Left Foot - Fifth Toe Fracture — ICD-10 S92.5

Example document — fictitious patient. Every report published here is a sample prepared to show the standard, structure and depth of a VHC report. The veteran described is fictitious: names, dates of birth, service numbers, units, locations and treating clinicians have been invented and all dates changed. It must not be relied upon as a record of any real claim.

Diagnostic Assessment — Left Foot - Fifth Toe Fracture

Example 1 of 1 · fictitious patient (Veteran BS)

Example document — fictitious patient. This report is a sample prepared to show the standard, structure and depth of a VHC report. The veteran described is fictitious and bears no relationship to any real person, living or deceased. Names, dates of birth, contact details, service numbers, units, locations and treating clinicians have been invented and all dates have been changed. It must not be relied upon as a record of any real claim.

Diagnostic Assessment

Left Foot - Fifth Toe Fracture

BOP Code: 63 of 2024 (Fracture)
RH Code: 62 of 2024 (Fracture)

ADF History

Veteran BS, date of birth 17 June 1978, Royal Australian Navy, Marine Technician (later Leading Seaman), enlisted 12 January 1997, medically discharged 03 March 2016. Operational service: East Timor, 21 September 1999 to 25 January 2000 (warlike); Middle East Area of Operations (maritime security), 08 January 2013 to 30 July 2013 (warlike).

Occupational History

Marine technicians operate and maintain a ship's propulsion, power generation and auxiliary machinery. They stand long watches in hot, noisy engine rooms, climb steep steel ladders many times a shift, work on steel deck plates in safety boots, and move rapidly through narrow passageways and over raised watertight door coamings during drills, emergencies and action stations.

The work carries a high risk of trips, stubbed and crushed toes, falls into bilges and down ladders, and repetitive loading of the feet. Long periods below decks on extended deployments limit sunlight exposure, shift work disrupts eating and exercise, and the shipboard culture of the period included high rates of smoking.

History

Veteran BS, a marine technician in the Royal Australian Navy, sustained a fracture of the proximal phalanx of the left fifth toe on 14 April 2013 on warlike service in the Middle East, when he struck the toe on a watertight door coaming at action stations, through a stress fracture caused by months of repetitive loading on a foot overloaded by a varus tibial malunion. The fracture progressed to non-union, confirmed on 21 November 2013, after delayed treatment at sea, continued smoking, diabetes, osteoporosis, vitamin D deficiency and severe obesity.

Timeline

06 Aug 2004 — During a peacetime maintenance period the veteran fell into an engine room bilge and sustained a fracture of the left tibial shaft. It was treated in a cast and healed with 8 degrees of varus malalignment, which was not corrected. From 2005 he had recurrent callus and soreness under the lateral border of the left foot, and a podiatrist recorded lateral column overload. "tibial fracture, varus malunion"
22 Jun 2009 — Investigation of iron deficiency and diarrhoea led to a diagnosis of coeliac disease on duodenal biopsy. A gastroenterologist commenced a gluten-free diet, which was difficult to maintain at sea. Serum 25-hydroxyvitamin D was 38 nmol/L. He smoked 20 cigarettes a day. "coeliac disease, vitamin D low"
14 Mar 2011 — A medical officer diagnosed type 2 diabetes mellitus with an HbA1c of 8.1 per cent and commenced metformin. Weight 108 kg, height 1.76 m, BMI 34.9. A DEXA scan on 02 May 2011 showed osteoporosis with a lumbar spine Z-score of minus 2.7, attributed to coeliac disease and vitamin D deficiency, and calcium and vitamin D supplements were started. "type 2 diabetes, osteoporosis"
10 Mar 2013 — On warlike service in the Middle East the veteran reported three weeks of aching along the outer border of the left forefoot after 12-hour watches on steel deck plates, repeated climbs of engine room ladders and daily circuit training on the flight deck. The ship's medical officer recorded tenderness over the left fifth toe and advised simple analgesia. There was no X-ray on board. "lateral forefoot ache, ladders"
14 Apr 2013 — While running to his damage control station at action stations, called when a suspicious vessel approached the ship at speed, he struck his left little toe at full pace on a steel watertight door coaming. He had immediate severe pain, swelling, bruising and visible deformity of the toe. The ship's medical officer reduced the deformity, buddy-taped the toe and returned him to watchkeeping in safety boots. The ship remained at sea on patrol. "struck coaming, deformed little toe"
27 May 2013 — At the first port visit, six weeks later, X-ray showed a displaced oblique fracture of the proximal phalanx of the left fifth toe, with periosteal reaction and sclerosis at the fracture site indicating a pre-existing stress fracture. An orthopaedic opinion by telehealth recommended a stiff-soled boot and restricted weight bearing, which could not be provided on board. He continued to smoke 20 cigarettes a day. "displaced phalanx fracture, stress reaction"
21 Nov 2013 — Seven months after injury, CT showed no bridging callus and sclerotic, rounded fracture margins, confirming atrophic non-union. Weight 124 kg, BMI 40.0. HbA1c 8.9 per cent. Serum 25-hydroxyvitamin D 31 nmol/L. A repeat DEXA scan on 10 October 2013 showed a lumbar spine Z-score of minus 2.9. An orthopaedic surgeon advised smoking cessation, optimisation of diabetes and vitamin D, and open reduction and internal fixation with bone graft. "atrophic non-union, BMI 40"
04 Apr 2014 — Open reduction, internal fixation and autologous bone grafting of the left fifth toe proximal phalanx were performed. Union was achieved by October 2014 with a residual stiff, malrotated toe and painful callus over the lateral border of the foot. He was medically discharged on 03 March 2016 with several conditions. "ORIF and bone graft"

