Diagnostic Assessment — Ankylosis of Left and Right MCP Joints
Example 1 of 1 · fictitious patient
Diagnostic Assessment Ankylosis of Left and Right MCP Joints BOP Code: N/A (there is no Statement of Principles for this condition) RH Code: N/A
ADF History
The veteran, date of birth [withheld], served in the Australian Army as a Transport Driver from 17 June 1987 to 2 April 1994
History
The veteran has bilateral ankylosis of the first MCP joints of both thumbs as a result of bilateral thumb MCP joint arthrodesis performed during ADF service on 14 February 1990 by the treating doctor, orthopaedic surgeon.
After a fall in the shower disrupted the right fusion in April 1990, a further operation planned as a re-arthrodesis was performed on 23 May 1990, at which the right fusion was found to have united and the fixation wires were removed from both thumbs.
The left fusion was angulated and was re-fused on 27 December 1991.
Both thumbs achieved solid ankylosis confirmed on X-ray 29 April 2023.
The left thumb retains two oblique K-wires protruding beyond the dorsal cortex with osteolysis around the screw tract
Timeline
14 Feb 1990 — Bilateral thumb MCP joint arthrodesis by the treating doctor. "Arthrodesis both MCP joints" 17 Apr 1990 — Right thumb arthrodesis disrupted by shower fall. "Right arthrodesis torn apart" 23 May 1990 — Operation on right thumb planned as re-arthrodesis: fusion found solidly united, fixation removed; left side also solid, wires removed. "Arthrodesis had, in fact, joined solidly" 30 May 1990 — Both arthrodeses rock solid clinically. "Rock solid" 11 Jun 1991 — Left thumb angulated. "Left arthrodesis angulated" 27 Sep 1991 — the treating doctor re-fusion left thumb in 10 degrees flexion. "Refusion left thumb" 27 Dec 1991 — Re-fusion of left thumb first MCP joint performed. "Fusion 1st mcp left hand" 29 Apr 2023 — X-ray bilateral thumbs.
Right: solid ankylosis, no residual K-wire, mild IP degeneration.
Left: solid ankylosis, 2 retained K-wires protruding beyond cortex, IP degeneration with large dorsal osteophyte. "Solid ankylosis bilateral" 2000 — Patient letter stating "the operation on his thumbs is causing him a lot of pain and suffering." "Pain and suffering"
Symptoms
The veteran has permanent bilateral thumb MCP ankylosis with associated pain, functional limitation, and IP joint degeneration bilaterally.
The left thumb has retained metalwork causing clicking and crepitus
Imaging
29 Apr 2023 — X-ray bilateral thumbs: "Right: solid MCP ankylosis, no residual K- wire, mild IP degeneration.
Left: solid MCP ankylosis, 2 retained K-wires protruding beyond cortex, IP degeneration with large dorsal osteophyte."
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Bilateral Ankylosis of the First MCP Joints (ICD-10: M24.641, M24.642) — post-surgical, following bilateral thumb MCP joint arthrodesis performed during ADF service
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition? 14 February 1990 (date of arthrodesis) When did the veteran first present to a health / medical provider for this condition? 14 February 1990 When was the condition confirmed / formally diagnosed? 30 May 1990 (both arthrodeses confirmed "rock solid") When did the veteran first present to you (or your practice) for this condition? 27 October 2018
3. How was this diagnosis confirmed?
The bilateral MCP ankylosis was confirmed clinically by the treating doctor on 30 May 1990 and radiologically on X-ray bilateral thumbs 29 April 2023 [ [CHART REVIEW document]; Report - MIHC-XRAY BILATERAL THUMBS - 2023-02-14]
4. What do you consider to be the cause(s) of the condition in this veteran?
Legislation: The clinical onset of this condition was before 14 September 2007 (see
Date of Clinical Onset
Below), and it did not arise on warlike or non-warlike deployment (the veteran had no deployments).
This is therefore a DRCA claim.
Statements of Principles do not apply to DRCA claims, so there are no binding SOP factors for this condition.
Under the DRCA the question is whether the injury or disease arose out of, or in the course of, the veteran's ADF service, or (for a disease or an aggravation) whether that service contributed to it to a significant degree.
Plausible links to service outside the SOP factors are set out below.
The absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.
There is no Statement of Principles for ankylosis produced by surgical arthrodesis; the fusion of the veteran's thumb joints is the result of operations rather than of a disease process, so no Statement of Principles can properly be applied by analogy.
The question under the DRCA is whether the condition arose out of, or in the course of, his service, including as a consequence of medical treatment paid for by the Commonwealth, or was contributed to by his service to a significant degree.
Plausible Links to Service The ankylosis of both thumb metacarpophalangeal joints is the planned result of surgery performed during the veteran's service.
On about 13 January 1990, while serving in a logistics unit, he dislocated his left thumb metacarpophalangeal joint in a motor vehicle accident near Cooktown; the record does not state whether he was on duty.
After admission to Cooktown Hospital, the dislocation was reduced under general anaesthetic in a logistics unit on 16 January 1990 by the treating doctor, consultant orthopaedic surgeon, who recorded a familial tendency to recurrent dislocation of the thumbs over three generations, with dislocations that required reduction, were very painful and interfered with his activity.
