairment due to limitation of motion or ankylosis. We also 
propose to add Roman numeral designations for the digits: The thumb is 
digit I; the index, long, ring, and little fingers are digits II, III, 
IV, and V, respectively.
    In the current schedule, ankylosis, i.e., immobility of a joint, 
and limitation of motion, i.e., loss of any portion of the normal range 
of motion of a joint, are evaluated using the same criteria. We propose 
to revise the criteria under diagnostic codes 5216 through 5227 so that 
they address ankylosis only, and to add three new diagnostic codes, 
5228, 5229, and 5230, to evaluate limitation of motion of the thumb, 
the index or long finger, and the ring or little finger, respectively. 
The proposed criteria are derived from the material contained in note 
(3) preceding DC 5216 and note (3) preceding DC 5220, which state that 
with only one joint of a digit ankylosed or limited in its motion, 
evaluation will be based on whether motion is possible to within 2 
inches (5.1 cms.) of the median transverse fold of the palm, and in 
note (a) following DC 5223, which states that limitation of motion of 
less than 1 inch (2.5 cms.) in either direction is not considered 
disabling. We propose to evaluate limitation of motion of the index, 
long, ring, and little fingers on either the number of degrees by which 
extension is limited, or on a measurement of the gap between the 
fingertip and the palm when the finger is flexed to the extent 
possible. We propose to evaluate the thumb based on its most important 
function, opposing the fingers, as measured by the gap between the 
thumb pad and the fingers with the thumb attempting to oppose the 
fingers. These criteria are consistent with Sec. 4.71, ``Measurement of 
ankylosis and joint motion,'' which states that motion of the thumb and 
fingers should be described by appropriate reference to the joints 
whose movement is limited, with a statement as to how near, in 
centimeters, the tip of the thumb can approximate the fingers, or how 
near the tips of the fingers can approximate the median transverse fold 
of the palm.
    Current note (a) under DC 5219 indicates that extremely unfavorable 
ankylosis, i.e., all joints in extension or in extreme flexion, will be 
evaluated as amputation; note (1) preceding DC 5216 establishes that 
ankylosis of both the metacarpophalangeal and proximal interphalangeal 
joints, with either in extension or extreme flexion, will be evaluated 
as amputation. We propose to evaluate an ankylosed digit as amputation 
when both joints are ankylosed, and either is in extension or ``full'' 
flexion. (Flexion of the fingers is not possible beyond ``full,'' or 
complete, flexion.)
    In DC's 5217 through 5223, we propose to simplify the criteria 
where feasible by indicating, for example, ``thumb and any three 
fingers,'' rather than separately listing ``thumb, index, middle, and 
ring,'' ``thumb, index, middle, and little,'' etc.
    The current schedule refers to motion of the fingertips to within 
certain distances of the ``median transverse fold of the palm.'' Since 
that fold is mentioned neither in standard anatomy texts nor in 
``Dorland's Illustrated Medical Dictionary,'' we propose to change that 
term to ``proximal transverse crease of the palm,'' an anatomic 
landmark where the fingertips normally meet the palm when they are in 
full flexion. The current schedule uses different language in different 
places to describe limited motion between the fingers and the palm or 
between the thumb and the fingers, e.g., using ``whether motion is 
possible to within 2 inches (5.1 cms.) of the median transverse fold of 
the palm'' in one place and ``limited motion preventing flexion of tips 
to within 2 inches (5.1 cms.) of median transverse fold of the palm'' 
in another place. For the sake of clarity, we propose to measure these 
distances in terms of the gap, expressed in inches or centimeters, 
between the fingertips and the proximal transverse crease of the palm, 
with the finger flexed to the extent possible, or between the pad of 
the thumb and the fingers, with the thumb attempting to oppose the 
fingers.

Paperwork Reduction Act

    This document contains no provisions constituting a collection of 
information under the Paperwork Reduction Act (44 U.S.C. 3501-3520).

Executive Order 12866

    This document has been reviewed by the Office of Management and 
Budget under Executive Order 12866.

