Left Hip - ASIS Avulsion Fracture — DVA claim example

Diagnostic Assessment — Left Hip - ASIS Avulsion Fracture

Example 1 of 1 · fictitious patient (Veteran BB)

Diagnostic Assessment

Left Hip - ASIS Avulsion Fracture

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

ADF History

Veteran BB, date of birth 11 September 1985, Royal Australian Navy, Marine Technician (Leading Seaman), enlisted 07 July 2004, medically discharged 14 May 2021. Operational service: Middle East Area of Operations aboard a frigate, 02 February 2014 to 20 September 2014 (warlike); Middle East Area of Operations aboard a frigate, 15 January 2018 to 10 August 2018 (warlike).

Occupational History

As a marine technician the veteran maintained and operated the propulsion, power generation and auxiliary machinery of major fleet units. The work involves climbing steep, often wet and oily ladders between decks many times a day, crawling and crouching in confined machinery spaces, lifting pumps, valves and tools of 20 to 40 kilograms, and responding at speed to damage-control and firefighting exercises in heavy protective equipment.

Shipboard life at sea brings long periods below decks with little sunlight, irregular watch-keeping hours, limited access to fresh food and a culture of smoking during breaks. Physical training at sea is restricted to treadmills, flight deck circuits and running on hard steel decks, and there is no access to imaging or specialist medical care until the ship reaches port.

History

Veteran BB, a marine technician in the Royal Australian Navy, sustained an avulsion fracture of the left anterior superior iliac spine through a pre-existing stress fracture when he slipped on a ladder during a damage-control exercise at sea on warlike service in the Middle East on 17 June 2014. Specialist care was delayed until the ship returned to Australia, the fragment displaced further, and the fracture progressed to non-union, confirmed on CT on 22 April 2015.

Timeline

• 26 Mar 2009 — On a peacetime field training activity the veteran fell from the rear of a truck and sustained a displaced fracture of the right tibial shaft, treated with an intramedullary nail. The fracture healed with 2.2 cm of shortening, confirmed on a standing leg length radiograph in October 2009. A shoe raise was recommended but not supplied, and the leg length inequality was never corrected. "R tibia malunion, 2.2 cm short"
• 14 Oct 2013 — At his annual fitness assessment the veteran failed the 2.4 km run. Weight 112 kg, height 1.75 m, BMI 36.6. He was placed on a compulsory remedial fitness program of running 5 to 8 km on five days a week, which he continued in Australia and then on deployment on the ship's treadmill and flight deck. His pre-deployment medical examination on 06 January 2014 recorded no hip pain and a normal hip examination. "remedial program, run 5-8 km"
• 22 Apr 2014 — At sea in the Middle East the veteran reported to the ship's medical sailor with two weeks of aching left anterior hip pain during and after running, with tenderness over the left anterior superior iliac spine. He was given ibuprofen and told to continue his remedial program. No imaging was available on board. "L ASIS tenderness with running"
• 17 Jun 2014 — During a damage-control exercise at sea the veteran slipped on a wet ladder while descending at speed in firefighting equipment. His left leg shot backwards with the knee bent as he caught himself, and he felt a sudden tearing pain and pop in the left front of the hip. The ship's medical officer recorded severe pain, inability to bear weight, a palpable step and bruising over the left anterior superior iliac spine, and pain on resisted hip flexion. "ladder slip, pop, L ASIS"
• 19 Jun 2014 — Radiographs at a coalition medical facility during a port visit showed a displaced avulsion fracture of the left anterior superior iliac spine, with the fragment 15 mm from its bed and sclerotic margins at the fracture site indicating a pre-existing stress fracture. No orthopaedic surgeon was available. He was given crutches and oxycodone and returned to the ship, which sailed for a patrol of nine weeks. He continued watch-keeping and climbing ladders throughout. "displaced ASIS avulsion, 15 mm"
• 02 Oct 2014 — After the ship returned to Australia an orthopaedic surgeon found the fragment displaced to 28 mm on CT, with early fibrous callus. Open reduction and screw fixation was performed on 14 October 2014. The veteran smoked 15 to 20 cigarettes a day throughout his treatment, having increased his smoking at sea, and declined cessation support. Weight had risen to 119 kg. "displaced 28 mm, ORIF performed"
• 10 Mar 2015 — A medical officer diagnosed type 2 diabetes mellitus with an HbA1c of 8.1 per cent and commenced metformin. Morning testosterone was low at 6.2 nmol/L, attributed to opioid-induced androgen deficiency from continuous oxycodone since June 2014. Weight 124 kg. "type 2 diabetes, HbA1c 8.1"
• 22 Apr 2015 — CT of the pelvis showed non-union of the left anterior superior iliac spine fracture, with a persistent lucent gap, sclerotic bone ends and loosening of one screw. DXA on 15 April 2015 showed osteoporosis, with a lumbar spine T-score of -2.6. Serum 25-hydroxyvitamin D was 28 nmol/L. Weight 124.5 kg, BMI 40.7. Revision fixation with bone grafting was performed on 18 June 2015. "non-union, osteoporosis, vitamin D 28"

Symptoms

Before onset the veteran had two months of aching left anterior hip pain with running. At onset he had sudden tearing pain and a pop in the left front of the hip, could not bear weight, and had bruising, a palpable step and pain on lifting the leg. In the months after onset he walked with crutches, had pain at the front of the hip with climbing ladders and stairs, and had numbness on the outer thigh.

