Diagnostic Assessment — Left Elbow - Ulnar Neuropathy
Example 1 of 1 · fictitious patient (Veteran EE)
Diagnostic Assessment
Left Elbow - Ulnar Neuropathy
BOP Code: 66 of 2017 (Ulnar Neuropathy at the Elbow)
RH Code: 65 of 2017 (Ulnar Neuropathy at the Elbow)
ADF History
Veteran EE, date of birth 12 March 1984, Australian Army, Electronics Technician, enlisted 15 January 2003, medically discharged 30 April 2018. Operational service: Solomon Islands, 05 February 2007 to 20 August 2007 (non-warlike); Afghanistan, 01 February 2010 to 22 June 2010 (warlike).
Occupational History
An Army electronics technician maintains and repairs radios, weapon sights, surveillance and electronic warfare equipment in workshops and in the field. The work involves long hours at a bench holding soldering irons, probes and fine instruments with the wrists extended and elbows flexed and resting on the bench, and lifting and carrying equipment cases, batteries and generators weighing more than 10 kilograms.
Technicians attached to deployed units travel in protected vehicles and are exposed to improvised explosive device blasts, burns from electrical faults and soldering equipment, and tropical infections in endemic areas. After serious injury, members retained on light duties often continue bench work from a wheelchair.
History
Veteran EE, an Army electronics technician, sustained an incomplete spinal cord injury with paraplegia, a fracture-dislocation of the left elbow and a carotid dissection with stroke in an improvised explosive device blast on warlike service in Afghanistan on 22 June 2010, and developed ulnar neuropathy at the left elbow on 12 October 2016, while on haemodialysis for amyloidosis, under treatment for leprosy acquired in the Solomon Islands, and twelve days after a caesarean section. The neuropathy worsened after ulnar nerve decompression in November 2016.
Timeline
- 22 Jun 2010 — On warlike service in Afghanistan her vehicle struck an improvised explosive device. She sustained a T12 burst fracture with an incomplete spinal cord injury, a fracture of the left medial epicondyle with posterior dislocation of the left elbow, and a right internal carotid artery dissection. Open reduction and internal fixation of the medial epicondyle was performed at the role 3 hospital. On day two she developed a right middle cerebral artery infarct with left hemiplegia. "T12 SCI, medial epicondyle fracture"
- 05 Aug 2014 — After two years of a chronic sacral pressure injury with osteomyelitis, a consequence of her paraplegia, renal biopsy on 10 Mar 2014 had shown AA amyloidosis with nephrotic-range proteinuria and progressive renal failure. She commenced haemodialysis three times a week through a right forearm fistula. She remained in service on light duties as an electronics technician in a workshop, mobilising in a manual wheelchair and walking short distances with forearm crutches. "AA amyloidosis, haemodialysis commenced"
- 14 Nov 2015 — A flash fire from a faulty soldering station at her workbench caused partial thickness burns to 6 per cent of her body surface, including the left forearm and elbow. Her left arm, weakened by the 2010 stroke, could not be withdrawn quickly. She was admitted to a burns unit for six days. Earlier in 2015 she had been diagnosed with acromegaly from a pituitary macroadenoma and with type 2 diabetes mellitus. "left forearm burns, admitted"
- 18 Jan 2016 — A dermatologist and infectious diseases physician diagnosed borderline tuberculoid leprosy from an anaesthetic hypopigmented patch on the left forearm, a thickened tender left ulnar nerve at the elbow and acid-fast bacilli on skin biopsy. The infection was attributed to her service in the Solomon Islands in 2007. Multidrug therapy for twelve months was commenced. She was 8 weeks pregnant. "leprosy, thickened left ulnar nerve"
- 12 Jun 2016 — While transferring from her wheelchair to a workshop stool she fell onto her flexed left elbow. She had immediate pain, swelling and loss of movement, and the elbow was splinted for three weeks. X-ray showed post-traumatic osteoarthritis and a loose bony fragment near the medial epicondyle. On 26 Jul 2016 an orthopaedic surgeon performed elbow arthroscopy under a regional block to remove the fragment and debride the joint. "fall onto left elbow, splinted"
- 14 Oct 2016 — She presented with tingling and numbness of the left ring and little fingers and a weak grip that began on 12 Oct 2016. She had delivered by caesarean section under general anaesthesia on 30 Sep 2016 and was in hospital, positioned supine with her arms flexed, until 05 Oct 2016. Examination showed reduced sensation in the ulnar distribution, weak finger abduction, a positive Tinel sign and a positive elbow flexion test. "ulnar paraesthesia, Tinel positive"
- 02 Nov 2016 — Nerve conduction studies showed slowing of left ulnar motor conduction across the elbow to 32 m/s, compared with 54 m/s in the forearm, with a reduced sensory action potential. Ultrasound showed an enlarged ulnar nerve at the elbow compressed by heterotopic bone and scar. A neurologist confirmed ulnar neuropathy at the left elbow. "slowing across elbow, 32 m/s"
- 05 Dec 2016 — She had undergone ulnar nerve decompression and anterior transposition under general anaesthesia on 21 Nov 2016 and was in hospital until 25 Nov 2016 with a wound infection. At review she reported constant numbness, wasting of the hand muscles and clawing of the ring and little fingers. Repeat nerve conduction studies on 13 Dec 2016 showed a new conduction block and denervation in the first dorsal interosseous. "worse after transposition, clawing"
Symptoms
At onset the veteran had tingling and numbness of the left ring and little fingers and the ulnar side of the hand, worse when the elbow was bent, at night and when leaning on the elbow, with a weak grip and clumsiness with fine tools.
