Diagnostic Assessment — Left Thumb - Osteoarthritis
Example 1 of 1 · fictitious patient
Diagnostic Assessment Left Thumb — Osteoarthritis BOP Code: 62 of 2017 (Osteoarthritis) RH Code: 61 of 2017 (Osteoarthritis)
ADF History
The veteran, date of birth [withheld], served in the Australian Army as a Rifleman from 29 July 1981 to 14 May 1988
History
The veteran has left thumb osteoarthritis at the interphalangeal (IP) joint, documented on X-ray on 10 June 2017 with degenerative change and a large dorsal osteophyte.
The IP joint degeneration is a direct consequence of the MCP joint arthrodesis performed during ADF service on 28 March 1984, as fusion of the MCP joint transfers all thumb motion to the IP joint, placing excessive loading on this joint and accelerating degenerative change
Timeline
28 Mar 1984 — Bilateral thumb MCP arthrodesis performed during ADF service.
Fusion of the MCP joint eliminated motion at that level, transferring all mechanical stress to the IP joint. "MCP arthrodesis" 04 Jul 1984 — Operation: both MCP arthrodeses found solid and the original fixation wires removed from both thumbs. "removed the wires from that" 23 Jul 1985 — Left thumb MCP arthrodesis angulated (about 30° flexion); difficulty using the left thumb. "Angulated (L) thumb 1st MCP arthrodesis" 07 Feb 1986 — Re-fusion of the left thumb MCP joint in about 10° flexion with K- wires (the wires retained on the 2017 X-rays); physiotherapy to mobilise the IP joint requested 01 Mar 1986. "Fusion 1st mcp left hand" 11 May 2017 — X-ray left thumb: MCP arthrodesis with K-wires in situ.
Mild IP joint degenerative change. "Mild IP degenerative change" 10 Jun 2017 — X-ray bilateral thumbs: Left thumb IP joint degeneration with large dorsal osteophyte. "Large dorsal osteophyte"
Symptoms
The veteran reports pain, clicking, and crepitus at the left thumb IP joint, as documented on the X-ray referral (fused thumb, clicking)
Imaging
11 May 2017 — X-ray left thumb: "Arthrodesis first MCP joint.
K-wires in situ.
Mild IP degenerative change." 10 Jun 2017 — X-ray bilateral thumbs: "Left thumb: solid MCP ankylosis, 2 retained K-wires protruding beyond cortex, IP degeneration with large dorsal osteophyte."
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Left Thumb Osteoarthritis — IP Joint (ICD-10: M18.12).
The relevant Statements of Principles are those concerning Osteoarthritis (Balance of Probabilities No.
62 of 2017; Reasonable Hypothesis No.
61 of 2017), applied by analogy as this is a DRCA claim
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition? Insidious onset following MCP arthrodesis (28 March 1984).
First imaging confirmation: 11 May 2017.
When did the veteran first present to a health / medical provider for this condition? 11 May 2017 (X-ray for clicking left thumb) When was the condition confirmed / formally diagnosed? 11 May 2017 When did the veteran first present to you (or your practice) for this condition? 9 December 2022
3. How was this diagnosis confirmed?
The diagnosis was confirmed on X-ray on 11 May 2017 and 10 June 2017, demonstrating IP joint degenerative change with a large dorsal osteophyte
4. What do you consider to be the cause(s) of the condition in this veteran?
Legislation: The clinical onset of this condition was before 26 October 2001 (see
Date of Clinical Onset
Below), and it did not arise on warlike or non-warlike deployment (the veteran had no deployments).
This is therefore a DRCA claim.
Statements of Principles do not apply to DRCA claims, so there are no binding SOP factors for this condition.
The factors of the relevant Statements of Principles are applied below by analogy, as a guide to the causes of this condition that are recognised in the medical-scientific literature, and every factor of both the Balance of Probabilities and the Reasonable Hypothesis instruments is addressed.