Symptoms

At the time of the fracture the veteran had immediate severe pain, swelling, bruising and deformity of the left little toe, with inability to bear weight on the outer border of the foot or to fit a boot comfortably. In the preceding weeks he had aching along the outer border of the left forefoot after long watches and ladder climbing. After the injury the toe remained painful and swollen for months, worse in safety boots and on ladders.

Since the non-union and surgery he has a stiff, malrotated left little toe with painful callus over the lateral border of the foot. He cannot walk more than 30 minutes or stand more than an hour without pain, needs wide-fitting footwear with orthoses, and avoids uneven ground and stairs where possible.

Imaging

06 Aug 2004 — X-ray left tibia and fibula: "Displaced oblique fracture of the mid-shaft of the left tibia with an intact fibula."
27 May 2013 — X-ray left foot: "Displaced oblique fracture of the proximal phalanx of the fifth toe with periosteal reaction and sclerosis at the fracture site, consistent with an acute fracture through a pre-existing stress fracture. Generalised osteopenia."
17 Jun 2013 — Long-leg standing alignment X-ray: "Healed left tibial shaft fracture with 8 degrees of varus angulation and lateral shift of the weight-bearing axis."
10 Oct 2013 — DEXA bone densitometry: "Lumbar spine Z-score minus 2.9, femoral neck Z-score minus 2.6, consistent with osteoporosis."
21 Nov 2013 — CT left foot: "Atrophic non-union of the fifth toe proximal phalanx fracture with no bridging callus, rounded sclerotic margins and a 2 mm gap."

Onset Date

The most likely date of onset of this condition is 14 Apr 2013.

At that date the veteran was serving full time as a marine technician aboard a frigate on warlike service in the Middle East Area of Operations. He had been standing 12-hour engine room watches on steel deck plates and climbing ladders repeatedly since January 2013, and he had had aching over the outer border of the left forefoot since mid-February 2013. On 14 April 2013 he struck his left little toe at full pace on a watertight door coaming while running to his action station.

This date is appropriate because his pre-deployment medical examination of 15 November 2012 recorded normal feet apart from lateral callus, and the fracture was sustained in a witnessed incident on 14 April 2013 and confirmed on X-ray on 27 May 2013. The stress reaction seen on X-ray completed into a displaced fracture on that date. The date falls within uninterrupted full-time service.

