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C&P Exam Prep: Radius and Ulna, Nonunion with Flail False Joint
DBQ Overview
Interview + Physical- Form Name
- Elbow_and_Forearm
- Form Code
- Elbow_and_Forearm
- Page Count
- 15
- Examiner Type
- Physician or Physician Assistant
- Estimated Duration
- 30-45 minutes
- Exam Format
- Interview + Physical
What to Expect During Your Exam
Exam Overview
To document the nature and severity of nonunion of the radius and/or ulna with flail false joint, including range of motion, functional loss, pain, and impact on daily activities, to establish or confirm a disability rating under DC 5210.
What the examiner evaluates:
- Confirmed diagnosis of radius and/or ulna nonunion with flail false joint
- Location of nonunion (upper half vs. lower half)
- Presence and degree of false movement at the nonunion site
- Loss of bone substance (1 inch or more)
- Presence of marked deformity (cubitus valgus or varus)
- Active and passive range of motion for elbow flexion, extension, forearm pronation, and supination
- Pain on active motion, passive motion, weight-bearing, and non-weight-bearing
- DeLuca factors: pain, fatigue, weakness, incoordination, flare-ups during or after repetitive use
- Grip strength and functional use of the upper extremity
- Presence of flail joint characteristics
- Surgical history including arthroplasty or other elbow/forearm procedures
- Assistive device use
- Functional impairment in daily activities and occupational tasks
Exam will include both interview and physical examination. The examiner will handle your forearm and elbow to assess mobility, instability, and false movement at the nonunion site. Wear loose or easily removable clothing for easy access to the affected arm. The examiner may compare your affected arm to the unaffected side. Bring all relevant imaging (X-rays, CT scans, MRIs) if available.
Typical duration: 30-45 minutes
Elbow Flexion Range of Motion
Active and passive ability to bend the elbow; normal endpoint is 145 degrees
What to expect:
Examiner will ask you to bend your elbow as far as possible, then will gently push it further to test passive motion. Both arms will likely be tested.
Key thresholds:
- Full ROM (145-) — No limitation of flexion; may not support rating under limitation of motion alone
- Significantly reduced flexion — Contributes to functional loss finding and may support higher rating under analog codes
- Fixed/ankylosed — Rated separately under DC 5205 ankylosis provisions
Tips:
- Report your pain level at the starting point and at the point where motion stops
- Do not push through pain to demonstrate greater motion - report accurately
- Tell the examiner if your range worsens after repeated movement (DeLuca)
- Report if cold weather, morning stiffness, or prolonged use makes your ROM worse
Pain considerations: Clearly state where pain begins during the arc of motion, not just at the endpoint. Pain that begins early in the arc is more limiting than pain only at the endpoint. Report any radiation of pain into the wrist, hand, or shoulder.
Elbow Extension Range of Motion
Active and passive ability to straighten the elbow; normal endpoint is 0 degrees (full extension)
What to expect:
Examiner will ask you to straighten your elbow fully, then apply gentle passive force. An extension endpoint different from 0 degrees indicates a flexion contracture.
Key thresholds:
- 0- (full extension) — Normal; no extension limitation
- Limited extension (e.g., 10-30- flexion contracture) — Supports functional loss finding; may elevate rating under analog limitation of motion codes
- Fixed in flexion — Supports ankylosis evaluation
Tips:
- Note if you cannot fully straighten your arm during everyday activities
- Report morning stiffness or post-activity stiffness that limits extension
- Tell the examiner if your extension worsens with repetitive use
Pain considerations: Report any sharp or aching pain at the nonunion site when attempting to extend the elbow, particularly if it radiates distally.
Forearm Pronation Range of Motion
Ability to rotate forearm palm-down; normal endpoint is 80 degrees
What to expect:
Examiner will ask you to rotate your forearm with elbow at 90 degrees. This movement is critical for DC 5210 as loss of supination and pronation directly affects the rating.