The treating doctor fusion of both joints on 4 and 30 January 1990 and fused them with a tension band wire technique on 14 February 1990, and the left joint was re-fused on 27 December 1991.
The treatment was arranged through the Navy's medical officers, and the Navy sought and was granted approval to pay the civilian hospital, theatre, anaesthetic and surgical fees, as the signals of January 1990 and May 1990 record.
The Medical Board of Survey held at a logistics unit on 20 April 1990 assessed this disability, recorded as fusion of both first metacarpophalangeal joints, as constitutional in origin but aggravated by naval service, with 30% incapacity, unfit for sea and medical category 5 for three months.
The Board did not record its reasons, but the acute dislocation that prompted the operation occurred while he was serving, and his duties as a Transport Driver and Transport Driver, which he described in April 1990 as operating survey equipment, working ships' lines, rope work and cleaning tasks such as scrubbing decks and deckheads, place repeated forceful pinch and grip loads on the thumbs.
The familial instability was therefore a predisposition, but the decision to fuse both joints was made during his service immediately after the in-service dislocation, consistent with the Board's contemporaneous finding that service aggravated the condition.
Although fusion was the aim, the course of treatment brought consequences that were not intended.
The right fusion was disrupted in a fall in the shower at home on about 17 April 1990 and required a further operation on 23 May 1990, planned as a re-arthrodesis, at which the fusion was found to have united and the fixation was removed from both thumbs.
The left fusion, on his dominant hand, was found on 11 June 1991 to be angulated, with difficulty using the thumb; on 27 September 1991 the treating doctor it in 30 degrees of flexion and recommended re-fusion in 10 degrees of flexion, which was performed on 27 December 1991.
The X-rays of 15 January and 29 April 2023 showed solid ankylosis of both joints but two retained K-wires in the left thumb, which date from that re-fusion because the earlier wires were removed in May 1990 and no later thumb surgery is recorded, with metalwork protruding about 5 mm beyond the dorsal cortex of the proximal phalanx, mild osteolysis around its track, a tiny metallic fragment in the soft tissues, clicking and crepitus, and degenerative change in both interphalangeal joints with a large dorsal osteophyte on the left.
The malposition of the left fusion that required re-operation and the retained, protruding metalwork are unintended consequences of medical treatment paid for by the Commonwealth, and under section 6A of the DRCA an injury suffered as an unintended consequence of such treatment is taken to have arisen out of, or in the course of, his employment.
Fusion of a thumb metacarpophalangeal joint also increases the demand on the adjacent interphalangeal joint, and the interphalangeal degeneration found in 2023 is consistent with that later effect of the fusions.
In 2000 the veteran wrote to Defence that the operation on his thumbs, done at a logistics unit during his naval career, was causing him a lot of pain and suffering, which shows continuing symptoms from the surgery performed in service.
Conclusion The ankylosis of both of the veteran's thumb metacarpophalangeal joints was produced by bilateral arthrodesis performed during his service on 14 February 1990, with re-fusion of the left joint on 27 December 1991, treatment arranged and paid for by the Navy after the in- service dislocation of his left thumb on a background of familial thumb instability.
The Medical Board of Survey of 20 April 1990 found the condition aggravated by naval service; the malposition that required re-fusion and the retained, protruding K-wires are unintended consequences of that Commonwealth-funded treatment within section 6A of the DRCA, and the later interphalangeal degeneration is consistent with the added load that the fusions place on the adjacent joints.
The condition is therefore attributable to his service.
The % contribution of the causes is 100% and significant
Sequelae
The bilateral MCP ankylosis is associated with retained metalwork with protruding K-wires in the left thumb (from the re-fusion of 27 December 1991), ongoing pain and functional impairment, and with bilateral IP joint degeneration consistent with the added load that the fusions place on the adjacent joints
Unintended Consequence
The angulation of the left fusion that required re-fusion on 27 December 1991 and the retained K-wires protruding beyond the dorsal cortex, with osteolysis around the track, are unintended consequences of surgery arranged and paid for by the Navy during ADF service; under section 6A of the DRCA they are taken to have arisen out of, or in the course of, his employment, and the IP joint degeneration is consistent with the fusions — MET
Inability to Attain Appropriate Medical Management
The thumb injury was treated promptly during service, with reduction under general anaesthetic within days, specialist orthopaedic care, fusion, and re-fusion when the left fusion was found to be angulated, so there is no evidence of inability to obtain appropriate clinical management for this condition — NOT MET
Date of Clinical Onset
Ankylosis of the left and right thumb MCP joints is a permanent condition that was produced surgically.
Its date of clinical onset is the date of the operation that fused the joints, not the date on which the fusion was later confirmed or imaged.
Operation: 14 February 1990 — bilateral thumb MCP joint arthrodesis (surgical fusion) performed by the treating doctor at Calvary Hospital, a logistics unit [ [CHART REVIEW document], pages 132 134].
The later records, including the confirmation that both arthrodeses were solid on 30 May 1990 and the X-rays of 15 January and 29 April 2023, confirm or image the fusion and do not alter the date of clinical onset.
Date of clinical onset: 14 February 1990.
This date falls within the veteran's ADF service (17 June 1987 2 April 1994).
In-service events and exposures before this date relate to clinical onset, and those after it to clinical worsening
