Ankylosis of Three Digits of One Hand — VA Disability Rating Criteria (DC 5218)

Diagnostic Code 5218 · 38 CFR §4.71a

What Is It?

DC 5218 is the three-digit step of the multiple-digit ankylosis block in 38 CFR 4.71a, and it is written for unfavorable ankylosis — three digits of one hand fixed in positions that do not leave the hand usable. Three combinations are listed and each pays differently, so which three digits are fused matters as much as the fact that three are. Unfavorable ankylosis of the thumb and any two fingers is 50 percent major and 40 minor. The index with two of the remaining fingers — index and long and ring, index and long and little, or index and ring and little — is 40 and 30. The long, ring and little fingers together, with both the thumb and the index finger spared, is 20 percent on either hand. Handedness is settled under 38 CFR 4.69, and the schedule calls the middle finger the long finger. Favorable ankylosis of three digits is a different code: DC 5222, at 40 and 30 percent for the thumb and any two fingers, 30 and 20 for the index trios, and 20 percent on either hand for the long, ring and little fingers. The fixed position decides between the two codes. Under 38 CFR 4.71a, a finger with both the metacarpophalangeal and the proximal interphalangeal joint ankylosed is unfavorable even where each joint is individually in a favorable position; where only one of those joints is fused, a gap of more than two inches (5.1 cm) between the fingertip and the proximal transverse crease of the palm, with the finger flexed as far as it will go, is unfavorable and two inches or less is favorable. The Note under this code directs the rater also to consider whether evaluation as amputation is warranted. Running the other way, 38 CFR 4.68 caps the combined rating for disabilities of one extremity at the evaluation for amputation at the elective level.

Rating Criteria

Evidence Needed

• Range of motion testing on every joint of every affected digit, recorded in degrees, showing zero motion. Ankylosis is the absence of motion; severely limited motion is a different finding rated under different codes.
• The three digits named individually. This code moves through four percentages depending on whether the thumb is involved, whether the index finger is involved, or neither — "three digits" alone cannot be rated.
• A description of the position each digit is fixed in, and whether the ankylosis is favorable or unfavorable. Unfavorable three-digit ankylosis is DC 5218; favorable three-digit ankylosis is DC 5222, one step lower at each combination.
• Whether both the metacarpophalangeal and proximal interphalangeal joints of a digit are ankylosed. Under 38 CFR 4.71a that combination is unfavorable by definition, even if each joint is individually in a favorable position.
• Where only one of those joints is fused, the measured gap between the fingertip and the proximal transverse crease of the palm with the finger flexed as far as possible. More than two inches is unfavorable; two inches or less is favorable.
• Documentation of handedness in the record. It is worth ten percentage points on the two higher combinations of this code, though not on the long-ring-little row, which pays the same on either hand.
• Imaging showing the fusion, operative reports where the fusion was surgical, and the service treatment records covering the original injury.

C&P Exam Tips

• Ask the examiner to record zero degrees joint by joint rather than describing the hand as a whole.
• Have each ankylosed digit named. Thumb-plus-two, index-plus-two and long-ring-little are three different rows of this code.
• Ask for the fixed position of each digit to be described. Favorable and unfavorable are defined terms in 38 CFR 4.71a, not impressions.
• If only one joint of a finger is fused, ask for the fingertip-to-palm gap to be measured with the finger flexed as far as it will go, and written down. That measurement decides favorable against unfavorable.
• Make sure the examination establishes which hand is dominant and records it.
• Report whether the fused digits interfere with the motion of the digits that still move — the block's Notes contemplate additional evaluation for that interference.
• Ask whether evaluation as amputation would be more favorable, which is what the Note to this code directs.
• Describe what the other hand has taken on. Overuse of the sound side is a common and claimable consequence.

How to File

File for ankylosis of the hand and name the three digits that are fixed, because this code carries four percentages and the digits decide which one applies. State which hand is dominant in the claim itself rather than leaving it to the examination; under 38 CFR 4.69 handedness is settled on the evidence of record or by testing, and it is worth ten percentage points on the thumb and index combinations. Provide range of motion findings showing zero degrees at each joint together with a description of the position each digit is fixed in, since that description is what separates DC 5218 from DC 5222. Ask that evaluation as amputation be considered, which the Note to this code directs, and expect 38 CFR 4.68 to apply in the other direction: the combined rating for disabilities of one extremity cannot exceed the evaluation for amputation at the elective level.

Common Mistakes

• Reading DC 5218 as a single figure. It carries four — 50, 40, 30 and 20 — and the digits involved decide which one applies.
• Not naming the three digits. A decision written from "ankylosis of three digits" cannot tell a 50 percent picture from a 20 percent one.
• Assuming the dominant hand always pays more. It does on the thumb and index combinations, but the long, ring and little row is 20 percent on either hand.
• Treating severe limitation of motion as ankylosis. Ankylosis is zero motion; where the joints still move, the limitation-of-motion codes for individual digits apply.
• Missing the line between favorable and unfavorable ankylosis, which is the line between DC 5218 and DC 5222.
• Overlooking the amputation comparison the Note requires — and being surprised by 38 CFR 4.68 when separate hand, wrist and nerve evaluations are capped.

Frequently Asked Questions

Why does DC 5218 have four different percentages?

Because the schedule lists three combinations, each with a major and a minor column: the thumb and any two fingers at 50 and 40, the index with two of the remaining fingers at 40 and 30, and the long, ring and little fingers at 20 on either hand. Those six column entries produce four distinct percentages.

Does the dominant hand always get the higher figure?

Not always. On the thumb combination and the index combinations the major hand is ten points higher, but the long, ring and little row is 20 percent in both columns, so handedness makes no difference there.

What is the difference between DC 5218 and DC 5222?

DC 5218 is unfavorable ankylosis of three digits and DC 5222 is favorable ankylosis of the same three digits, one step lower at every combination — 40 and 30, 30 and 20, and 20 on either hand. 38 CFR 4.71a defines the two terms by joint position and by the fingertip-to-palm gap.

What counts as unfavorable ankylosis of a finger?

Under 38 CFR 4.71a, a finger with both the metacarpophalangeal and the proximal interphalangeal joint ankylosed is unfavorable, even if each joint is individually fixed in a favorable position. Where only one of those joints is ankylosed, a gap of more than two inches between the fingertip and the proximal transverse crease of the palm, with the finger flexed as far as possible, is unfavorable.

Can the fingers that still move be rated as well?

The Notes to this part of 38 CFR 4.71a contemplate an additional evaluation for resulting limitation of motion of other digits or interference with overall function of the hand, and where two or more digits show limitation of motion the schedule directs that each digit be evaluated separately and the evaluations combined. Everything assigned for that hand remains subject to the amputation rule in 38 CFR 4.68.