Key thresholds:
- 80- (full pronation) — Normal pronation
- Motion lost beyond middle of arc — May support rating for limitation of pronation (DC 5213 analog)
- Motion lost beyond last quarter of arc (hand does not approach full pronation) — Higher rating threshold for limitation of pronation
- Complete loss of pronation — Maximum rating for isolated pronation loss
Tips:
- Report exactly where pain begins during the pronation arc
- Indicate if the nonunion site shifts or moves abnormally during forearm rotation
- Note daily tasks that require pronation: pouring, typing, using a screwdriver, handshake
Pain considerations: The flail false joint creates instability during rotation. Tell the examiner if you feel grinding, crepitus, or abnormal movement at the forearm during pronation.
Forearm Supination Range of Motion
Ability to rotate forearm palm-up; normal endpoint is 85 degrees
What to expect:
Examiner will test your ability to rotate the forearm palm-upward. Supination is often more affected in radius nonunion cases.
Key thresholds:
- 85- (full supination) — Normal supination
- 30- or less supination — Meets threshold for limitation of supination rating
- Complete loss of supination — Maximum rating for supination loss
Tips:
- Demonstrate difficulty with common supination tasks: receiving change, carrying a bowl, turning a doorknob
- Report pain and instability at the nonunion site during supination
- If the hand is fixed in a specific rotation position due to the nonunion, clearly describe and demonstrate this
Pain considerations: In flail false joint, the forearm bones may move independently during supination, causing pain and instability. Describe this sensation specifically to the examiner.
Assessment of False Movement at Nonunion Site
Degree of abnormal movement (pseudarthrosis) at the nonunion site of the radius and/or ulna
What to expect:
Examiner will stabilize one bone segment and apply gentle stress to assess abnormal motion at the fracture site. This is a key finding for DC 5210 diagnosis.
Key thresholds:
- False movement present (flail false joint) — Establishes DC 5210 diagnosis; directs toward 40-50% rating range
- Loss of bone substance 1 inch or more — Critical threshold for higher ratings under DC 5211/5212 analog provisions
- No false movement present — DC 5210 may not apply; condition may fall under malunion or simple nonunion codes
Tips:
- Do not resist the examiner's assessment of mobility at the nonunion site
- Tell the examiner about any clicking, grinding, or instability you feel in your forearm during lifting or gripping activities
- Bring any imaging that shows the nonunion gap size
Pain considerations: False movement at the nonunion site causes pain with loading and rotation. Describe pain with grip, lifting, and twisting activities.
DeLuca Repetitive Use Testing
Whether range of motion decreases, pain increases, or weakness/fatigue develops after repeated movement
What to expect:
Examiner may ask you to perform repetitive elbow flexion/extension or forearm rotation movements and reassess your range of motion and pain level after the repetitions.
Key thresholds:
- ROM decreases after repetition — Supports finding of greater functional limitation than initial ROM suggests
- Pain increases with repeated use — Supports higher effective limitation of motion; rater must consider the more limiting finding
- Weakness or fatigue develops — Additional DeLuca functional loss factors that can increase the effective rating
Tips:
- Before the exam, recall your actual functional limits during a full workday, not just at rest
- Report how long you can use your arm before pain or fatigue forces you to stop
- Describe whether symptoms are worse at the end of the day vs. the morning
Pain considerations: If repetitive use makes your symptoms significantly worse, tell the examiner before testing begins so it can be documented. The examiner is required to record DeLuca findings per M21-1 guidance.
Grip Strength and Upper Extremity Function
Functional strength and coordination of the affected arm, which is impaired by forearm bone instability
What to expect:
Examiner may test grip strength using a dynamometer or manual resistance testing. Muscle atrophy measurement of the forearm may also be performed.
Key thresholds:
- Significant grip strength deficit vs. contralateral side — Supports functional loss documentation and atrophy findings
- Forearm muscle atrophy (circumference measurement) — Documented disuse atrophy supports functional loss and severity
Tips:
- Report difficulty with pinching, gripping tools, opening jars, and carrying objects
- Note any dropping of objects due to weakness or instability
- Report if you have modified how you perform tasks due to forearm weakness
Pain considerations: Weakness from a flail false joint is often associated with pain on loading. Clearly describe pain that occurs with gripping or lifting activities.