After the non-union he had persistent pain at the front of the hip, weakness lifting the leg, and pain on prolonged standing and walking. He now reports ongoing left anterior hip pain, a limp after walking more than 1 kilometre, difficulty with stairs and getting in and out of a car, and burning numbness over the outer left thigh from irritation of the lateral femoral cutaneous nerve.

Imaging

• 19 Jun 2014 — X-ray pelvis and left hip: "Displaced avulsion fracture of the left anterior superior iliac spine, fragment 15 mm from its bed. Sclerotic margins at the fracture site consistent with a pre-existing stress fracture."
• 02 Oct 2014 — CT pelvis: "Left anterior superior iliac spine avulsion fragment displaced 28 mm inferiorly with early fibrous callus. Pelvic obliquity with the right hemipelvis lower."
• 15 Apr 2015 — DXA bone densitometry: "Lumbar spine T-score -2.6, Z-score -2.4. Left femoral neck T-score -2.1. Osteoporosis."
• 22 Apr 2015 — CT pelvis: "Non-union of the left anterior superior iliac spine fracture with a persistent 4 mm lucent gap, sclerotic bone ends and lucency around one screw indicating loosening."

Onset Date

The most likely date of onset of this condition is 17 Jun 2014.

At that date the veteran was on warlike service in the Middle East Area of Operations aboard a frigate, taking part in a damage-control exercise at sea. He slipped on a wet ladder and his left leg was forced backwards with the knee bent, producing a sudden forceful pull of the sartorius muscle on the anterior superior iliac spine, which had been weakened by a stress fracture from two months of repetitive running.

This date is appropriate because his pre-deployment medical examination of 06 January 2014 recorded a normal hip, and the stress-related hip pain first recorded on 22 April 2014 was followed by the acute injury, palpable step and inability to bear weight recorded by the ship's medical officer on 17 June 2014, with the displaced avulsion fracture confirmed on radiographs two days later.

For the significant physical force factor, the force was applied at the moment of onset on 17 Jun 2014. For the stress fracture factors, the repetitive loading began with the remedial running program on 14 Oct 2013 and continued for eight months, from 14 Oct 2013 to 17 Jun 2014, with the stress fracture symptomatic from early April 2014. The abnormal loading from the uncorrected 2.2 cm leg length inequality was present from October 2009 continuously to the date of onset.

For the worsening factors, the worsening was the fracture non-union, confirmed on CT on 22 Apr 2015. During treatment, from 17 Jun 2014 to 22 Apr 2015, he smoked 15 to 20 cigarettes a day. Diabetes was diagnosed on 10 Mar 2015, osteoporosis on 15 Apr 2015 and vitamin D deficiency of 28 nmol/L on 15 Apr 2015, and his BMI was 40.7 on 22 Apr 2015, so each was present at the time of the non-union. Specialist management was not available from 19 Jun 2014 until 02 Oct 2014, the period in which the fragment displaced from 15 mm to 28 mm.

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

The formal diagnosis is Left Hip - ASIS Avulsion Fracture, an avulsion fracture of the left anterior superior iliac spine through a pre-existing stress fracture, complicated by non-union (ICD-10-AM S32.3, fracture of ilium), under the Statements of Principles concerning fracture, Balance of Probabilities No. 63 of 2024 and Reasonable Hypothesis No. 62 of 2024.

The anterior superior iliac spine is the bony prominence at the front of the pelvis to which the sartorius muscle and the tensor fasciae latae attach. An avulsion fracture occurs when a sudden forceful contraction or stretch of these muscles, typically with the hip extended and the knee flexed, pulls a fragment of bone away from the pelvis. Repetitive traction from running can first cause a fatigue-type stress fracture at the attachment, which weakens the bone and allows a complete avulsion with a lesser force. Most heal with rest, but marked displacement, continued loading, smoking, diabetes, osteoporosis, vitamin D deficiency and obesity all impair healing and increase the risk of non-union. The lateral femoral cutaneous nerve runs close to the fragment and may be irritated.

The stress fracture developed during a compulsory running program from October 2013, the avulsion occurred at sea on warlike service on 17 June 2014, specialist care was delayed for more than three months, and the fracture progressed to non-union confirmed on 22 April 2015.

