What Is the VA Rating for Fracture Residuals? Nonunion, Malunion, Arthritis, and the Quasi-Presumptive Service Connection Policy

If you broke a bone during service, you might assume the VA rates the fracture itself. They do not. The VA rates the residual conditions that persist after the bone heals — the limitation of motion, the arthritis, the nerve damage, the painful joint that never quite worked right again.

This distinction is not academic. It is the single most important thing to understand about fracture claims because it determines which diagnostic code you file under, what evidence you need, and how high your rating can go. A veteran who files for "broken wrist" gets a confusing denial. A veteran who files for "limitation of motion of the wrist with post-traumatic arthritis, secondary to in-service fracture" gets a rating.

There is also a policy buried in the VA Manual that almost no advocacy website mentions: M21-1 V.iii.1.F.1.a treats documented in-service fractures as quasi-presumptive for service connection. If you have an X-ray, surgical report, or casting record from active duty, the VA is supposed to grant service connection in most cases — without requiring a separate nexus letter.

In this guide, I am going to break down exactly how the VA rates fracture residuals, which diagnostic codes apply to which body parts, the quasi-presumptive policy and how to invoke it, and the documentation strategy that separates a 0% rating from a 40% or higher one.

The Fundamental Rule: The VA Rates Residuals, Not Fractures

Under 38 CFR 4.71a, the VA's musculoskeletal rating schedule does not contain a diagnostic code for "broken bone" or "fracture." There is no line item that says "healed fracture of the tibia = 10%." Instead, the regulation explicitly states that fractures must be rated on their specific residuals.

What does "residuals" mean in practice? It means whatever functional impairment the fracture left behind after maximum medical improvement:

• Limitation of motion — the joint near the fracture site no longer moves through its full range
• Painful motion — the joint moves but with documented pain
• Degenerative arthritis — post-traumatic arthritis develops at the fracture site
• Nonunion or malunion — the bone did not heal properly
• Peripheral nerve damage — the fracture damaged nearby nerves
• Shortening of a long bone — the fractured limb is now measurably shorter
• Muscle injury — the fracture or surgical repair damaged surrounding muscle tissue

This residual-based architecture means your claim strategy must focus on documenting every functional consequence of the original fracture, not just proving the fracture occurred.

Nonunion vs. Malunion vs. Healed Fracture

The healing status of your fracture directly affects your rating potential. Here is what each category means and how the VA treats it.

Nonunion

Nonunion means the fracture never healed. The bone fragments remain separated with no progressive healing occurring, typically confirmed by imaging showing a persistent fracture line after the expected healing period (usually 6-9 months). Nonunion fractures generally produce the most severe functional impairment — instability, pain, and significant loss of motion — and therefore support the highest ratings.

For VA purposes, nonunion is rated through its functional consequences: the resulting limitation of motion, instability, or painful motion of the affected joint. There is no standalone "nonunion" diagnostic code. The VA evaluates what the nonunion does to your ability to use that body part.

Malunion

Malunion means the fracture healed but in an abnormal position — misaligned, angulated, or shortened. This can produce chronic pain, altered gait mechanics, secondary joint problems, and cosmetic deformity. Like nonunion, malunion is rated through its functional impact on the affected joints.

Certain diagnostic codes do specifically reference malunion. For example, DC 5255 (Femur, impairment of) provides ratings for malunion of the femur with slight, moderate, or marked knee or hip disability. DC 5262 (Tibia and fibula, impairment of) similarly rates malunion with slight, moderate, or marked knee or ankle disability.

Healed Fracture with Residuals

Most fractures heal anatomically but leave behind functional problems — reduced range of motion, painful motion, or degenerative arthritis that develops at the fracture site over time. These are the most common fracture residuals and are rated under the limitation of motion codes for the affected joint.

The Quasi-Presumptive Service Connection Policy

This is the most strategically valuable piece of information in fracture claims, and almost no commercial VA claims website mentions it.