Regulatory Flexibility Act

    The Secretary hereby certifies that this regulatory amendment will 
not have a significant economic impact on a substantial number of small 
entities as they are defined in the Regulatory Flexibility Act, 5 
U.S.C. 601-612. The reason for this certification is that this 
amendment would not directly affect any small entities. Only VA 
beneficiaries could be directly affected. Therefore, pursuant to 5 
U.S.C. 605(b), this amendment is exempt from the initial and final 
regulatory flexibility analysis requirements of sections 603 and 604.

    The Catalog of Federal Domestic Assistance numbers are 64.104 
and 64.109.

List of Subjects in 38 CFR Part 4

    Disability benefits, Individuals with disabilities, Pensions, 
Veterans.

    Approved: October 2, 2001.
Anthony J. Principi,
Secretary of Veterans Affairs.

    For the reasons set out in the preamble, 38 CFR part 4, subpart B, 
is proposed to be amended as set forth below:

PART 4--SCHEDULE FOR RATING DISABILITIES

    1. The authority citation for part 4 continues to read as follows:

    Authority:  38 U.S.C. 1155, unless otherwise noted.

Subpart B--Disability Ratings

    2. Section 4.71a is amended by removing the tables ``MULTIPLE 
FINGERS: UNFAVORABLE ANKYLOSIS''; MULTIPLE FINGERS: FAVORABLE 
ANKYLOSIS''; and ANKYLOSIS OF INDIVIDUAL FINGERS'' and adding, in their 
place, the following table to read as follows:


Sec. 4.71a  Schedule of ratings--musculoskeletal system.

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[[Page 55616]]



  Evaluation of Ankylosis or Limitation of Motion of Single or Multiple
                           Digits of the Hand
------------------------------------------------------------------------
                                                             Rating
                                                       -----------------
                                                         Major    Minor
------------------------------------------------------------------------
  (1) For the index, long, ring, and little fingers
   (digits II, III, IV, and V), 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 (digit
   I) 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 digits
   II through V, 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.
  (2) 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.
  (3) Evaluation of ankylosis of the index, long,
   ring, and little fingers:
    (i) If both the metacarpophalangeal and proximal
     interphalangeal joints of a digit are ankylosed,
     and either is in extension or full flexion, or
     there is rotation or angulation of a bone,
     evaluate as amputation without metacarpal
     resection, at proximal interphalangeal joint or
     proximal thereto.
    (ii) If both the metacarpophalangeal and proximal
     interphalangeal joints of a digit are ankylosed,
     evaluate as unfavorable ankylosis, even if each
     joint is individually fixed in a favorable
     position.
    (iii) If only the metacarpophalangeal or proximal
     interphalangeal joint is ankylosed, and there is
     a gap of more than two inches (5.1 cm.) between
     the fingertip(s) and the proximal transverse
     crease of the palm, with the finger(s) flexed to
     the extent possible, evaluate as unfavorable
     ankylosis.
    (iv) If only the metacarpophalangeal or proximal
     interphalangeal joint is ankylosed, and there is
     a gap of two inches (5.1 cm.) or less between the
     fingertip(s) and the proximal transverse crease
     of the palm, with the finger(s) flexed to the
     extent possible, evaluate as favorable ankylosis.
  (4) Evaluation of ankylosis of the thumb:
    (i) If both the carpometacarpal and
     interphalangeal joints are ankylosed, and either
     is in extension or full flexion, or there is
     rotation or angulation of a bone, evaluate as
     amputation at metacarpophalangeal joint or
     through proximal phalanx.
    (ii) If both the carpometacarpal and
     interphalangeal joints are ankylosed, evaluate as
     unfavorable ankylosis, even if each joint is
     individually fixed in a favorable position.
    (iii) If only the carpometacarpal or
     interphalangeal joint is ankylosed, and there is
     a gap of more than two inches (5.1 cm.) between
     the thumb pad and the fingers, with the thumb
     attempting to oppose the fingers, evaluate as
     unfavorable ankylosis.
    (iv) If only the carpometacarpal or
     interphalangeal joint is ankylosed, and there is
     a gap of two inches (5.1 cm.) or less between the
     thumb pad and the fingers, with the thumb
     attempting to oppose the fingers, evaluate as
     favorable ankylosis.
  (5) If there is limitation of motion of two or more
   digits, evaluate each digit separately and combine
   the evaluations.
------------------------------------------------------------------------
                I. Multiple Digits: Unfavorable Ankylosis
------------------------------------------------------------------------
5216  Five digits of one hand, unfavorable ankylosis         60       50
 of