Since the December 2016 worsening she has constant numbness in the ulnar distribution, wasting of the intrinsic hand muscles, clawing of the ring and little fingers and weak pinch. She cannot use soldering tools or fine instruments, and the weakness has made wheelchair transfers and self-propulsion harder.
Imaging
- 22 Jun 2010 — X-ray and CT left elbow (role 3 hospital): "Displaced fracture of the left medial epicondyle with posterior dislocation of the elbow."
- 12 Jun 2016 — X-ray left elbow: "Healed medial epicondyle fracture with fixation screw. Joint space narrowing and osteophytes consistent with post-traumatic osteoarthritis. 8 mm ossified fragment adjacent to the medial epicondyle in the cubital tunnel."
- 02 Nov 2016 — Ultrasound left ulnar nerve: "Ulnar nerve enlarged to a cross-sectional area of 16 mm2 at the medial epicondyle, compressed by heterotopic bone and scar tissue in the cubital tunnel, with fusiform thickening of the nerve proximally."
Onset Date
The most likely date of onset of this condition is 12 Oct 2016.
At that date the veteran was serving full time on light duties as an electronics technician, on maternity leave since 16 Sep 2016, twelve days after a caesarean section. She had paraplegia, used a manual wheelchair and forearm crutches, was on haemodialysis for amyloidosis and was taking multidrug therapy for leprosy.
This date is appropriate because her pre-anaesthetic assessment on 28 Sep 2016 recorded normal sensation and power in the left hand apart from the known mild weakness from her 2010 stroke, and she first presented with the symptoms on 14 Oct 2016, two days after they began. It falls within continuous full-time service.
For the short windows, the 2 weeks before onset run from 28 Sep 2016 to 12 Oct 2016 and contain her hospitalisation from 30 Sep 2016 to 05 Oct 2016; the 1 month before onset runs from 12 Sep 2016 to 12 Oct 2016 and contains the caesarean section under general anaesthesia on 30 Sep 2016. For the activity factors, the 3 months before onset run from 12 Jul 2016 to 12 Oct 2016 and the 6 months from 12 Apr 2016 to 12 Oct 2016; throughout them she performed wheelchair transfers and self-propulsion and used crutches daily, and worked at the bench until 16 Sep 2016, 26 days before onset. The 6 months before onset contain the elbow arthroscopy of 26 Jul 2016, the 1 year before onset, from 12 Oct 2015 to 12 Oct 2016, contains the elbow trauma of 12 Jun 2016, and the 2 years before onset, from 12 Oct 2014 to 12 Oct 2016, contain the burn of 14 Nov 2015. The 3 months before onset contain her pregnancy to 30 Sep 2016. She had been on haemodialysis since 05 Aug 2014, more than one year before onset.
For the worsening factors, the neuropathy began on 12 Oct 2016 and worsened as documented on 05 Dec 2016. The 2 weeks before the worsening run from 21 Nov 2016 to 05 Dec 2016 and contain her hospitalisation from 21 Nov 2016 to 25 Nov 2016; the 1 month before, from 05 Nov 2016 to 05 Dec 2016, contains the decompression under general anaesthesia on 21 Nov 2016. The 3 months before the worsening, from 05 Sep 2016 to 05 Dec 2016, contain her pregnancy and her return to part-time bench work from 07 Nov 2016 to 18 Nov 2016, and the 1 year before, from 05 Dec 2015 to 05 Dec 2016, contains the elbow trauma of 12 Jun 2016.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Ulnar Neuropathy at the Left Elbow (ICD-10 G56.2), worsened after surgical decompression and transposition, under the Statements of Principles concerning ulnar neuropathy at the elbow, Balance of Probabilities No. 66 of 2017 and Reasonable Hypothesis No. 65 of 2017.
Ulnar neuropathy at the elbow is an acquired persistent disturbance of function of the ulnar nerve where it passes behind the medial epicondyle and through the cubital tunnel. It causes numbness and tingling of the little and ring fingers and weakness and wasting of the small muscles of the hand. The nerve is vulnerable to compression and stretch with prolonged or repeated elbow flexion, leaning on the elbow, fractures and arthritis of the elbow, scar and bone fragments, and to systemic conditions that make nerves susceptible, including diabetes, renal failure, amyloidosis, acromegaly and leprosy. Severe or untreated neuropathy leads to permanent weakness and clawing of the hand.
The neuropathy followed a blast injury on warlike service in Afghanistan that fractured the left elbow and caused paraplegia and stroke, and later leprosy, amyloidosis with haemodialysis, elbow trauma and surgery, and pregnancy with caesarean section. It began on 12 October 2016, was confirmed on nerve conduction studies on 02 November 2016 and worsened in December 2016.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
12 October 2016.
When did the veteran first present to a health / medical provider for this condition?
14 October 2016.
When was the condition confirmed / formally diagnosed?
02 November 2016.
When did the veteran first present to you (or your practice) for this condition?
10 October 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 nerve conduction studies on 02 November 2016, which showed slowing of left ulnar motor conduction across the elbow to 32 m/s compared with 54 m/s in the forearm, and a reduced ulnar sensory action potential, with normal median nerve studies. A neurologist confirmed ulnar neuropathy at the left elbow. With altered sensation and weakness in the ulnar distribution and electrodiagnostic evidence of impaired ulnar nerve function at the elbow, this meets the Statement of Principles definition.