For the physical force factor, the force was applied at the time of onset on 14 April 2013. For the repetitive loading factor, the period before onset relied on runs from the start of the deployment on 08 Jan 2013 to 14 Apr 2013, during which he stood 12-hour watches, climbed engine room ladders 40 to 60 times a shift and completed daily circuit training on the flight deck. For the abnormal force direction factor, the uncorrected 8-degree varus tibial malunion from August 2004 was present at the time of onset.

For the worsening factors, the documented worsening is the non-union confirmed on CT on 21 Nov 2013. Treatment for the fracture ran from 14 Apr 2013 to 21 Nov 2013, during which he smoked 20 cigarettes a day. Diabetes, osteoporosis, a serum 25-hydroxyvitamin D of 31 nmol/L and a BMI of 40.0 were each present on 21 Nov 2013. The inability to obtain appropriate management ran from 14 Apr 2013 to the first port visit on 27 May 2013 and on to his return to Australia on 30 Jul 2013, before the worsening.

1. What is the formal diagnosis of the condition claimed above?

The formal diagnosis is Fracture of the proximal phalanx of the left fifth toe (ICD-10-AM S92.5), an acute displaced fracture through a stress fracture, complicated by atrophic non-union, under the Statements of Principles concerning fracture, Balance of Probabilities No. 63 of 2024 and Reasonable Hypothesis No. 62 of 2024.

A fracture is an acquired break in a bone caused by a force that would ordinarily break healthy bone. A stress fracture of the fatigue type develops when repetitive loading exceeds the bone's capacity to repair microdamage, and it can complete into a displaced fracture with a further impact. Toe fractures commonly result from stubbing or striking the toe against a hard edge. Most heal in six to eight weeks; non-union, the failure of a fracture to heal, is more likely with delayed immobilisation, continued loading, smoking, diabetes, osteoporosis, vitamin D deficiency and severe obesity, and non-union is treated as a clinical worsening of the fracture.

The fracture followed months of repetitive loading on warlike service on a foot overloaded by a varus tibial malunion from a peacetime injury in 2004. It occurred on 14 April 2013 when he struck the toe at action stations, was confirmed on X-ray on 27 May 2013, and progressed to non-union confirmed on CT on 21 November 2013.

2. For each diagnosis identified, please also provide the following dates:

When did the veteran first experience symptoms attributable to this condition?

14 April 2013.

When did the veteran first present to a health / medical provider for this condition?

14 April 2013.

When was the condition confirmed / formally diagnosed?

27 May 2013.

When did the veteran first present to you (or your practice) for this condition?

19 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 X-ray on 27 May 2013, which showed a displaced oblique fracture of the proximal phalanx of the left fifth toe with periosteal reaction and sclerosis indicating a pre-existing stress fracture, after a witnessed impact on 14 April 2013 with immediate pain, swelling, bruising and deformity. The fracture resulted from an applied force sufficient to break healthy bone, and the stress component is a stress fracture of the fatigue type, both within the Statement of Principles definition. It was not a pathological fracture through a tumour or other focal lesion.

The non-union was confirmed on CT on 21 November 2013, seven months after injury, showing no bridging callus and rounded sclerotic margins, and by the orthopaedic surgeon's assessment and the findings at open reduction, internal fixation and bone grafting on 04 April 2014. The contributing conditions were documented: type 2 diabetes with an HbA1c of 8.9 per cent, osteoporosis on DEXA, a serum 25-hydroxyvitamin D of 31 nmol/L, a BMI of 40.0 and continued smoking of 20 cigarettes a day.

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 14 April 2013, 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 Reasonable Hypothesis instrument applies because the fracture occurred, and treatment was delayed, on warlike service in the Middle East Area of Operations. The Balance of Probabilities instrument applies to the veteran's peacetime service, including the 2004 tibial fracture that left the varus malunion and the diabetes, osteoporosis and weight gain that developed and continued during peacetime service, and each of its factors is also analysed.

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 Fracture, No. 63 of 2024

Causative factors

Factor 9(1): having significant physical force applied to or through the affected bone at the time of clinical onset; — MET

- On 14 April 2013 the veteran struck his left little toe at full running pace against a steel watertight door coaming, a force that ordinarily breaks bone. The toe was immediately deformed, and X-ray on 27 May 2013 showed a displaced oblique fracture of the proximal phalanx. The incident occurred in the course of his duties as he ran to his action station.