Under the DRCA the question is whether the injury or disease arose out of, or in the course of, the veteran's ADF service, or (for a disease or an aggravation) whether that service contributed to it to a significant degree.
Plausible links to service outside the SOP factors are set out below.
The absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.
Causative Factors — Balance of Probabilities (Statement of Principles concerning Osteoarthritis, No.
62 of 2017) Factor 9(1): having inflammatory joint disease as specified, of the affected joint before the clinical onset of osteoarthritis in that joint — NOT MET - There is no record of ankylosing spondylitis, arthritis associated with Crohn's disease or ulcerative colitis, psoriatic arthropathy, reactive arthritis or rheumatoid arthritis, and nothing in his history suggests inflammatory joint disease of the left thumb IP joint.
Factor 9(2): having an infection of the affected joint as specified before the clinical onset of osteoarthritis in that joint — NOT MET - There is no record of a bacterial, viral, fungal or parasitic infection of the left thumb IP joint, and the thumb operations of 1983 and 1985 healed without recorded infection.
Factor 9(3): having an intra-articular fracture of the affected joint before the clinical onset of osteoarthritis in that joint — NOT MET - No fracture involving the articular surface of the left thumb IP joint is recorded; the 1983 injury was a MCP dislocation, the operations were on the MCP joint, and the pre-operative X-ray of February 1986 showed no abnormality apart from the fusion.
Factor 9(4): having haemarthrosis of the affected joint before the clinical onset of osteoarthritis in that joint — NOT MET - There is no record of bleeding into the left thumb IP joint; the injury and operations of 1983 to 1985 involved the MCP joint.
Factor 9(5): having a depositional joint disease as specified, in the affected joint before the clinical onset of osteoarthritis in that joint — NOT MET - There is no record of alkaptonuria, calcium pyrophosphate dihydrate deposition disease, gout, haemochromatosis or Wilson's disease, and nothing in his history suggests them.
Factor 9(6): having trauma to the affected joint within the 25 years before the clinical onset of osteoarthritis in that joint — NOT MET - Trauma to the affected joint requires a discrete event applying significant force to or through the left thumb IP joint that damages that joint and causes pain, tenderness and altered movement of it.
The motor vehicle accident of about 25 February 1984 dislocated the adjacent MCP joint, and the reduction and operations from March 1984 to February 1986 were on the MCP joint; no injury, damage or signs at the IP joint were recorded, the physiotherapy requested on 1 March 1986 to mobilise the IP joint followed post-operative splinting, and the pre-operative X-ray of February 1986 showed no abnormality apart from the fusion.
Trauma to the MCP joint does not satisfy this factor for the IP joint.
Factor 9(7): having an acute articular cartilage tear of the affected joint within the 25 years before the clinical onset of osteoarthritis in that joint — NOT MET - There is no record of an acute articular cartilage tear of the left thumb IP joint, and no imaging or arthroscopy has shown one.
Factor 9(8): having an acute meniscal tear of the affected knee within the 25 years before the clinical onset of osteoarthritis in that joint — NOT MET - This factor applies only to the knee; the veteran's osteoarthritis affects the left thumb IP joint.
Factor 9(9): having frostbite involving the affected joint before the clinical onset of osteoarthritis in that joint — NOT MET - There is no record of frostbite; his service was in Australian ports and coastal waters without recorded cold exposure.
Factor 9(10): having disordered joint mechanics of the affected joint for at least five years before the clinical onset of osteoarthritis in that joint — NOT MET - The left thumb MCP joint was fused on 28 March 1984 and healed angulated in about 30 degrees of flexion, a deformity that maldistributes load onto the IP joint, but this began only about two years before the estimated onset of 5 April 1986.
The earlier hyperextension deformity associated with his familial MCP dislocation is not shown, on the balance of probabilities, to have existed from April 1981, as no thumb problem was declared at his enlistment medical in May 1981, so five years is not established.