Ultrasound showed an enlarged ulnar nerve at the medial epicondyle compressed by heterotopic bone and scar, with leprous thickening proximally. Repeat nerve conduction studies on 13 December 2016 confirmed the worsening, with a new conduction block across the transposition site and denervation of the first dorsal interosseous.
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.
Legislation: the clinical onset of this condition was on 12 October 2016, after 1 July 2004, during continuous full-time service. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim and the Statements of Principles apply. The Balance of Probabilities instrument applies to peacetime service. The Reasonable Hypothesis instrument applies to the veteran's non-warlike service in the Solomon Islands in 2007, where she acquired leprosy, and her warlike service in Afghanistan in 2010, where the blast caused her elbow fracture, paraplegia and stroke, from which most of the other factors follow.
Each factor must be related to the person's relevant 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.
Balance of Probabilities — Statement of Principles concerning Ulnar Neuropathy at the Elbow, No. 66 of 2017
Causative factors
Factor 8(1): having a fracture of the bones of the affected elbow, including fracture of the medial epicondyle of the humerus, before the clinical onset of ulnar neuropathy at the elbow; — MET
- The veteran fractured the left medial epicondyle with a posterior elbow dislocation in a blast during service on 22 June 2010, treated with internal fixation, long before onset on 12 October 2016. The fracture lies directly over the ulnar nerve groove.
Factor 8(2): having trauma to the affected elbow within the one year before the clinical onset of ulnar neuropathy at the elbow; — MET
- On 12 June 2016, while transferring from her wheelchair at her workshop, she fell onto her flexed left elbow, with immediate pain, swelling and loss of movement, and the elbow was splinted for three weeks. This meets the definition of trauma to the affected elbow and occurred within the one year before onset, from 12 October 2015 to 12 October 2016.
Factor 8(3): performing repetitive and forceful activities involving flexion and extension of the affected elbow: (a) for a cumulative period of at least 90 hours, within a continuous period of three months before the clinical onset of ulnar neuropathy at the elbow; and (b) where the repetitive and forceful activities have not ceased more than 30 days before the clinical onset of ulnar neuropathy at the elbow; — MET
- From 12 July 2016 to 12 October 2016 the veteran made 15 to 20 wheelchair transfers a day, lifting her body weight of 64 kg through both elbows, and at work until 16 September 2016 she lifted equipment cases over 10 kilograms and used heavy crimping tools. The occupational therapist's diary records about 2 hours a day of such activity, well over 90 hours in the three months before onset, and transfers continued daily up to onset.
Factor 8(4): having a surgical procedure under general anaesthesia, within the one month before the clinical onset of ulnar neuropathy at the elbow; — MET
- She delivered by caesarean section under general anaesthesia on 30 September 2016, general anaesthesia being required because of her spinal injury and fixation. This was 12 days before onset, within the one month before onset.
Factor 8(5): having a surgical procedure to the affected elbow, including elbow arthroscopy, within the six months before the clinical onset of ulnar neuropathy at the elbow; — MET
- An orthopaedic surgeon performed arthroscopy of the left elbow with removal of a loose bony fragment and debridement on 26 July 2016, funded by Defence, within the six months before onset, from 12 April 2016 to 12 October 2016.
Factor 8(6): being hospitalised, or confined to bed in a supine position, for at least two days within the two weeks before the clinical onset of ulnar neuropathy at the elbow; — MET
- She was in hospital after the caesarean section from 30 September 2016 to 05 October 2016, five days, largely confined to bed supine with her arms flexed, within the two weeks before onset, from 28 September 2016 to 12 October 2016.
Factor 8(7): daily self-propulsion of a manual wheelchair: (a) for a cumulative period of at least 60 hours within a continuous period of three months before the clinical onset of ulnar neuropathy at the elbow; and (b) where this activity has not ceased more than 30 days before the clinical onset of ulnar neuropathy at the elbow; — MET
- Since her 2010 spinal cord injury the veteran has propelled a manual wheelchair every day, for 3 to 4 hours a day at work and home. Between 12 July 2016 and 12 October 2016 this amounted to more than 250 hours, and she continued daily self-propulsion up to onset.
Factor 8(8): having paraplegia at the time of the clinical onset of ulnar neuropathy at the elbow; — MET
- She has had paraplegia from an incomplete T12 spinal cord injury, ASIA grade C, since the blast of 22 June 2010, and it was present at onset.
Factor 8(9): using elbow or forearm crutches: (a) for a cumulative period of at least 60 hours within a continuous period of three months before the clinical onset of ulnar neuropathy at the elbow; and (b) where this activity has not ceased more than 30 days before the clinical onset of ulnar neuropathy at the elbow; — MET
- Her incomplete injury allows short-distance walking with knee-ankle-foot orthoses and forearm crutches, which her physiotherapy program required for at least one hour a day. Between 12 July 2016 and 12 October 2016 she used the crutches for more than 90 hours, and resumed daily use on 07 October 2016, before onset.
Factor 8(10): having an inflammatory or degenerative joint disease from the specified list of specified list of inflammatory and degenerative joint diseases, involving the affected elbow, at the time of the clinical onset of ulnar neuropathy at the elbow; — MET
- X-ray of 12 June 2016 and arthroscopy of 26 July 2016 showed post-traumatic osteoarthritis of the left elbow with joint space narrowing, osteophytes and chondral loss, following the 2010 fracture-dislocation. Osteoarthritis is on the specified list and was present at onset.
