Diagnostic Assessment — Bilateral Hands - Raynaud Phenomenon
Example 1 of 1 · fictitious patient (Veteran BX)
Diagnostic Assessment
Bilateral Hands - Raynaud Phenomenon
No Statement of Principles applies to this condition (non-SOP claim).
ADF History
Veteran BX, date of birth 11 January 1980, Royal Australian Navy, Clearance Diver (later Petty Officer Clearance Diver), enlisted 20 January 1998, medically discharged 05 December 2019. Operational service: East Timor, 20 September 1999 to 15 February 2000 (warlike); Iraq (northern Arabian Gulf and Umm Qasr), 10 March 2003 to 30 June 2003 (warlike); Middle East Area of Operations (maritime security), 02 February 2012 to 25 August 2012 (warlike).
Occupational History
As a clearance diver the veteran conducted mine countermeasures, explosive ordnance disposal, ship's hull searches and underwater battle damage repair, often in cold water for hours at a time with his hands exposed or in thin gloves. He used hand-held hydraulic and pneumatic tools above and below water, including underwater cutters, grinders and impact wrenches, rock drills, needle guns and chipping hammers.
Clearance divers have recognised exposure to cold water immersion and cold-weather operations, hand-arm vibration from powered tools, hand trauma from heavy equipment and hatches, and the regular use of decongestants to equalise the ears and sinuses before diving. Naval culture of the period normalised smoking between dives and on watch.
History
Veteran BX, a clearance diver in the Royal Australian Navy, developed Raynaud phenomenon of both hands on 12 July 2010, during a winter mine countermeasures exercise in cold water, after more than a decade of hand-arm vibration from powered diving tools, repeated cold water immersion, a cold injury of the fingers, a crush injury of the right hand, carpal tunnel syndrome, smoking, and treatment with propranolol, sumatriptan and pseudoephedrine. The condition, with features of the vascular component of hand-arm vibration syndrome, worsened in 2015 with daily attacks and a digital ulcer.
Timeline
- 20 Jan 1998 — The enlistment medical examination recorded normal peripheral pulses, normal hand examination and no history of cold sensitivity, finger blanching or connective tissue disease. He reported smoking about 10 cigarettes a day, which rose to 15 a day during diver training. "hands normal, no cold sensitivity"
- 19 Feb 2008 — During a cold-weather diving exchange with an allied navy in northern Europe, he conducted repeated dives in water of 2 to 4 degrees with thin gloves, and after a two-hour hull search developed numbness, pallor and then painful swelling of the fingers of both hands. The medical officer diagnosed non-freezing cold injury of both hands, with persisting cold sensitivity and tingling for four months. "non-freezing cold injury both hands"
- 08 Sep 2008 — His right hand was crushed in a watertight hatch on a mine countermeasures vessel. X-ray showed undisplaced fractures of the distal phalanges of the right index and middle fingers, and the nail bed of the middle finger was repaired. He returned to diving after eight weeks. "right index, middle finger fractures"
- 14 Apr 2009 — He reported numbness and tingling of the thumb, index and middle fingers of both hands at night and after using powered tools. Nerve conduction studies confirmed moderate bilateral carpal tunnel syndrome. A neurologist commenced propranolol 40 mg twice daily for frequent migraine, with sumatriptan 50 mg for attacks, used on about six days a month. The diving medical officer recorded regular pseudoephedrine 60 mg before most dives for ear equalisation since 2005. "bilateral carpal tunnel, propranolol commenced"
- 26 Jul 2010 — He presented with a two-week history of episodes of sharply demarcated whiteness of the fingers of both hands, followed by blueness and then painful redness on rewarming, beginning on 12 July 2010 during a winter mine countermeasures exercise in water of 11 degrees. Attacks occurred on cold exposure and during and after tool use, and lasted 15 to 40 minutes. His logbook recorded about 3 600 hours of hand-held vibrating tool use since 1998. "triphasic colour change, both hands"