Factor 9(11): having necrosis of the subchondral bone near the affected joint, including that from dysbaric osteonecrosis, before the clinical onset of osteoarthritis in that joint — NOT MET - the veteran dived with snorkel and SCUBA equipment for survey work in 1982, but no necrosis of subchondral bone near the left thumb IP joint has been shown on any X-ray, and dysbaric osteonecrosis characteristically affects the shoulder, hip and knee.
Factor 9(12): for osteoarthritis of a joint of the upper limb only, performing: (a) forceful or repetitive activities involving the affected joint; or (b) tasks involving repeated or sustained pinch grip or hand/power grip; for an average of at least 100 hours per month, for a cumulative period of at least ten years within a continuous period of 15 years, within the 25 years before the clinical onset of osteoarthritis in that joint — NOT MET - Ten cumulative years of qualifying hand use are required before onset, but the veteran enlisted as a young adult on 29 July 1981 and only about 4.7 years of service preceded the estimated onset of 5 April 1986, when he was 20.
Factor 9(13): for osteoarthritis of a joint of the hand, wrist or elbow joint only, using a hand- held, vibrating percussive tool or object on more days than not, for a cumulative period of at least ten years, within the 25 years before the clinical onset of osteoarthritis in that joint — NOT MET - There is no record of a hand-held vibrating percussive tool used on more days than not, and ten years of such use before the estimated onset of 5 April 1986, when he was 20, is not possible on his history.
Factor 9(14): for osteoarthritis of a joint of the lower limb only: (a) having: (i) an amputation involving either leg; or (ii) an asymmetric gait; for at least five years before the clinical onset of osteoarthritis in that joint; (b) lifting loads of at least 20 kilograms while bearing weight through the affected joint: (i) to a cumulative total of at least 150 000 kilograms within any ten year period before the clinical onset of osteoarthritis in that joint; and (ii) where the clinical onset of osteoarthritis in that joint occurs within the 25 years following that period; (c) carrying loads of at least 20 kilograms while bearing weight through the affected joint: (i) to a cumulative total of at least 3 800 hours within any ten year period before the clinical onset of osteoarthritis in that joint; and (ii) where the clinical onset of osteoarthritis in that joint occurs within the 25 years following that period; (d) ascending or descending at least 150 stairs or rungs of a ladder per day, on more days than not, for a continuous period of at least five years, within the 25 years before the clinical onset of osteoarthritis in that joint; or (e) having increased bone mineral density before the clinical onset of osteoarthritis in that joint — NOT MET - This factor applies only to joints of the lower limb; the veteran's osteoarthritis affects the left thumb IP joint.
Factor 9(15): for osteoarthritis of a joint of the lower limb or hand joint only: (a) being overweight for at least ten years before the clinical onset of osteoarthritis in that joint; (b) for males, having a waist circumference exceeding 102 centimetres for at least ten years before the clinical onset of osteoarthritis in that joint; or (c) for females, having a waist circumference exceeding 88 centimetres for at least ten years before the clinical onset of osteoarthritis in that joint — NOT MET - The thumb IP joint is a hand joint, but his weight is first recorded in early 1981 (89 kg, BMI about 25.5), giving under five years of being overweight before the estimated onset of 5 April 1986, and a waist above 102 cm was first recorded in 1984; ten years is not established.
Factor 9(16): for osteoarthritis of a hip or knee joint only: (a) kneeling or squatting for a cumulative period of at least one hour per day, on more days than not, for a continuous period of at least two years before the clinical onset of osteoarthritis in that joint; and (b) where the clinical onset of osteoarthritis in that joint occurs within the 25 years following that period — NOT MET - This factor applies only to the hip or knee; the veteran's osteoarthritis affects the left thumb IP joint.
Factor 9(17): for osteoarthritis of a knee joint only, having internal derangement of the affected joint before the clinical onset of osteoarthritis in that joint — NOT MET - This factor applies only to the knee; the veteran's osteoarthritis affects the left thumb IP joint.