Factor 8(11): having amyloidosis at the time of the clinical onset of ulnar neuropathy at the elbow; — MET
- Renal biopsy on 10 March 2014 showed AA amyloidosis secondary to chronic osteomyelitis of a sacral pressure injury, with renal failure requiring haemodialysis, so that vital function was compromised. The amyloidosis was present at onset.
Factor 8(12): having a cerebrovascular accident with hemiplegia, excluding transient ischaemic attack or transient symptoms with infarction, before the clinical onset of ulnar neuropathy at the elbow; — MET
- On 24 June 2010 she had a right middle cerebral artery infarct from a blast-related carotid dissection, confirmed on MRI, with left hemiplegia lasting several months and residual left arm weakness. This was before onset.
Factor 8(13): having an external burn to the affected arm requiring hospitalisation, within the two years before the clinical onset of ulnar neuropathy at the elbow; — MET
- On 14 November 2015 a flash fire from a faulty soldering station at her workbench caused partial thickness burns to the left forearm and elbow, and she was admitted to a burns unit for six days. This was within the two years before onset, from 12 October 2014 to 12 October 2016.
Factor 8(14): having an infection involving the affected ulnar nerve in the region of the elbow at the time of the clinical onset of ulnar neuropathy at the elbow; — MET
- Borderline tuberculoid leprosy was diagnosed on 18 January 2016, with a thickened, tender left ulnar nerve at the elbow and acid-fast bacilli on skin biopsy, acquired during service in the Solomon Islands. She was still on multidrug therapy at onset, and ultrasound on 02 November 2016 showed fusiform thickening of the nerve.
Factor 8(15): having a lesion as specified at the elbow that compresses or displaces the affected ulnar nerve at the time of the clinical onset of ulnar neuropathy at the elbow; — MET
- Ultrasound on 02 November 2016 showed the ulnar nerve compressed by heterotopic bone and scar tissue in the cubital tunnel at the site of the 2010 fracture and the 2016 arthroscopy. A bony fragment and scar are each a lesion as specified, and both were present at onset.
Factor 8(16): having acromegaly before the clinical onset of ulnar neuropathy at the elbow; — MET
- Acromegaly was diagnosed on 20 April 2015 from a raised IGF-1, failure of growth hormone suppression on glucose tolerance testing and a pituitary macroadenoma on MRI, before onset. Soft tissue overgrowth narrows the cubital tunnel.
Worsening factors
Factor 8(17): having a fracture of the bones of the affected elbow, including fracture of the medial epicondyle of the humerus, before the clinical worsening of ulnar neuropathy at the elbow; — MET
- The 2010 medial epicondyle fracture preceded the documented worsening on 05 December 2016.
Factor 8(18): having trauma to the affected elbow within the one year before the clinical worsening of ulnar neuropathy at the elbow; — MET
- The fall onto the left elbow on 12 June 2016, splinted for three weeks, occurred within the one year before the worsening, from 05 December 2015 to 05 December 2016.
Factor 8(19): performing repetitive and forceful activities involving flexion and extension of the affected elbow: (a) for a cumulative period of at least 90 hours, within a continuous period of three months before the clinical worsening of ulnar neuropathy at the elbow; and (b) where the repetitive and forceful activities have not ceased more than 30 days before the clinical worsening of ulnar neuropathy at the elbow; — MET
- From 05 September 2016 to 05 December 2016 she continued 15 to 20 wheelchair transfers a day and lifted equipment cases on her return to part-time duties from 07 November 2016, well over 90 hours, and transfers continued after her surgery up to the worsening.
Factor 8(20): having a surgical procedure under general anaesthesia, within the one month before the clinical worsening of ulnar neuropathy at the elbow; — MET
- Ulnar nerve decompression and anterior transposition were performed under general anaesthesia on 21 November 2016, within the one month before the worsening.
Factor 8(21): having a surgical procedure to the affected elbow, including elbow arthroscopy, within the six months before the clinical worsening of ulnar neuropathy at the elbow; — MET
- The left elbow arthroscopy of 26 July 2016 and the ulnar nerve transposition of 21 November 2016 both fall within the six months before the worsening, from 05 June 2016 to 05 December 2016.
Factor 8(22): being hospitalised, or confined to bed in a supine position, for at least two days within the two weeks before the clinical worsening of ulnar neuropathy at the elbow; — MET
- She was in hospital from 21 November 2016 to 25 November 2016 with a wound infection after the transposition, within the two weeks before the worsening.
Factor 8(23): daily self-propulsion of a manual wheelchair: (a) for a cumulative period of at least 60 hours within a continuous period of three months before the clinical worsening of ulnar neuropathy at the elbow; and (b) where this activity has not ceased more than 30 days before the clinical worsening of ulnar neuropathy at the elbow; — MET
- Daily wheelchair self-propulsion of 3 to 4 hours continued from 05 September 2016 to 05 December 2016, more than 250 hours, including in the days after the surgery.
Factor 8(24): having paraplegia at the time of the clinical worsening of ulnar neuropathy at the elbow; — MET
- Paraplegia from the T12 spinal cord injury was present at the worsening.