- 22 Sep 2010 — A vascular physician confirmed Raynaud phenomenon of both hands with features of the vascular component of hand-arm vibration syndrome, Stockholm vascular stage 2. Antinuclear antibodies were negative, nailfold capillaroscopy was normal, and cold provocation testing showed delayed rewarming of the fingers. Upper limb arterial Doppler excluded proximal arterial disease. He was advised to reduce vibration and cold exposure, but no change of duties was made. "Raynaud phenomenon, Stockholm stage 2"
- 03 Aug 2015 — After five further years of diving and powered tool use, including deployed maritime security operations in 2012, attacks had become daily and involved all fingers of both hands, including in summer. A painful ulcer developed on the tip of the right middle finger. Finger systolic pressures after cooling were markedly reduced, and the vascular physician recorded progression to Stockholm vascular stage 3 and commenced nifedipine. "daily attacks, digital ulcer, stage 3"
- 12 Jun 2019 — At his separation assessment he reported daily attacks in cool weather, numbness and clumsiness of the fingers, inability to handle cold water or frozen items, and continuing need for nifedipine and gloves in all but warm weather. He was found medically unfit for diving and was medically discharged. "unfit diving, daily attacks persist"
Symptoms
At onset the veteran had episodes of sharply demarcated white fingers in both hands, followed by blue and then painful red discolouration on rewarming, with numbness and clumsiness, triggered by cold water and by powered tool use. After onset the attacks became more frequent, longer and more extensive, and in 2015 they were daily, involved all fingers and caused a fingertip ulcer.
He now reports daily attacks in cool weather, numbness and tingling, reduced grip and dexterity, difficulty with fine tasks, and pain on rewarming. He wears gloves outdoors for most of the year and avoids cold water, refrigerated items and vibrating tools.
Imaging
- 08 Sep 2008 — X-ray right hand: "Undisplaced fractures of the distal phalanges of the right index and middle fingers."
- 22 Sep 2010 — Arterial Doppler ultrasound, both upper limbs: "Normal subclavian, axillary, brachial, radial and ulnar arteries with no stenosis, aneurysm or thoracic outlet compression. Normal palmar arches."
- 03 Aug 2015 — Digital plethysmography and finger systolic pressure after cold provocation: "Finger systolic pressure reduced to 20 to 35 per cent of baseline after cooling to 10 degrees in all digits of both hands, with delayed rewarming, consistent with severe vasospasm."
Onset Date
The most likely date of onset of this condition is 12 Jul 2010.
At that date the veteran was serving full time as a clearance diver on a winter mine countermeasures exercise in southern Australian waters, diving in water of 11 degrees and using hydraulic underwater tools. During that exercise he first noticed sharply demarcated whitening of the fingers of both hands on leaving the water.
This date is appropriate because his diving medical examination of 18 March 2010 recorded no finger blanching or cold-induced colour change, and he first presented with the symptoms on 26 July 2010, two weeks after they began. It falls within uninterrupted full-time service.
Before onset, from enlistment on 20 Jan 1998 to 12 Jul 2010, he accumulated about 3 600 hours of hand-held vibrating tool use and more than 1 500 hours of cold water immersion of the hands. The non-freezing cold injury of 19 Feb 2008, the crush fractures of 08 Sep 2008 and the carpal tunnel syndrome confirmed on 14 Apr 2009 all preceded onset. The six months before onset run from 12 Jan 2010 to 12 Jul 2010, during which he took propranolol 40 mg twice daily (from 14 Apr 2009), sumatriptan on about six days a month, and pseudoephedrine before most dives. By onset he had smoked about 15 cigarettes a day for 12 years, about nine pack-years.
