In accordance with the Code of Federal Regulations (38 CFR 4.63), "loss of use of a hand or a foot, for the purpose of special monthly compensation, will be held to exist when no effective function remains other than that which would be equally well served by an amputation stump at the site of election below elbow or knee with use of a suitable prosthetic appliance".

Disability is primarily an inability due to damage or infection in parts of the musculoskeletal system. In regards to amputation, congenital or developmental factors should also be considered. Amputations usually stem from disabilities of the musculoskeletal system due to damage from trauma, peripheral vascular disease, tumor, infection, or congenital anomaly.

The signs and symptoms associated with "functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity" (38 CFR 4.40).

Complete physical examination and psychiatric examination, including history and work, are indicated. "The duration of the initial, and any subsequent, period of total incapacity, especially periods reflecting delayed union, inflammation, swelling, drainage, or operative intervention, should be given close attention" (38 CFR 4.41).

Treatment modalities may vary depending on the underlying cause, extent of the anatomical loss, i.e., combinations of hand and foot, both hands, both feet etc., and loss of functionality. In the case of traumatic amputations, after healing of the wound, prosthesis is usually applied. However, if the loss of functionality is due to a condition, e.g., fibromyalgia, there is no specific treatment. Any treatment in this case would be directed towards patient education and reassurance.

• In the case of amputation, special care to the site of the removed limb or part is needed. This requires extensive rehabilitation and patient education. Contractures can occur if conditioning exercises are not done. In addition, correct limb bandaging is necessary to assist with limb shrinkage for a proper fit of the prosthesis. Finally, due to body image disturbances, patients may require emotional support and counseling.

• When deciding expressly claimed issues, decision makers must consider entitlement to any complications that are within the scope of the claim, including those identified by the rating criteria for that condition in 38 CFR Part 4. This could include but is not limited to, scars as the result of surgical intervention for a service-connected (SC) disability.

• The rating schedule for musculoskeletal was updated on February 7, 2021. Protection still does apply and should be considered with existing evaluations (38 CFR 3.951(a)).

• (5120-5130) Entitled to special monthly compensation under loss of use 38 CFR 3.350 (2)(i). Consider entitlement to SMC under 38 CFR 3.350 as an issue in every case where there is a severe degree of disability involving the loss or loss of use of an extremity or sensory organ or any other functional loss providing entitlement to SMC.

• To properly rate disability, accurate and complete descriptions of the affected extremity in the medical records are essential. Descriptions of the affected extremity should include exact place of amputation or resection, length of stump, limitations of motion, pain, weakness, carriage, gait, and posture. An occupational therapy work-up is extremely beneficial, especially when amputation of the hands or fingers is involved.

• Consider entitlement to specially adapted housing (SAH), special home adaptation (SHA), and/or automobile or other conveyances and adaptive equipment, if otherwise in order. See 38 CFR 3.808 – Automobile or other conveyances and adaptive equipment; 38 CFR 3.809 – Specially adapted housing; 38 CFR 3.809a – Special home adaptation grants.

• 38 CFR 4.30 provides for a temporary 100-percent evaluation without regard to other provisions of the rating schedule if treatment of a service-connected (SC) disability resulted in surgery necessitating at least one month convalescence surgery with severe postoperative residuals, or immobilization of at least one major joint by cast without surgery, including procedures performed at an outpatient clinic.

• Compensation is payable under 38 U.S.C. 1160 for disabilities involving certain paired organs or extremities, one service-connected (SC) and the other non-service-connected (NSC), provided the NSC disability is not the result of the Veteran’s own willful misconduct.

• A determination as to loss of use (LOU) of a hand is not restricted to organic loss; it includes functional LOU as well.

• Where an NSC cause necessitates amputation of an extremity resulting in elimination of an SC disability distal to the site of the amputation, do not sever SC for or reduce the evaluation of the SC disability.

• Loss of use of the hand will be held to exist when no effective function remains other than that which would be equally well served by an amputation stump with a suitable prosthetic appliance. 38 CFR 4.71a [Schedule of ratings-musculoskeletal system]