VA Manual M21-1, Part V, Subpart iii, Chapter 1, Section F, Topic 1.a establishes that in-service fractures with medical evidence should be granted service connection in most cases. The medical evidence threshold is straightforward:

• X-ray showing the fracture during service
• Surgical report from in-service fracture treatment
• Casting or splinting record in service treatment records
• Emergency room or sick call documentation of the fracture

If you have any of these, the M21-1 policy instructs VA adjudicators that service connection should be conceded without requiring a separate nexus letter — the documented fracture plus current residuals is typically sufficient.

Diagnostic Codes for Fracture Residuals by Body Part

Because fractures are rated on residuals, the diagnostic code you file under depends on which joint or structure is affected and what type of residual you have. Here are the most common fracture locations and their corresponding diagnostic codes.

Upper Extremity

Lower Extremity

Spine

Post-Traumatic Arthritis: The Secondary Claim Most Veterans Miss

Post-traumatic arthritis — degenerative joint disease that develops at a fracture site — is one of the most under-claimed secondary conditions in the VA system. Fractures that involve the joint surface (intra-articular fractures) have a particularly high rate of developing arthritis, often appearing years or decades after the original injury.

Under DC 5003, degenerative arthritis confirmed by X-ray is rated based on limitation of motion of the affected joint using the appropriate limitation of motion diagnostic code. If the limitation of motion is noncompensable (does not meet the threshold for a minimum rating), DC 5003 provides:

• 10% for involvement of 2 or more major joints or 2 or more minor joint groups
• 20% for the above with occasional incapacitating exacerbations

The timing is important. Post-traumatic arthritis can develop 5, 10, or even 20 years after the original fracture. A veteran who received a 0% rating for a healed wrist fracture in 2010 and now has X-ray confirmed arthritis in that wrist should file a claim for increase — the current residual (arthritis with painful motion) may now warrant a compensable rating.

The 38 CFR 4.59 Painful Motion Floor

38 CFR 4.59 is the regulation that establishes a minimum compensable rating for any joint with painful motion. The landmark case Burton v. Shinseki, 25 Vet. App. 1 (2011) confirmed that this applies to all joint conditions, not just arthritis.

For fracture residuals, this means: if you have a service-connected fracture that resulted in any painful motion of the affected joint — even if your range of motion is technically normal — you are entitled to a minimum 10% rating for that joint.

The VA cannot rate painful motion at 0%. If the joint hurts when you move it and that condition is service-connected, you get at least 10%.

DeLuca Factors and Fracture Residuals

The DeLuca v. Brown, 8 Vet. App. 202 (1995) trilogy applies to all musculoskeletal claims, including fracture residuals rated on limitation of motion. These factors require the C&P examiner to assess functional loss beyond what the goniometer measures on a single exam.

For fracture residuals, the DeLuca factors are particularly relevant because fracture sites often produce:

• Pain on repetitive motion — the fracture site aches more with repeated use, progressively reducing functional ROM
• Weakness — muscle atrophy around the fracture site reduces joint strength
• Fatigability — the affected limb tires faster than the uninjured side
• Incoordination — altered joint mechanics after malunion or hardware placement
• Flare-ups — weather changes, overuse, or sustained positioning triggers increased pain and reduced function

Sharp v. Shulkin (2017) requires the examiner to provide a specific estimate of ROM loss during flare-ups in degrees. They cannot simply write "unable to estimate without speculation." If your forward flexion measures 45 degrees on exam day but drops to 25 degrees during flare-ups, the rater must consider the functional ROM of 25 degrees.

Peripheral Nerve Damage as a Separate Rating

Fractures — especially long bone fractures of the humerus, femur, tibia, and fibula — can damage peripheral nerves that run adjacent to the fracture site. This nerve damage is separately ratable from the musculoskeletal residual because it involves a different body system (neurological vs. musculoskeletal).