For the worsening factors, the period after onset runs from 12 Jul 2010 to the documented worsening on 03 Aug 2015. During that period he used vibrating tools for about a further 1 200 hours and spent about 600 more hours in cold water, including on warlike maritime operations in the Middle East in 2012, and he continued to smoke 15 cigarettes a day.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Bilateral Hands - Raynaud Phenomenon (ICD-10 I73.0), secondary Raynaud phenomenon with features of the vascular component of hand-arm vibration syndrome (vibration white finger). No Statement of Principles has been determined for Raynaud phenomenon, and it is assessed on the sound medical-scientific evidence.
Raynaud phenomenon is an exaggerated constriction of the small arteries of the fingers in response to cold or emotional stress. Attacks cause sharply demarcated whitening of the fingers as blood flow stops, followed by blueness as the remaining blood loses oxygen, and painful redness as blood flow returns. Primary Raynaud phenomenon has no underlying cause. Secondary Raynaud phenomenon is caused by injury to the digital arteries or nerves, including hand-arm vibration, cold injury and trauma, by connective tissue disease, and by drugs that constrict blood vessels, such as beta-blockers, triptans and sympathomimetic decongestants. Smoking and continued exposure to cold and vibration worsen it, and severe cases develop fingertip ulcers.
The condition began on 12 July 2010 during a winter diving exercise, was confirmed by a vascular physician on 22 September 2010, and worsened to daily attacks with a digital ulcer by 03 August 2015.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
12 July 2010.
When did the veteran first present to a health / medical provider for this condition?
26 July 2010.
When was the condition confirmed / formally diagnosed?
22 September 2010.
When did the veteran first present to you (or your practice) for this condition?
21 May 2025.
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was confirmed by a vascular physician on 22 September 2010 on the history of recurrent, cold-induced, sharply demarcated triphasic colour change of the fingers of both hands, with delayed rewarming on cold provocation testing. Antinuclear antibodies were negative and nailfold capillaroscopy was normal, which makes an underlying connective tissue disease unlikely, and upper limb Doppler excluded proximal arterial disease and thoracic outlet compression. The history of more than 3 600 hours of hand-arm vibration, cold injury and trauma establishes the phenomenon as secondary, with the vascular component of hand-arm vibration syndrome classified as Stockholm stage 2.
The worsening was confirmed on 03 August 2015 by daily attacks involving all fingers, a digital ulcer and finger systolic pressures reduced to 20 to 35 per cent of baseline after cooling, classified as Stockholm stage 3.
4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.
No Statement of Principles has been determined by the Repatriation Medical Authority for Raynaud phenomenon. The claim is therefore decided on the sound medical-scientific evidence of what causes and worsens the condition, without the limits of a Statement of Principles. The recognised causes below are drawn from the medical literature on secondary Raynaud phenomenon and hand-arm vibration syndrome.
Legislation: the clinical onset of this condition was on 12 July 2010, after 1 July 2004, during continuous full-time service. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim. For operational service the reasonable hypothesis standard applies, and for peacetime service the balance of probabilities standard applies. The veteran's warlike service in East Timor in 1999 to 2000 and in Iraq in 2003, where he used powered tools and dived for long periods, and in the Middle East in 2012, where the condition worsened, is operational service. Each factor must be related to the person's service. Under the beneficial approach required by the legislation, the absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.
Recognised causes on the medical-scientific evidence (no Statement of Principles)
Causative factors
Cause 1: using hand-held vibrating tools for a cumulative period of at least 2 000 hours before the clinical onset of Raynaud phenomenon; — MET
- The veteran's diving and maintenance logbooks record about 3 600 hours of hand-held vibrating tool use from 1998 to 12 July 2010, including hydraulic underwater cutters, grinders and impact wrenches, rock drills for demolition charges and pneumatic needle guns and chipping hammers. About 400 of those hours were on warlike service in East Timor in 1999 to 2000 and in Iraq in 2003, clearing obstructions and ordnance from ports and wharves. Hand-arm vibration damages the digital arteries and their nerve supply and is the best-established occupational cause of secondary Raynaud phenomenon.