Factor 8(25): using elbow or forearm crutches: (a) for a cumulative period of at least 60 hours within a continuous period of three months before the clinical worsening of ulnar neuropathy at the elbow; and (b) where this activity has not ceased more than 30 days before the clinical worsening of ulnar neuropathy at the elbow; — MET
- She used forearm crutches for at least one hour a day from 05 September 2016 until her surgery on 21 November 2016, more than 60 hours, ceasing 14 days before the worsening.
Factor 8(26): having an inflammatory or degenerative joint disease from the specified list of specified list of inflammatory and degenerative joint diseases, involving the affected elbow, at the time of the clinical worsening of ulnar neuropathy at the elbow; — MET
- Post-traumatic osteoarthritis of the left elbow was present at the worsening and was seen at the transposition operation.
Factor 8(27): having amyloidosis at the time of the clinical worsening of ulnar neuropathy at the elbow; — MET
- AA amyloidosis with renal failure on haemodialysis was present at the worsening.
Factor 8(28): having a cerebrovascular accident with hemiplegia, excluding transient ischaemic attack or transient symptoms with infarction, before the clinical worsening of ulnar neuropathy at the elbow; — MET
- The 2010 stroke with left hemiplegia preceded the worsening.
Factor 8(29): having an external burn to the affected arm requiring hospitalisation, within the two years before the clinical worsening of ulnar neuropathy at the elbow; — MET
- The left forearm and elbow burn of 14 November 2015, requiring six days in a burns unit, falls within the two years before the worsening, from 05 December 2014 to 05 December 2016.
Factor 8(30): having an infection involving the affected ulnar nerve in the region of the elbow at the time of the clinical worsening of ulnar neuropathy at the elbow; — MET
- Leprosy of the left ulnar nerve was still under multidrug therapy at the worsening, and the surgeon recorded a thickened, inflamed nerve at operation, with granulomatous neuritis on biopsy.
Factor 8(31): having a lesion as specified at the elbow that compresses or displaces the affected ulnar nerve at the time of the clinical worsening of ulnar neuropathy at the elbow; — MET
- After the transposition, a haematoma and fresh scar at the new site compressed the nerve, shown on ultrasound on 13 December 2016 at the level of the new conduction block.
Factor 8(32): having acromegaly before the clinical worsening of ulnar neuropathy at the elbow; — MET
- Acromegaly, diagnosed on 20 April 2015 and only partly controlled after pituitary surgery, preceded the worsening.
Factor 8(33): inability to obtain appropriate clinical management for ulnar neuropathy at the elbow. — MET
- Nerve conduction studies were not available for three weeks after she presented on 14 October 2016, and the surgery was performed while her leprous neuritis was active and her diabetes poorly controlled, leading to a wound infection, a postoperative haematoma and worsening. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.
Reasonable Hypothesis — Statement of Principles concerning Ulnar Neuropathy at the Elbow, No. 65 of 2017
Causative factors
Factor 8(1): having a fracture of the bones of the affected elbow, including fracture of the medial epicondyle of the humerus, before the clinical onset of ulnar neuropathy at the elbow; — MET
- The left medial epicondyle fracture-dislocation was sustained in an improvised explosive device blast on warlike service in Afghanistan on 22 June 2010.
Factor 8(2): having trauma to the affected elbow within the two years before the clinical onset of ulnar neuropathy at the elbow; — MET
- The fall onto the left elbow on 12 June 2016, within the two years before onset, occurred during a wheelchair transfer made necessary by the paraplegia she sustained on warlike service in Afghanistan.
Factor 8(3): performing repetitive and forceful activities involving flexion and extension of the affected elbow: (a) for a cumulative period of at least 90 hours, within a continuous period of six months before the clinical onset of ulnar neuropathy at the elbow; and (b) where the repetitive and forceful activities have not ceased more than 30 days before the clinical onset of ulnar neuropathy at the elbow; — MET
- The repeated wheelchair transfers lifting her body weight through the elbows, more than 300 hours from 12 April 2016 to 12 October 2016 and continuing up to onset, are required by the paraplegia caused on warlike service in Afghanistan.
Factor 8(4): holding a tool, device or instrument in position, with the wrist in an extended position and the affected elbow in a flexed position: (a) for a cumulative period of at least 90 hours, within a continuous period of six months before the clinical onset of ulnar neuropathy at the elbow; and (b) where this activity has not ceased more than 30 days before the clinical onset of ulnar neuropathy at the elbow; — MET
- Retained on light duties at a workshop bench because of her operational injuries, she held a soldering iron and test probes in the left hand with the wrist extended and elbow flexed for 4 to 5 hours a day, over 400 hours from 12 April 2016 until she began maternity leave on 16 September 2016, 26 days before onset.
Factor 8(5): using the affected elbow as a support in a posture that is required as part of the activity being performed: (a) with the forearm pronated on a hard surface, or holding the arm with the elbow flexed by 30° or more; and (b) for a cumulative period of at least 90 hours, within a continuous period of six months before the clinical onset of ulnar neuropathy at the elbow; and (c) where this activity has not ceased more than 30 days before the clinical onset of ulnar neuropathy at the elbow; — MET
- Working from her wheelchair at a bench of fixed height, the veteran had to rest her left forearm pronated on the hard bench surface, with the elbow flexed beyond 30 degrees, to steady her stroke-weakened arm while soldering. This occupied more than 300 hours from 12 April 2016 to 16 September 2016, ceasing 26 days before onset, and resulted from her injuries on warlike service in Afghanistan.