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

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

17 June 2014.

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

17 June 2014.

When was the condition confirmed / formally diagnosed?

19 June 2014.

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

17 June 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 radiographs on 19 June 2014, which showed a displaced avulsion fracture of the left anterior superior iliac spine with the fragment 15 mm from its bed and sclerotic margins indicating a pre-existing fatigue-type stress fracture. This meets the Statement of Principles definition of fracture, which includes avulsion fracture and stress fracture of the fatigue type, and the injury was caused by an applied force. The clinical findings were consistent: sudden pain and a pop during a forceful hip movement, inability to bear weight, a palpable step, bruising and pain on resisted hip flexion.

CT on 02 October 2014 confirmed further displacement to 28 mm, and CT on 22 April 2015 confirmed non-union, with a persistent lucent gap, sclerotic bone ends and screw loosening. Non-union is a clinical worsening of the fracture. DXA on 15 April 2015 confirmed osteoporosis, and blood tests confirmed type 2 diabetes and vitamin D deficiency at the time of the non-union.

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 17 June 2014, 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 to the veteran's warlike service in the Middle East Area of Operations in 2014, during which the stress fracture developed, the avulsion occurred and specialist care was unavailable. The Balance of Probabilities instrument applies to peacetime service, including the 2009 tibial injury that caused the leg length inequality, the remedial running program begun in Australia in October 2013, and the treatment period in Australia during which the non-union developed.

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 17 June 2014, while taking part in a damage-control exercise in the course of his duties, the veteran slipped on a wet ladder and his left leg was forced backwards with the knee bent. The sudden violent contraction of the sartorius applied a significant physical force to the left anterior superior iliac spine, avulsing a fragment of bone. Pain, a pop, a palpable step and inability to bear weight followed immediately, so the force was applied at the time of clinical onset. The injury arose out of his service.

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

- From 14 October 2013 the veteran was required by his command to complete a remedial fitness program of running 5 to 8 km on five days a week, which he began in Australia and continued at sea. Each stride loaded the anterior superior iliac spine through the sartorius and tensor fasciae latae. Left anterior hip pain with running was recorded on 22 April 2014, and the radiographs of 19 June 2014 showed a pre-existing fatigue-type stress fracture at the avulsion site. The significant repetitive loading stress occurred for eight months before clinical onset and was a requirement of his service.

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

- A right tibial fracture sustained on a peacetime training activity on 26 March 2009 healed with 2.2 cm of shortening, and the recommended shoe raise was never supplied. The resulting pelvic obliquity, shown on CT on 02 October 2014, increased and redirected the traction load on the left anterior superior iliac spine with every step. This uncorrected substantial leg length inequality was present continuously from 2009 to the onset on 17 June 2014, so the abnormal chronic loading existed at the time of clinical onset and arose from a service injury.

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 15 to 20 cigarettes a day throughout his treatment, from the fracture on 17 June 2014 through the fixation of 14 October 2014 to the non-union confirmed on 22 April 2015. His smoking increased during long periods at sea, where smoking breaks were part of the watch-keeping routine, and continued during his treatment in Australia. Smoking impairs blood supply to healing bone and is documented by the orthopaedic surgeon as a contributor to the non-union.

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

- Type 2 diabetes mellitus was diagnosed on 10 March 2015 with an HbA1c of 8.1 per cent, after weight gain from 112 kg to 124 kg during prolonged immobility on crutches following the service fracture. The diabetes was present, and poorly controlled, when non-union was confirmed on CT on 22 April 2015.

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

- After the fracture was diagnosed on 19 June 2014 no orthopaedic surgeon was available, and the veteran was returned to his ship, which sailed for nine weeks. He continued watch-keeping and climbing ladders, and he did not receive a specialist opinion until 02 October 2014, by which time the fragment had displaced from 15 mm to 28 mm and fibrous callus had formed. Under Brew v Repatriation Commission (1999), this is an inability to obtain appropriate clinical management before the clinical worsening, the non-union confirmed on 22 April 2015.

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 warlike service in the Middle East aboard a frigate on 17 June 2014, the veteran slipped on a wet ladder during a damage-control exercise, and the forced extension of his hip with the knee bent caused a violent contraction of the sartorius that avulsed the left anterior superior iliac spine. The significant force was applied at the moment of clinical onset and arose directly from his operational duties.

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

- From his arrival in the area of operations on 02 February 2014 to the fracture on 17 June 2014, the veteran ran 5 to 8 km on five days a week on the ship's treadmill and on the steel flight deck as part of his compulsory remedial fitness program, in addition to repeatedly climbing ladders between machinery spaces. A stress fracture of the anterior superior iliac spine was symptomatic from April 2014 and was shown on the radiographs of 19 June 2014. This repetitive loading occurred on warlike service before clinical onset.