Cause 2: being exposed to cold water immersion of the hands for a cumulative period of at least 500 hours before the clinical onset of Raynaud phenomenon; — MET
- His dive log records more than 1 500 hours of diving in water below 18 degrees from 1998 to 12 July 2010, with thin gloves or bare hands for fine work on mines and ordnance. The onset occurred during dives in water of 11 degrees on 12 July 2010. Repeated cold immersion causes chronic vasoconstriction and injury to the digital vessels.
Cause 3: having a non-freezing cold injury or frostbite involving the affected digits before the clinical onset of Raynaud phenomenon; — MET
- A medical officer diagnosed non-freezing cold injury of the fingers of both hands on 19 February 2008 after a two-hour hull search in water of 2 to 4 degrees during a cold-weather diving exchange, with cold sensitivity and tingling persisting for four months. Cold injury damages the endothelium and sympathetic nerve supply of the digital arteries and is followed by Raynaud-type cold sensitivity in a high proportion of cases.
Cause 4: having a crush injury or fracture of the affected digits before the clinical onset of Raynaud phenomenon; — MET
- On 08 September 2008 his right hand was crushed in a watertight hatch on a mine countermeasures vessel, fracturing the distal phalanges of the right index and middle fingers and lacerating the nail bed, as shown on X-ray. Trauma to the digits damages the digital arteries and is a recognised cause of localised secondary Raynaud phenomenon, and the right middle finger was the site of the later ulcer.
Cause 5: having carpal tunnel syndrome of the affected hand at the time of the clinical onset of Raynaud phenomenon; — MET
- Nerve conduction studies on 14 April 2009 confirmed moderate bilateral carpal tunnel syndrome, attributed to repetitive gripping and powered tool use, and it was present at onset on 12 July 2010. Carpal tunnel syndrome is associated with Raynaud phenomenon through disturbance of the sympathetic fibres in the median nerve and shares hand-arm vibration as a cause.
Cause 6: smoking at least five pack-years of cigarettes, or the equivalent thereof in other tobacco products, before the clinical onset of Raynaud phenomenon; — MET
- The veteran smoked about 15 cigarettes a day from diver training in 1998 to onset, about nine pack-years, smoking between dives and on watch, as recorded at enlistment and at each diving medical. Nicotine causes digital vasoconstriction and smoking increases the risk of vibration-induced Raynaud phenomenon.
Cause 7: taking a beta-adrenergic blocking agent for at least the six months before the clinical onset of Raynaud phenomenon; — MET
- A neurologist commenced propranolol 40 mg twice daily for migraine on 14 April 2009, and the veteran took it continuously throughout the six months before onset, from 12 January 2010 to 12 July 2010. Non-selective beta-blockers leave alpha-adrenergic vasoconstriction unopposed and are a recognised cause of cold extremities and Raynaud phenomenon.
Cause 8: taking a triptan or ergot derivative on at least four days per month for at least the six months before the clinical onset of Raynaud phenomenon; — MET
- Sumatriptan 50 mg was prescribed on 14 April 2009 for migraine attacks and was used on about six days a month throughout the six months before onset, as recorded in his medication history. Triptans constrict blood vessels through serotonin receptors and are a recognised cause of digital vasospasm.
Cause 9: taking a sympathomimetic drug, including pseudoephedrine, on more days than not for at least the six months before the clinical onset of Raynaud phenomenon; — MET
- The diving medical officer recorded on 14 April 2009 that the veteran had taken pseudoephedrine 60 mg before most dives since 2005 to equalise his ears and sinuses, a common practice among clearance divers. He dived on more days than not, and took pseudoephedrine on those days, throughout the six months before onset. Sympathomimetic drugs stimulate alpha-adrenergic vasoconstriction in the fingers.