Factor 8(6): having a surgical procedure under general anaesthesia, within the two months before the clinical onset of ulnar neuropathy at the elbow; — MET
- The caesarean section on 30 September 2016, within the two months before onset, required general anaesthesia because regional anaesthesia was contraindicated by the spinal injury and fixation from warlike service in Afghanistan.
Factor 8(7): having a surgical procedure to the affected elbow, including elbow arthroscopy, within the one year before the clinical onset of ulnar neuropathy at the elbow; — MET
- The left elbow arthroscopy of 26 July 2016, within the one year before onset, treated post-traumatic arthritis and a bony fragment from the fracture sustained on warlike service in Afghanistan.
Factor 8(8): being hospitalised, or confined to bed in a supine position, for at least two days within the 30 days before the clinical onset of ulnar neuropathy at the elbow; — MET
- She was in hospital from 30 September 2016 to 05 October 2016, within the 30 days before onset, for a caesarean delivery managed as high risk because of the paraplegia and renal failure that followed warlike service.
Factor 8(9): daily self-propulsion of a manual wheelchair: (a) for a cumulative period of at least 60 hours within a continuous period of six months before the clinical onset of ulnar neuropathy at the elbow; and (b) where this activity has not ceased more than 30 days before the clinical onset of ulnar neuropathy at the elbow; — MET
- Daily manual wheelchair propulsion, more than 500 hours from 12 April 2016 to onset, results from the paraplegia sustained on warlike service in Afghanistan.
Factor 8(10): having paraplegia at the time of the clinical onset of ulnar neuropathy at the elbow; — MET
- The paraplegia was caused by the T12 spinal cord injury in the blast on warlike service in Afghanistan on 22 June 2010.
Factor 8(11): using elbow or forearm crutches: (a) for a cumulative period of at least 60 hours within a continuous period of six months before the clinical onset of ulnar neuropathy at the elbow; and (b) where this activity has not ceased more than 30 days before the clinical onset of ulnar neuropathy at the elbow; — MET
- Forearm crutch walking for at least one hour a day, more than 150 hours from 12 April 2016 and resumed on 07 October 2016, was prescribed for the incomplete spinal cord injury from warlike service.
Factor 8(12): having an inflammatory or degenerative joint disease from the specified list of inflammatory and degenerative joint diseases, involving the affected elbow, at the time of the clinical onset of ulnar neuropathy at the elbow; — MET
- Post-traumatic osteoarthritis of the left elbow, present at onset, followed the fracture-dislocation sustained on warlike service in Afghanistan.
Factor 8(13): having amyloidosis at the time of the clinical onset of ulnar neuropathy at the elbow; — MET
- AA amyloidosis, present at onset, was secondary to chronic osteomyelitis of a pressure injury caused by the paraplegia from warlike service in Afghanistan.
Factor 8(14): having haemodialysis or peritoneal dialysis for at least the one year before the clinical onset of ulnar neuropathy at the elbow; — MET
- She had haemodialysis three times a week from 05 August 2014, more than two years before onset, for renal failure from amyloidosis that followed her operational paraplegia.
Factor 8(15): having a cerebrovascular accident with hemiplegia, excluding transient ischaemic attack or transient symptoms with infarction, before the clinical onset of ulnar neuropathy at the elbow; — MET
- The right middle cerebral artery infarct with left hemiplegia on 24 June 2010 resulted from a carotid dissection caused by the blast on warlike service in Afghanistan.
Factor 8(16): having an external burn to the affected arm requiring hospitalisation, within the five years before the clinical onset of ulnar neuropathy at the elbow; — MET
- The burn of 14 November 2015 to the left forearm and elbow, requiring six days in hospital, occurred within the five years before onset; she could not withdraw her arm from the flash fire because of the weakness from the stroke caused on warlike service.
Factor 8(17): being pregnant within the three months before the clinical onset of ulnar neuropathy at the elbow; — MET
- The veteran was pregnant until her caesarean delivery on 30 September 2016, within the three months before onset, from 12 July 2016 to 12 October 2016. The pregnancy was managed in the setting of the paraplegia and dialysis that followed her operational injuries, which increased fluid retention and the time she spent bed-bound.
Factor 8(18): having an infection involving the affected ulnar nerve in the region of the elbow at the time of the clinical onset of ulnar neuropathy at the elbow; — MET
- Leprosy involving the left ulnar nerve at the elbow, under treatment at onset, was acquired on non-warlike service in the Solomon Islands from February to August 2007, where the disease is endemic.
Factor 8(19): smoking at least ten pack-years of cigarettes, or the equivalent thereof in other tobacco products, before the clinical onset of ulnar neuropathy at the elbow, and: (a) smoking commenced at least five years before the clinical onset of ulnar neuropathy at the elbow; and (b) where smoking has ceased, the clinical onset of ulnar neuropathy at the elbow has occurred within five years of cessation; — MET
- She began smoking in 2000 and had smoked about 16 pack-years by onset, increasing to 30 a day on both operational deployments and after her injuries. She was still smoking at onset.
Factor 8(20): having a lesion as specified at the elbow that compresses or displaces the affected ulnar nerve at the time of the clinical onset of ulnar neuropathy at the elbow; — MET
- The heterotopic bone and scar compressing the ulnar nerve at onset arose from the fracture-dislocation and fixation after the blast on warlike service in Afghanistan.