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 uncorrected 2.2 cm right leg shortening from the 2009 service tibial fracture caused pelvic obliquity and abnormal traction on the left anterior superior iliac spine. This was present throughout his warlike service in 2014, during which he ran and climbed ladders daily on a moving ship, and it was present at the time of clinical onset on 17 June 2014.

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

- During treatment for the fracture, from 17 June 2014, the veteran smoked 15 to 20 cigarettes a day, an increase from about 10 a day before his warlike deployment that occurred at sea during the stress of operations in the Middle East. He continued at this level until the non-union was confirmed on 22 April 2015.

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

- Type 2 diabetes mellitus, diagnosed on 10 March 2015 after weight gain during immobility from the fracture sustained on warlike service, was present when non-union was confirmed on 22 April 2015.

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

- DXA on 15 April 2015 showed osteoporosis, with a lumbar spine T-score of -2.6 and a Z-score of -2.4. The osteoporosis followed severe vitamin D deficiency from months below decks on warlike service and opioid-induced androgen deficiency from oxycodone prescribed for the fracture since June 2014. It was present when non-union was confirmed on 22 April 2015.

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 28 nmol/L on 15 April 2015, one week before non-union was confirmed on 22 April 2015. The deficiency arose from long periods below decks with little sunlight during his warlike deployment from February to September 2014 and his restricted outdoor activity during recovery.

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

- On 22 April 2015 the veteran weighed 124.5 kg at a height of 1.75 m, a BMI of 40.7, when non-union was confirmed. His weight had risen from 112 kg during prolonged immobility on crutches after the fracture sustained on warlike service.

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

- On warlike service, after the displaced fracture was diagnosed in port on 19 June 2014, no orthopaedic surgeon was available and the veteran remained aboard for a nine-week patrol, climbing ladders and keeping watches. Specialist assessment was not obtained until 02 October 2014, by which time the fragment had displaced to 28 mm. Under Brew v Repatriation Commission (1999), operational circumstances that prevent timely specialist care are an inability to obtain appropriate clinical management, and this occurred before the clinical worsening, the non-union confirmed on 22 April 2015.

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

Sequelae

The non-union and the two operations have led to chronic left anterior hip pain, weakness of hip flexion, and meralgia paraesthetica from irritation of the left lateral femoral cutaneous nerve by the displaced fragment and the surgical scarring. The veteran's altered gait has also contributed to left-sided low back pain. Each of these is a sequela of the accepted fracture and may be claimed in its own right.

Unintended Consequence

Met. The opioid-induced androgen deficiency and the osteoporosis that contributed to the non-union are unintended consequences of continuous oxycodone prescribed by Defence medical officers for the fracture from June 2014, and the loosening of a fixation screw followed the surgery funded by the Commonwealth while he was serving (section 6A of the DRCA and the equivalent provisions of the MRCA).

Inability to Attain Appropriate Medical Management

MET. After his displaced fracture was diagnosed on warlike service on 19 June 2014, no orthopaedic surgeon was available and the veteran was returned to his ship for a nine-week patrol, during which he continued watch-keeping and climbing ladders on crutches. He did not see a specialist until 02 October 2014, when the fragment had displaced from 15 mm to 28 mm and fibrous callus had already formed, making fixation more difficult and less likely to unite. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), the circumstances of his operational service prevented him from obtaining the timely specialist treatment that was clinically appropriate, and this inability contributed to the non-union confirmed on 22 April 2015.

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

See attached report.

References

1. 26 Mar 2009, Hospital admission and operation report, Orthopaedic surgeon
2. 14 Oct 2013, Annual fitness assessment and remedial program record, Physical training instructor
3. 06 Jan 2014, Pre-deployment medical examination, Medical Officer
4. 22 Apr 2014, Ship's sick bay record, Medical sailor, Middle East
5. 17 Jun 2014, Ship's sick bay record, Ship's Medical Officer, Middle East
6. 19 Jun 2014, X-ray report, Coalition medical facility
7. 02 Oct 2014, Specialist consultation and CT report, Orthopaedic surgeon and Radiologist
8. 14 Oct 2014, Operation report, open reduction and internal fixation, Orthopaedic surgeon
9. 10 Mar 2015, Outpatient health record and pathology, Medical Officer
10. 15 Apr 2015, DXA report and vitamin D result, Radiologist and Pathologist
11. 22 Apr 2015, CT pelvis report, Radiologist
12. 18 Jun 2015, Operation report, revision fixation and bone grafting, Orthopaedic surgeon
13. Statement of Principles concerning Fracture (Balance of Probabilities) No. 63 of 2024, Repatriation Medical Authority
14. Statement of Principles concerning Fracture (Reasonable Hypothesis) No. 62 of 2024, Repatriation Medical Authority