Factor 9(18): for osteoarthritis of the patello-femoral joint only, having chondromalacia patella before the clinical onset of osteoarthritis in that joint — NOT MET - This factor applies only to the patello-femoral joint; the veteran's osteoarthritis affects the left thumb IP joint.
Factor 9(19): having a disorder associated with loss of pain sensation or proprioception involving the affected joint before the clinical onset of osteoarthritis in that joint — NOT MET - No disorder causing loss of pain sensation or proprioception at the left thumb IP joint is recorded; the left ulnar neuropraxia of late 1981 affected the ulnar side of the hand, which does not supply the thumb IP joint, and settled with splinting and physiotherapy.
Factor 9(20): having Paget's disease of bone of the affected joint before the clinical onset of osteoarthritis in that joint — NOT MET - There is no record of Paget's disease of bone, and no imaging of the thumb has shown it.
Factor 9(21): having acromegaly before the clinical onset of osteoarthritis in that joint — NOT MET - There is no record of acromegaly or growth hormone excess, and nothing in his history suggests it.
Factor 9(22): having joint instability or dislocation of the affected joint, at least one year before the clinical onset of osteoarthritis in that joint — NOT MET - The recorded instability and dislocations were of the MCP joint: the familial recurrent dislocation of both thumb MCP joints and the left MCP dislocation of about 25 February 1984.
No instability or dislocation of the left thumb IP joint, the affected joint, is recorded.
Factor 9(23): for osteoarthritis of a hip joint only, having femoroacetabular impingement syndrome of the affected joint, before the clinical onset of osteoarthritis in that joint — NOT MET - This factor applies only to the hip; the veteran's osteoarthritis affects the left thumb IP joint.
Causative Factors — Reasonable Hypothesis (Statement of Principles concerning Osteoarthritis, No.
61 of 2017) the veteran had no operational deployments.
The Reasonable Hypothesis standard applies only to operational service, so these factors are assessed for completeness and, like the Balance of Probabilities factors, by analogy only.
Factor 9(1): being a prisoner of war before the clinical onset of osteoarthritis — NOT MET - the veteran was never a prisoner of war; he had no operational deployments.
Factor 9(2): having inflammatory joint disease as specified, of the affected joint before the clinical onset of osteoarthritis in that joint — NOT MET - There is no record of ankylosing spondylitis, arthritis associated with Crohn's disease or ulcerative colitis, psoriatic arthropathy, reactive arthritis or rheumatoid arthritis, and nothing in his history suggests inflammatory joint disease of the left thumb IP joint.
Factor 9(3): having an infection of the affected joint as specified before the clinical onset of osteoarthritis in that joint — NOT MET - There is no record of a bacterial, viral, fungal or parasitic infection of the left thumb IP joint, and the thumb operations of 1983 and 1985 healed without recorded infection.
Factor 9(4): having an intra-articular fracture of the affected joint before the clinical onset of osteoarthritis in that joint — NOT MET - No fracture involving the articular surface of the left thumb IP joint is recorded; the 1983 injury was a MCP dislocation, the operations were on the MCP joint, and the pre-operative X-ray of February 1986 showed no abnormality apart from the fusion.
Factor 9(5): having haemarthrosis of the affected joint before the clinical onset of osteoarthritis in that joint — NOT MET - There is no record of bleeding into the left thumb IP joint; the injury and operations of 1983 to 1985 involved the MCP joint.
Factor 9(6): having a depositional joint disease as specified, in the affected joint before the clinical onset of osteoarthritis in that joint — NOT MET - There is no record of alkaptonuria, calcium pyrophosphate dihydrate deposition disease, gout, haemochromatosis or Wilson's disease, and nothing in his history suggests them.
Factor 9(7): having trauma to the affected joint before the clinical onset of osteoarthritis in that joint — NOT MET - The definition requires significant force to or through the left thumb IP joint itself, damaging that joint and causing pain, tenderness and altered movement of it.