Factor 8(21): having diabetes mellitus at the time of the clinical onset of ulnar neuropathy at the elbow; — MET
- Type 2 diabetes mellitus was diagnosed in 2015 with an HbA1c of 7.8 per cent, associated with acromegaly and the inactivity of paraplegia from warlike service, and was treated with insulin at onset.
Factor 8(22): having acromegaly before the clinical onset of ulnar neuropathy at the elbow; — MET
- Acromegaly was diagnosed on 20 April 2015, during continuous service that included her operational service, before onset.
Worsening factors
Factor 8(23): having a fracture of the bones of the affected elbow, including fracture of the medial epicondyle of the humerus, before the clinical worsening of ulnar neuropathy at the elbow; — MET
- The fracture from warlike service in Afghanistan in 2010 preceded the worsening on 05 December 2016.
Factor 8(24): having trauma to the affected elbow within the two years before the clinical worsening of ulnar neuropathy at the elbow; — MET
- The elbow trauma of 12 June 2016, during a transfer required by her operational paraplegia, falls within the two years before the worsening.
Factor 8(25): performing repetitive and forceful activities involving flexion and extension of the affected elbow: (a) for a cumulative period of at least 90 hours, within a continuous period of six months before the clinical worsening of ulnar neuropathy at the elbow; and (b) where the repetitive and forceful activities have not ceased more than 30 days before the clinical worsening of ulnar neuropathy at the elbow; — MET
- Transfers required by her operational paraplegia continued daily from 05 June 2016 to the worsening, well over 90 hours.
Factor 8(26): holding a tool, device or instrument in position, with the wrist in an extended position and the affected elbow in a flexed position: (a) for a cumulative period of at least 90 hours, within a continuous period of six months before the clinical worsening of ulnar neuropathy at the elbow; and (b) where this activity has not ceased more than 30 days before the clinical worsening of ulnar neuropathy at the elbow; — MET
- She held soldering tools with the wrist extended and elbow flexed for over 300 hours from 05 June 2016, last on 18 November 2016, 17 days before the worsening, in the bench role she held because of her operational injuries.
Factor 8(27): using the affected elbow as a support in a posture that is required as part of the activity being performed: (a) with the forearm pronated on a hard surface, or holding the arm with the elbow flexed by 30° or more; and (b) for a cumulative period of at least 90 hours, within a continuous period of six months before the clinical worsening of ulnar neuropathy at the elbow; and (c) where this activity has not ceased more than 30 days before the clinical worsening of ulnar neuropathy at the elbow; — MET
- She rested the pronated left forearm on the bench, elbow flexed beyond 30 degrees, for more than 200 hours from 05 June 2016, last on 18 November 2016, to steady the arm weakened by the operational stroke.
Factor 8(28): having a surgical procedure under general anaesthesia, within the two months before the clinical worsening of ulnar neuropathy at the elbow; — MET
- The caesarean section of 30 September 2016 and the transposition of 21 November 2016, both under general anaesthesia required because of her operational spinal injury, fall within the two months before the worsening.
Factor 8(29): having a surgical procedure to the affected elbow, including elbow arthroscopy, within the one year before the clinical worsening of ulnar neuropathy at the elbow; — MET
- The arthroscopy of 26 July 2016 and the transposition of 21 November 2016 on the elbow fractured on warlike service fall within the one year before the worsening.
Factor 8(30): being hospitalised, or confined to bed in a supine position, for at least two days within the 30 days before the clinical worsening of ulnar neuropathy at the elbow; — MET
- She was in hospital from 21 November 2016 to 25 November 2016, within the 30 days before the worsening.
Factor 8(31): daily self-propulsion of a manual wheelchair: (a) for a cumulative period of at least 60 hours within a continuous period of six months before the clinical worsening of ulnar neuropathy at the elbow; and (b) where this activity has not ceased more than 30 days before the clinical worsening of ulnar neuropathy at the elbow; — MET
- Daily wheelchair propulsion for her operational paraplegia continued from 05 June 2016 to the worsening.
Factor 8(32): having paraplegia at the time of the clinical worsening of ulnar neuropathy at the elbow; — MET
- Paraplegia from warlike service in Afghanistan was present at the worsening.
Factor 8(33): using elbow or forearm crutches: (a) for a cumulative period of at least 60 hours within a continuous period of six months before the clinical worsening of ulnar neuropathy at the elbow; and (b) where this activity has not ceased more than 30 days before the clinical worsening of ulnar neuropathy at the elbow; — MET
- Forearm crutch walking for her operational spinal injury continued from 05 June 2016 to 21 November 2016, more than 120 hours, ceasing 14 days before the worsening.
Factor 8(34): having an inflammatory or degenerative joint disease from the specified list of inflammatory and degenerative joint diseases, involving the affected elbow, at the time of the clinical worsening of ulnar neuropathy at the elbow; — MET
- Post-traumatic osteoarthritis of the left elbow from the operational fracture was present at the worsening.
Factor 8(35): having amyloidosis at the time of the clinical worsening of ulnar neuropathy at the elbow; — MET
- AA amyloidosis secondary to her operational paraplegia was present at the worsening.
Factor 8(36): having haemodialysis or peritoneal dialysis for at least the one year before the clinical worsening of ulnar neuropathy at the elbow; — MET
- Haemodialysis had continued since 05 August 2014, more than one year before the worsening.
Factor 8(37): having a cerebrovascular accident with hemiplegia, excluding transient ischaemic attack or transient symptoms with infarction, before the clinical worsening of ulnar neuropathy at the elbow; — MET
- The blast-related stroke with left hemiplegia of June 2010 preceded the worsening.