Common nerve injuries from fractures:

Peripheral nerve ratings range from 10% to 70% for the upper extremity and 10% to 80% for the lower extremity, depending on severity (mild, moderate, or severe incomplete paralysis vs. complete paralysis) and whether the dominant or non-dominant side is affected.

C&P Exam Preparation for Fracture Residuals

The C&P exam for fracture residuals focuses on current functional impairment, not the historical fracture. Here is what to expect and how to prepare.

What the Examiner Will Assess

• Range of motion of the affected joint(s) with goniometer measurements
• Pain on motion — where in the arc pain begins and ends
• Repetitive use testing — ROM after three repetitions to identify DeLuca functional loss
• Flare-up assessment — estimated ROM loss during flare-ups (Sharp requirement)
• Strength testing — muscle strength grading (0/5 to 5/5)
• Stability testing — joint laxity or instability
• Imaging review — X-rays or MRI showing current status of the fracture site
• Neurological screening — sensation, reflexes, and motor function near the fracture

Before the Exam

• Obtain current imaging (X-ray minimum) of the fracture site — arthritis and malunion need radiographic confirmation
• Write a personal statement describing your worst-day function, not your best-day function
• Document flare-up frequency, duration, and triggers in writing
• Note any activities you can no longer perform or must modify due to the fracture residuals
• If you have nerve symptoms, request NCS/EMG testing before the C&P exam
• Bring a list of all current residuals — ROM loss, pain, nerve symptoms, arthritis — so nothing is missed

During the Exam

• Report pain at the point it begins, not the point it becomes unbearable
• Do not push through pain to demonstrate "toughness" — the examiner needs to see your actual functional limitation
• If asked about flare-ups, provide specific frequency ("3-4 times per week") and duration ("lasting 2-4 hours")
• Mention any nerve symptoms even if the examiner does not ask — numbness, tingling, weakness, or altered sensation
• If the examiner skips repetitive use testing, ask them to perform it — it is required under DeLuca

Common Mistakes That Kill Fracture Claims

1. Filing for the Fracture Instead of the Residuals

The most common error. "Service connection for broken arm" will confuse the process. File for the specific residual: "Limitation of motion of the left elbow, residual of in-service fracture of the left distal humerus." Name the body part, the functional impairment, and the causal fracture.

2. No Current Medical Evidence

Service treatment records proving the fracture occurred are necessary but not sufficient. You need current medical evidence showing the residual condition exists today. Recent X-rays, a current physical examination, or a DBQ from your treating physician documenting current ROM and symptoms.

3. Missing Secondary Conditions

Filing only for the primary residual (usually limitation of motion) while ignoring secondary conditions like post-traumatic arthritis, nerve damage, muscle atrophy, or adjacent joint problems. Each of these is a separate ratable condition.

4. Not Citing M21-1 V.iii.1.F.1.a

Letting the VA treat your well-documented in-service fracture like any other service connection claim — requiring a nexus letter, scheduling unnecessary exams, and adding months to the process — when their own manual says service connection should be conceded in most cases.

5. Accepting a 0% Rating Without Understanding Its Value

A 0% service-connected rating is not worthless. It establishes the service connection, preserves your right to file for an increase when residuals worsen (arthritis is progressive), qualifies you for VA healthcare for that condition, and serves as the anchor for secondary service connection claims. Do not appeal a 0% rating just to appeal — but do file for an increase when your condition worsens.

6. Failing to Document Bilateral Injuries

If you fractured both the left and right versions of the same bone (both wrists, both ankles), each side is rated separately, and the bilateral factor (38 CFR 4.26) adds an additional 10% to the combined value of paired extremity ratings before VA math rounds it. This is free rating percentage that many veterans leave on the table.

Now I would like to hear from you — do you have an in-service fracture with residuals you have not claimed, or are you looking to increase an existing fracture-related rating?