[[Page 55617]]

 
Note: Also consider whether evaluation as amputation
 is warranted
5217  Four digits of one hand, unfavorable ankylosis
 of:
    Thumb and any three fingers.......................       60       50
    Index, long, ring, and little fingers.............       50       40
Note: Also consider whether evaluation as amputation
 is warranted.
5218  Three digits of one hand, unfavorable ankylosis
 of:
    Thumb and any two fingers.........................       50       40
    Index, long, and ring; index, long, and little; or       40       30
     index, ring, and little fingers..................
    Long, ring, and little fingers....................       30       20
Note: Also consider whether evaluation as amputation
 is warranted.
5219  Two digits of one hand, unfavorable ankylosis
 of:
    Thumb and any finger..............................       40       30
    Index and long; index and ring; or index and             30       20
     little fingers...................................
    Long and ring; long and little; or ring and little       20       20
     fingers..........................................
Note: Also consider whether evaluation as amputation
 is warranted.
------------------------------------------------------------------------
                II. Multiple Digits: Favorable Ankylosis
------------------------------------------------------------------------
5220  Five digits of one hand, favorable ankylosis of        50       40
5221  Four digits of one hand, favorable ankylosis of:
    Thumb and any three fingers.......................       50       40
    Index, long, ring, and little fingers.............       40       30
5222  Three digits of one hand, favorable ankylosis
 of:
    Thumb and any two fingers.........................       40       30
    Index, long, and ring; index, long, and little; or       30       20
     index, ring, and little fingers..................
    Long, ring and little fingers.....................       20       20
5223  Two digits of one hand, favorable ankylosis of:
    Thumb and any finger..............................       30       20
    Index and long; index and ring; or index and             20       20
     little fingers...................................
    Long and ring; long and little; or ring and little       10       10
     fingers..........................................
------------------------------------------------------------------------
                   III. Ankylosis of Individual Digits
------------------------------------------------------------------------
5224  Thumb, ankylosis of:
    Unfavorable.......................................       20       20
    Favorable.........................................       10       10
Note: Also consider whether evaluation as amputation
 is warranted.
5225  Index finger, ankylosis of:
    Unfavorable or favorable..........................       10       10
Note: Also consider whether evaluation as amputation
 is warranted.
5226  Long finger, ankylosis of:
    Unfavorable or favorable..........................       10       10
Note: Also consider whether evaluation as amputation
 is warranted.
5227  Ring or little finger, ankylosis of:
    Unfavorable or favorable..........................        0        0
Note: Also consider whether evaluation as amputation
 is warranted.
------------------------------------------------------------------------
              IV. Limitation of motion of individual digits
------------------------------------------------------------------------
5228  Thumb, limitation of motion:
    With a gap of more than two inches (5.1 cm.)             20       20
     between the thumb pad and the fingers, with the
     thumb attempting to oppose the fingers...........
    With a gap of one to two inches (2.5 to 5.1 cm.)         10       10
     between the thumb pad and the fingers, with the
     thumb attempting to oppose the fingers...........
    With a gap of less than one inch (2.5 cm.) between        0        0
     the thumb pad and the fingers, with the thumb
     attempting to oppose the fingers.................
5229  Index or long finger, limitation of motion:
    With a gap of one inch (2.5 cm.) or more between         10       10
     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.......................................
    With a gap of less than one inch (2.5 cm.) between        0        0
     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..................................
5230  Ring or little finger, limitation of motion:
    Any limitation of motion..........................        0        0
------------------------------------------------------------------------

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[FR Doc. 01-27426 Filed 11-1-01; 8:45 am]
BILLING CODE 8320-01-P