Rating Criteria Breakdown
| Rating % | Criteria | Key Symptoms |
|---|---|---|
| 50% | Radius and ulna, nonunion of, with flail false joint - dominant arm (major extremity) |
CFR: 38 CFR 4.71a, DC 5210: 'Radius and ulna, nonunion of, with flail false joint' - rated 50% for dominant (major) extremity. |
| 40% | Radius and ulna, nonunion of, with flail false joint - non-dominant arm (minor extremity) |
CFR: 38 CFR 4.71a, DC 5210: 'Radius and ulna, nonunion of, with flail false joint' - rated 40% for non-dominant (minor) extremity. |
50% Radius and ulna, nonunion of, with flail false joint - domin ...
Radius and ulna, nonunion of, with flail false joint - dominant arm (major extremity)
Key Symptoms
- Confirmed nonunion of both radius and ulna at the same site
- Presence of flail false joint (pseudarthrosis with abnormal movement)
- Significant instability of the forearm
- Loss of functional pronation and supination
- Pain with any loading, gripping, or rotation of the forearm
- Weakness and incoordination of the affected upper extremity
- Inability to perform sustained grip or lifting tasks
CFR: 38 CFR 4.71a, DC 5210: 'Radius and ulna, nonunion of, with flail false joint' - rated 50% for dominant (major) extremity.
40% Radius and ulna, nonunion of, with flail false joint - non-d ...
Radius and ulna, nonunion of, with flail false joint - non-dominant arm (minor extremity)
Key Symptoms
- Same diagnostic findings as 50% but on the non-dominant extremity
- Confirmed nonunion of both radius and ulna with false movement
- Flail joint characteristics present
- Functional instability and pain limiting use of the non-dominant arm
- Impaired rotation, grip, and load-bearing of the non-dominant forearm
CFR: 38 CFR 4.71a, DC 5210: 'Radius and ulna, nonunion of, with flail false joint' - rated 40% for non-dominant (minor) extremity.
How to Describe Your Symptoms
Pain at the Nonunion Site
How to describe:
Describe pain as constant or activity-triggered, located specifically at the midforearm or wrist area over the fracture site. Use a 0-10 scale. Distinguish between rest pain, pain with light activity, and pain with loading or lifting.
Worst-day example:
“On my worst days, I have a constant 7/10 aching pain in my forearm even at rest, and any attempt to grip or twist causes sharp 9/10 pain at the fracture site that radiates toward my wrist. I cannot hold a coffee cup without bracing my forearm with my other hand.”
What the examiner listens for:
Location-specific pain at the nonunion site, pain triggered by rotation and loading, pain that limits duration of use, radiation patterns, and whether pain prevents sleep or requires medication.
Understatements to avoid:
Saying 'it only hurts sometimes' or 'I manage the pain' without explaining what 'managing' actually involves - such as constant activity modification, bracing, or medication use.
Forearm Instability and False Movement
How to describe:
Describe the sensation of bones shifting or moving independently in the forearm. Use concrete examples of when you feel instability - lifting, rotating, gripping, pushing, or pulling.
Worst-day example:
“When I try to turn a doorknob or use a screwdriver, I can feel my forearm bones shifting against each other at the break site. It feels like the bones are not connected. I hear and feel a grinding sensation, and my forearm gives out on me when I try to carry anything heavier than a few pounds.”
What the examiner listens for:
Patient-reported awareness of abnormal bone movement, functional instability during routine tasks, crepitus, and avoidance behaviors developed due to unpredictable forearm failure.
Understatements to avoid:
Not mentioning the instability sensation because you assume the examiner will detect it on physical exam alone. The examiner must document your subjective experience of the flail joint.
Loss of Rotation (Pronation and Supination)
How to describe:
Describe which daily tasks you cannot perform or perform with difficulty due to limited or painful rotation of the forearm. Be specific about which direction is more limited.
Worst-day example:
“I cannot fully turn my palm down or palm up without severe pain and instability. I cannot pour from a pitcher, eat with a fork properly, or type on a keyboard for more than a few minutes. I have to use my whole shoulder and body to compensate for what my forearm cannot do.”
What the examiner listens for:
Specific functional tasks lost due to rotation limitation, compensatory movements using the shoulder or trunk, and whether the limitation is pain-limited versus mechanically fixed.
Understatements to avoid:
Describing only the range of motion loss in degrees without explaining the functional consequences. The examiner needs to understand what you cannot do in real life.