Factor 8(38): having an external burn to the affected arm requiring hospitalisation, within the five years before the clinical worsening of ulnar neuropathy at the elbow; — MET
- The burn of 14 November 2015, requiring hospitalisation, falls within the five years before the worsening.
Factor 8(39): being pregnant within the three months before the clinical worsening of ulnar neuropathy at the elbow; — MET
- She was pregnant until 30 September 2016, within the three months before the worsening, from 05 September 2016 to 05 December 2016.
Factor 8(40): having an infection involving the affected ulnar nerve in the region of the elbow at the time of the clinical worsening of ulnar neuropathy at the elbow; — MET
- Leprous neuritis of the left ulnar nerve, acquired on non-warlike service in the Solomon Islands, was active at the worsening and confirmed on nerve biopsy at the transposition.
Factor 8(41): smoking at least ten pack-years of cigarettes, or the equivalent thereof in other tobacco products, before the clinical worsening of ulnar neuropathy at the elbow, and: (a) smoking commenced at least five years before the clinical worsening of ulnar neuropathy at the elbow; and (b) where smoking has ceased, the clinical worsening of ulnar neuropathy at the elbow has occurred within five years of cessation; — MET
- About 16 pack-years had been smoked by the worsening, commencing in 2000, with heavier smoking on operational deployments, and she was still smoking.
Factor 8(42): having a lesion as specified at the elbow that compresses or displaces the affected ulnar nerve at the time of the clinical worsening of ulnar neuropathy at the elbow; — MET
- Haematoma and scar at the transposition site compressed the nerve at the worsening, on an elbow deformed by the operational fracture.
Factor 8(43): having diabetes mellitus at the time of the clinical worsening of ulnar neuropathy at the elbow; — MET
- Diabetes mellitus, poorly controlled after the caesarean section with an HbA1c of 8.6 per cent in November 2016, was present at the worsening.
Factor 8(44): having acromegaly before the clinical worsening of ulnar neuropathy at the elbow; — MET
- Acromegaly, diagnosed in April 2015, preceded the worsening.
Factor 8(45): inability to obtain appropriate clinical management for ulnar neuropathy at the elbow. — MET
- The three-week delay in nerve conduction studies and the complicated surgery occurred while her care was fragmented across dialysis, obstetric, leprosy and spinal services for conditions that followed her operational service, and the neuropathy worsened.
The % contribution of the causes is 100% and significant.
Sequelae
Ulnar neuropathy at the left elbow is a sequela of the veteran's accepted blast injuries from warlike service in Afghanistan: the left elbow fracture-dislocation with its post-traumatic arthritis, heterotopic bone and scar, the paraplegia that requires wheelchair use, transfers and crutches, the stroke, and the amyloidosis and renal failure that followed her pressure injury. Leprosy acquired in the Solomon Islands is a further cause. The neuropathy has caused permanent weakness and clawing of the left hand, which has reduced her independence in transfers and wheelchair use.
Unintended Consequence
Met. The worsening of the neuropathy is an unintended consequence of the ulnar nerve transposition of 21 November 2016, complicated by wound infection, haematoma and a new conduction block, and the onset was contributed to by positioning during the caesarean section and the elbow arthroscopy, all provided through Defence health services while the veteran was serving (section 6A of the DRCA and the equivalent provisions of the MRCA).
Inability to Attain Appropriate Medical Management
MET. After the veteran presented on 14 October 2016, nerve conduction studies were not available for almost three weeks, and the transposition on 21 November 2016 was performed while her leprous neuritis was active and without coordination between her dialysis, leprosy and spinal teams. The operation was complicated by wound infection and haematoma, and by 05 December 2016 she had a new conduction block, wasting and clawing. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), delayed investigation and fragmented, poorly coordinated surgical care amount to an inability to obtain appropriate clinical management, and they contributed to the worsening.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 22 Jun 2010, Trauma admission and operation report, Role 3 hospital, Afghanistan
- 24 Jun 2010, MRI brain and stroke assessment, Neurologist
- 10 Mar 2014, Renal biopsy report, Renal physician
- 05 Aug 2014, Haemodialysis commencement, Renal physician
- 20 Apr 2015, Endocrinology consultation, Endocrinologist
- 14 Nov 2015, Burns unit discharge summary, Burns surgeon
- 18 Jan 2016, Skin biopsy and specialist consultation, Infectious diseases physician
- 12 Jun 2016, X-ray left elbow and orthopaedic consultation, Orthopaedic surgeon
- 26 Jul 2016, Elbow arthroscopy operation report, Orthopaedic surgeon
- 28 Sep 2016, Pre-anaesthetic assessment, Anaesthetist
- 30 Sep 2016, Operation report and discharge summary, caesarean section, Obstetrician
- 14 Oct 2016, Outpatient health record, Medical Officer, Garrison health centre
- 02 Nov 2016, Nerve conduction study and ultrasound, Neurologist
- 21 Nov 2016, Operation report, ulnar nerve transposition, Hand surgeon
- 13 Dec 2016, Repeat nerve conduction study, Neurologist
- Statement of Principles concerning Ulnar Neuropathy at the Elbow (Balance of Probabilities) No. 66 of 2017, Repatriation Medical Authority
- Statement of Principles concerning Ulnar Neuropathy at the Elbow (Reasonable Hypothesis) No. 65 of 2017, Repatriation Medical Authority