Factor 9(2): for stress fracture only, having significant repetitive loading stress to the affected bone prior to clinical onset; — MET

- From 08 January to 14 April 2013 he stood 12-hour engine room watches on steel deck plates in safety boots, climbed steep ladders 40 to 60 times a shift and completed daily circuit training. Lateral forefoot pain was recorded on 10 March 2013, and the X-ray showed periosteal reaction and sclerosis at the fracture site, confirming a stress fracture that preceded the acute break. The same pattern of loading had been part of his peacetime sea service since 1997.

Factor 9(3): for stress fracture only, having significant chronic repetitive loading stress to the affected bone due to abnormal force intensity or direction of application, at the time of clinical onset; — MET

- The left tibial shaft fracture sustained in a fall into an engine room bilge during peacetime service on 06 August 2004 healed with 8 degrees of uncorrected varus malalignment, confirmed on long-leg alignment X-ray on 17 June 2013. This shifted his weight-bearing axis laterally and overloaded the lateral column of the left foot, recorded by a podiatrist from 2005, and was present at the time of onset.

Worsening factors

Factor 9(4): smoking at least 5 cigarettes per day, or the equivalent thereof in other tobacco products, during treatment for fracture prior to fracture non-union; — MET

- The veteran smoked 20 cigarettes a day throughout treatment of the fracture, from 14 April 2013 to the confirmation of non-union on 21 November 2013, as recorded at the port visit of 27 May 2013 and by the orthopaedic surgeon. Smoking was entrenched in the shipboard culture during his service.

Factor 9(5): having diabetes mellitus at the time of the fracture non-union; — MET

- Type 2 diabetes mellitus was diagnosed on 14 March 2011 during peacetime service and treated with metformin. It was poorly controlled at the time of the non-union, with an HbA1c of 8.9 per cent on 21 November 2013.

Factor 9(6): inability to obtain appropriate clinical management for fracture before clinical worsening. — MET

- After the injury on 14 April 2013 no X-ray was available for six weeks, the fracture was buddy-taped only, and the recommended stiff-soled boot and restricted weight bearing could not be provided at sea, so he kept climbing ladders in safety boots. Orthopaedic review in person did not occur until after his return to Australia on 30 July 2013, before the non-union. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.

Reasonable Hypothesis — Statement of Principles concerning Fracture, No. 62 of 2024

Causative factors

Factor 9(1): having significant physical force applied to or through the affected bone at the time of clinical onset; — MET

- On 14 April 2013, on warlike service in the Middle East, the veteran struck his left little toe at full pace on a watertight door coaming while running to his damage control station at action stations, called when a suspicious vessel approached the ship. The impact displaced the proximal phalanx fracture shown on X-ray.

Factor 9(2): for stress fracture only, having significant repetitive loading stress to the affected bone prior to clinical onset; — MET

- On warlike service from 08 January to 14 April 2013 he stood 12-hour watches on steel deck plates, climbed engine room ladders 40 to 60 times a shift and completed daily flight deck circuit training to maintain fitness on a long patrol. Lateral forefoot pain began in mid-February, and the stress fracture was confirmed by periosteal reaction and sclerosis on X-ray.

- The uncorrected 8-degree varus malunion of the left tibia from 2004 shifted load onto the lateral column of the left foot throughout his warlike deployment, and was present at the time of onset on 14 April 2013.

Worsening factors

Factor 9(4): smoking at least 5 cigarettes per day, or the equivalent thereof in other tobacco products, during treatment for fracture prior to fracture non-union; — MET

- The veteran smoked 20 cigarettes a day throughout treatment from 14 April 2013, including the remainder of his warlike deployment, where duty-free cigarettes were readily available on board, to the non-union on 21 November 2013.

Factor 9(5): having diabetes mellitus at the time of the fracture non-union; — MET

- Type 2 diabetes mellitus, diagnosed in 2011, was present and poorly controlled at the non-union, with HbA1c rising to 8.9 per cent after shift work and irregular meals on warlike service disrupted his diabetes management.