Weakness and Muscle Atrophy
How to describe:
Describe grip strength loss, inability to lift objects, dropping items, and any visible muscle wasting in the forearm. Compare current strength to pre-injury baseline if known.
Worst-day example:
“My affected forearm is visibly smaller than my other arm. I drop objects without warning because my grip gives out. I cannot carry groceries, open medication bottles, or use tools at work. My forearm tires within minutes of any use.”
What the examiner listens for:
Specific weight limits the veteran can no longer lift, duration of use before fatigue, visible atrophy on inspection, and occupational or ADL limitations from weakness.
Understatements to avoid:
Saying 'I am weak' without quantifying it. Say instead: 'I cannot lift more than X pounds' or 'I can only use my forearm for X minutes before it becomes too weak to continue.'
Flare-Ups
How to describe:
Describe how often flare-ups occur, what triggers them, how long they last, and how severe they become. Include activities that predictably worsen the condition.
Worst-day example:
“Two to three times a week, after any extended use of my forearm - even light tasks like typing or cooking - I experience a severe flare where the pain spikes to 9/10, my forearm swells, and I cannot use the arm at all for 24 to 48 hours. I have to ice it and take prescription pain medication.”
What the examiner listens for:
Frequency, duration, triggering activities, severity at peak, functional loss during flare-up, and whether flare-ups require medical intervention or medication.
Understatements to avoid:
Not mentioning flare-ups at all because you are not currently in one at the time of the exam. The DBQ specifically asks about flare-ups, and your response on exam day reflects only a single point in time.
Functional Impact on Daily Living and Work
How to describe:
Describe concrete impacts on employment, household tasks, personal care, recreation, and social activities. Be specific about what you can no longer do, do differently, or need help with.
Worst-day example:
“I am unable to return to my prior occupation as a mechanic because I cannot grip tools or apply torque with the affected forearm. At home, I cannot cook, open containers, or lift laundry. My spouse has taken over all physical tasks. I cannot participate in recreational activities I previously enjoyed. I have had to modify my car with hand controls because the instability makes controlling the wheel unsafe.”
What the examiner listens for:
Specific occupational duties lost, whether the veteran has changed jobs or stopped working, modifications to living environment, degree of dependence on others, and recreational or social activity limitations.
Understatements to avoid:
Saying 'it limits what I can do' without specifics. List exact tasks by name and explain why each is impossible or significantly more difficult.
Common Mistakes to Avoid
Performing better than usual on exam day due to adrenaline or desire to appear capable
C&P exams assess your typical and worst-day functioning. Performing at your absolute maximum may result in the examiner documenting better function than actually exists.
Instead: Pace yourself during the examination as you would on a normal day with your condition. Tell the examiner: 'This is not representative of my typical day - I can do this now but would not be able to sustain it.'
Impact: Could prevent 50% rating if dominant arm instability is underrepresented
Failing to report the sensation of false movement and bone shifting
The distinguishing feature of DC 5210 vs. other forearm conditions is the flail false joint. If the examiner only performs limited palpation and the veteran does not describe instability, this critical finding may be underreported.
Instead: Specifically tell the examiner: 'I can feel the bones moving against each other at the fracture site when I try to rotate or grip.' Bring imaging that confirms the nonunion if available.
Impact: Could result in rating under a lower DC (5211/5212) rather than 5210
Not describing flare-ups because the exam occurs on a relatively good day
The DBQ requires documentation of flare-ups. If not mentioned, the examiner cannot document them, and the rater will have no basis to consider flare-up severity.
Instead: Proactively tell the examiner about your flare-up pattern, even if you are not currently in one: 'I want to make sure you know that 2-3 times a week my symptoms are significantly worse than today.'
Impact: Affects overall severity documentation at both 40% and 50% levels
Describing pain only at the endpoint of motion
Per DeLuca v. Brown, pain that begins early in the arc of motion effectively limits range of motion to the point where pain begins. Early-onset pain is more disabling than endpoint pain.
Instead: Report exactly where in the arc of motion pain begins, not just where movement stops. Example: 'Pain begins as soon as I start rotating my forearm, not just at the end.'
Impact: Affects effective ROM measurement and DeLuca functional loss documentation
Not mentioning dominance of the affected arm
DC 5210 differentiates between major (dominant) and minor (non-dominant) extremity, with a 10% difference in rating (50% vs. 40%). Dominant arm involvement must be clearly established.