Worsening factors
Worsening 1: continuing to use hand-held vibrating tools for a cumulative period of at least 500 hours after the clinical onset of Raynaud phenomenon and before its clinical worsening; — MET
- Although the vascular physician advised reduced vibration exposure on 22 September 2010, no change of duties was made, and the veteran used hydraulic and pneumatic tools for about a further 1 200 hours between onset and the worsening documented on 03 August 2015, including on warlike maritime security operations in the Middle East in 2012. The worsening was objectively confirmed by daily attacks, a digital ulcer and progression from Stockholm stage 2 to stage 3.
Worsening 2: continuing to be exposed to cold water immersion of the hands for a cumulative period of at least 100 hours after the clinical onset of Raynaud phenomenon and before its clinical worsening; — MET
- He continued to dive in cold southern waters on mine countermeasures and hull search tasks, logging about 600 further hours of cold water immersion between 12 July 2010 and 03 August 2015.
Worsening 3: smoking at least five cigarettes per day, or the equivalent thereof in other tobacco products, for at least the 12 months before the clinical worsening of Raynaud phenomenon; — MET
- He continued to smoke about 15 cigarettes a day throughout the 12 months before the worsening, from 03 August 2014 to 03 August 2015, as recorded by the vascular physician.
Worsening 4: inability to obtain appropriate clinical management for Raynaud phenomenon. — MET
- After the diagnosis on 22 September 2010 the vascular physician's advice to reduce vibration and cold exposure was not acted on, no change of duties or protective equipment was provided, and propranolol was continued until 2015. During warlike service in the Middle East in 2012 he had no access to vascular review or to heated gloves. The condition progressed to daily attacks and a digital ulcer. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.
The % contribution of the causes is 100% and significant.
Sequelae
The Raynaud phenomenon has caused a digital ulcer of the right middle fingertip with residual pulp scarring, and persisting numbness and reduced dexterity of both hands. The sensorineural component of hand-arm vibration syndrome and the bilateral carpal tunnel syndrome arise from the same vibration exposure and should be considered for acceptance alongside it.
Unintended Consequence
Met. Propranolol and sumatriptan prescribed and paid for by the Commonwealth for the veteran's migraine, and pseudoephedrine supplied for diving, each constrict the digital blood vessels and contributed to the onset of the Raynaud phenomenon, and propranolol was continued after the diagnosis. These are unintended consequences of treatment provided by the Commonwealth (section 6A of the DRCA and the equivalent provisions of the MRCA).
Inability to Attain Appropriate Medical Management
MET. After the vascular physician confirmed Raynaud phenomenon on 22 September 2010 and advised that vibration and cold exposure be reduced, the veteran remained in full diving and tool-using duties for almost five years without modified duties, heated gloves or a review of the propranolol that was aggravating the condition, and on warlike service in the Middle East in 2012 he had no access to vascular review. The condition progressed to daily attacks, a digital ulcer and Stockholm stage 3. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), the failure to implement clinically indicated exposure controls and medication changes because of service demands amounts to an inability to obtain appropriate clinical management.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 20 Jan 1998, Enlistment medical examination, Medical Officer, Recruit health centre
- 19 Feb 2008, Outpatient health record, Medical Officer, cold-weather diving exchange
- 08 Sep 2008, Emergency record and X-ray right hand report, Medical Officer and Radiologist
- 14 Apr 2009, Nerve conduction study report, Neurophysiologist
- 14 Apr 2009, Neurology consultation, Neurologist
- 14 Apr 2009, Diving medical examination, Diving Medical Officer
- 18 Mar 2010, Diving medical examination, Diving Medical Officer
- 26 Jul 2010, Outpatient health record, Medical Officer, Naval health centre
- 22 Sep 2010, Vascular medicine consultation and upper limb Doppler report, Vascular physician
- 03 Aug 2015, Vascular medicine review and digital plethysmography report, Vascular physician
- 12 Jun 2019, Separation medical examination, Medical Officer