Factor 9(6): having osteoporosis at the time of the fracture non-union; — MET

- Osteoporosis was diagnosed on DEXA on 02 May 2011, from coeliac disease and vitamin D deficiency, and was present at the non-union, with a lumbar spine Z-score of minus 2.9 on 10 October 2013. His gluten-free diet and supplements could not be maintained on warlike service.

Factor 9(7): having vitamin D deficiency, with a serum 25(OH)D level of less than 50 nanomoles per litre at the time of the fracture non-union; — MET

- Serum 25-hydroxyvitamin D was 31 nmol/L on 21 November 2013, at the time of the non-union. Seven months of 12-hour watches below decks on warlike service, with almost no sunlight exposure, compounded his coeliac-related malabsorption.

Factor 9(8): having a Body Mass Index (BMI) of 40 or greater at the time of the fracture non-union; — MET

- On 21 November 2013 the veteran weighed 124 kg at a height of 1.76 m, a BMI of 40.0. He had gained 16 kg since 2011, largely after the injury of April 2013, when he could not exercise on board and relied on shipboard meals on warlike service.

Factor 9(9): inability to obtain appropriate clinical management for fracture before clinical worsening. — MET

- On warlike service the ship remained on patrol after the injury, with no X-ray for six weeks, and the stiff-soled boot and restricted weight bearing recommended by telehealth on 27 May 2013 could not be provided, so he continued watchkeeping and ladder climbing. The fracture progressed to non-union by 21 November 2013.

The % contribution of the causes is 100% and significant.

Sequelae

The fifth toe fracture is a sequela of the veteran's service-related left tibial fracture of 2004, whose uncorrected varus malunion overloaded the lateral column of the foot. The non-union was contributed to by his diabetes, osteoporosis and vitamin D deficiency. In turn, the fracture and its surgery have left a stiff, malrotated toe with painful lateral callus and an altered gait.

Unintended Consequence

Not met. No treatment provided or funded by the Commonwealth caused the fracture or the non-union. The delay in imaging and immobilisation at sea is addressed under inability to obtain appropriate clinical management.

Inability to Attain Appropriate Medical Management

MET. After the fracture on 14 April 2013 on warlike service, the ship had no X-ray capability and remained on patrol for six weeks, so the fracture was buddy-taped without imaging and the veteran continued 12-hour watches and ladder climbing in safety boots. When the X-ray on 27 May 2013 showed a displaced fracture, the stiff-soled boot and restricted weight bearing recommended by the orthopaedic surgeon could not be provided on board, and he was not seen in person until after his return to Australia. The fracture progressed to atrophic non-union, confirmed on 21 November 2013, and required internal fixation and bone grafting. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), operational circumstances that prevent timely imaging and immobilisation of a fracture amount to an inability to obtain appropriate clinical management.

5. Please provide a Health Summary and a medication / prescribing history.

See attached report.

References

06 Aug 2004, Emergency department record and X-ray left tibia, Regional hospital
22 Jun 2009, Gastroenterology consultation and duodenal biopsy report, Gastroenterologist
14 Mar 2011, Outpatient health record, Medical Officer, Naval base health centre
02 May 2011, DEXA bone densitometry, Radiologist
15 Nov 2012, Pre-deployment medical examination, Medical Officer
10 Mar 2013, Ship's sick bay record, Ship's Medical Officer
14 Apr 2013, Ship's sick bay record and incident report, Ship's Medical Officer
27 May 2013, X-ray left foot and telehealth orthopaedic opinion, Radiologist and Orthopaedic surgeon
17 Jun 2013, Long-leg alignment X-ray, Radiologist
10 Oct 2013, DEXA bone densitometry, Radiologist
21 Nov 2013, CT left foot and orthopaedic consultation, Orthopaedic surgeon
04 Apr 2014, Operation report, Orthopaedic surgeon
Statement of Principles concerning Fracture (Balance of Probabilities) No. 63 of 2024, Repatriation Medical Authority
Statement of Principles concerning Fracture (Reasonable Hypothesis) No. 62 of 2024, Repatriation Medical Authority

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Left Foot - Fifth Toe Fracture — DVA claim example