Instead: At the start of the exam, clearly state whether the affected arm is your dominant hand. Example: 'My right arm is affected and I am right-handed.'
Impact: Determines 50% vs. 40% rating
Understating weakness and atrophy
Muscle atrophy from disuse is a documented indicator of functional loss. Veterans often minimize weakness to appear capable but this underrepresentation costs them accurate ratings.
Instead: Ask the examiner to measure forearm circumference bilaterally and document any atrophy. Describe specific weight limits and duration limits for arm use.
Impact: Affects functional loss documentation at all rating levels
Not bringing imaging records confirming nonunion
The examiner must confirm the diagnosis of nonunion. Without imaging, the examiner may be unable to document the flail false joint finding adequately.
Instead: Bring copies of all relevant X-rays, CT scans, or MRI reports that show the nonunion. If you do not have them, request them from your treating provider before the exam.
Impact: Affects diagnostic confirmation required for DC 5210 rating
Prep Checklist
Before Your Exam
Day Of
During the Exam
After the Exam
Your Rights During a C&P Exam
- You have the right to request a copy of your completed DBQ examination report through FOIA or VA.gov after it is filed.
- In most states, you have the right to record your C&P examination. Notify the examiner at the start of the appointment. Check your specific state law prior to the exam.
- You have the right to submit additional evidence (personal statements, buddy statements, private medical opinions) before a rating decision is issued if you believe the C&P exam was inadequate.
- You have the right to request an additional C&P examination or a review of a flawed examination through your VSO or by filing a Supplemental Claim with new and relevant evidence.
- You have the right to have a VSO representative or accredited claims agent assist you in preparing for and attending VA examinations.
- You have the right to challenge an inadequate examination. Per Barr v. Nicholson, the VA has a duty to provide an adequate examination. An exam that fails to address DeLuca factors, passive ROM (Correia), or functional loss may be legally insufficient.
- You have the right to an examination that addresses the full scope of your disability, including flare-ups, functional loss beyond measured ROM, and all DeLuca factors (pain, fatigue, weakness, incoordination, lack of endurance) under 38 CFR 4.40 and 4.45.
- You have the right to have your condition rated under the most favorable diagnostic code applicable to your symptoms, including consideration of DC 5210, 5211, 5212, or analog codes, whichever produces the highest rating.
Related Conditions
- Ulna, Impairment of DC 5211 governs isolated ulna nonunion. When both radius and ulna are involved in a nonunion with flail false joint, DC 5210 applies and typically produces a higher rating than individual bone codes.
- Radius, Impairment of DC 5212 governs isolated radius nonunion. DC 5210 applies when both bones form a combined flail false joint and is the controlling code in that scenario.
- Elbow, Ankylosis of If the nonunion results in a fixed elbow position, ankylosis provisions under DC 5205 may apply. The examiner should document whether any elbow motion limitation coexists with the forearm nonunion.
- Limitation of Forearm Pronation and Supination DC 5213 covers impairment of supination and pronation. If the flail false joint causes specific rotational loss without meeting DC 5210 criteria, DC 5213 may apply as an alternative or the rater may consider the most favorable code.
- Post-Traumatic Arthritis, Elbow Secondary post traumatic arthritis frequently develops in the elbow and wrist joints adjacent to a forearm nonunion. This may be ratable as a separate condition under DC 5003 if X ray confirmed arthritic changes are present.
- Heterotopic Ossification Heterotopic ossification can develop at or near the nonunion site, particularly after traumatic injury or surgery, and may further limit forearm rotation. This is a separately documentable condition on the DBQ.
- Peripheral Nerve Conditions of the Upper Extremity Radial, median, or ulnar nerve involvement can occur secondary to forearm bone injury, malunion, or hardware. Nerve entrapment or damage producing numbness, tingling, or weakness in the hand should be separately claimed and documented.
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This C&P exam preparation guide is for educational purposes only and does not constitute legal, medical, or claims advice. Always consult with a qualified Veterans Service Organization (VSO) representative or VA-accredited attorney for guidance specific to your claim. Never exaggerate, minimize, or fabricate symptoms during a C&P examination.