The dislocation of about 25 February 1984 and the operations of 1983 to 1985 involved the adjacent MCP joint, and no injury, damage or signs at the IP joint are recorded, so trauma to the MCP joint does not satisfy this factor.
Factor 9(8): having an acute articular cartilage tear of the affected joint before the clinical onset of osteoarthritis in that joint — NOT MET - There is no record of an acute articular cartilage tear of the left thumb IP joint, and no imaging or arthroscopy has shown one.
Factor 9(9): having an acute meniscal tear of the affected knee before the clinical onset of osteoarthritis in that joint — NOT MET - This factor applies only to the knee; the veteran's osteoarthritis affects the left thumb IP joint.
Factor 9(10): having frostbite involving the affected joint before the clinical onset of osteoarthritis in that joint — NOT MET - There is no record of frostbite; his service was in Australian ports and coastal waters without recorded cold exposure.
Factor 9(11): having disordered joint mechanics of the affected joint for at least three years before the clinical onset of osteoarthritis in that joint — MET - Before its fusion, the veteran's left thumb MCP joint had a hyperextension deformity associated with his familial recurrent dislocation, moving only from neutral to about 20 degrees of hyperextension without flexion (orthopaedic report of 13 March 1984), with dislocations previously reduced under local anaesthetic (orthopaedic report of 29 February 1984); it is a reasonable hypothesis that this deformity, which shifts pinch and grip loads onto the IP joint, was present from at least April 1983.
From 28 March 1984 the MCP joint was fused angulated in about 30 degrees of flexion and, from 7 February 1986, in about 10 degrees, so the IP joint had disordered mechanics for at least three years before the estimated onset of 5 April 1986.
Factor 9(12): having necrosis of the subchondral bone near the affected joint, including that from dysbaric osteonecrosis, before the clinical onset of osteoarthritis in that joint — NOT MET - the veteran dived with snorkel and SCUBA equipment for survey work in 1982, but no necrosis of subchondral bone near the left thumb IP joint has been shown on any X-ray, and dysbaric osteonecrosis characteristically affects the shoulder, hip and knee.
Factor 9(13): for osteoarthritis of a joint of the upper limb only: (a) performing: (i) forceful or repetitive activities involving the affected joint; or (ii) tasks involving repeated or sustained pinch grip or hand/power grip; for an average of at least 100 hours per month, for a cumulative period of at least ten years within a continuous period of 15 years, before the clinical onset of osteoarthritis in that joint; or (b) using a hand-held, vibrating percussive tool or object on more days than not, for a cumulative period of at least ten years, before the clinical onset of osteoarthritis in that joint — NOT MET - Both limbs of this factor require at least ten cumulative years of exposure before onset, but only about 4.7 years of service preceded the estimated onset of 5 April 1986, when he was 20, and there is no record of hand-held vibrating percussive tool use.
Factor 9(14): for osteoarthritis of a joint of the lower limb only: (a) having: (i) an amputation involving either leg; or (ii) an asymmetric gait; for at least three years before the clinical onset of osteoarthritis in that joint; (b) lifting loads of at least 20 kilograms while bearing weight through the affected joint to a cumulative total of at least 100 000 kilograms within any ten year period before the clinical onset of osteoarthritis in that joint; (c) carrying loads of at least 20 kilograms while bearing weight through the affected joint to a cumulative total of at least 3 800 hours within any ten year period before the clinical onset of osteoarthritis in that joint; (d) ascending or descending at least 150 stairs or rungs of a ladder per day, on more days than not, for a continuous period of at least two years before the clinical onset of osteoarthritis in that joint; or (e) having increased bone mineral density before the clinical onset of osteoarthritis in that joint — NOT MET - This factor applies only to joints of the lower limb; the veteran's osteoarthritis affects the left thumb IP joint.
Factor 9(15): for osteoarthritis of a joint of the lower limb or hand joint only: (a) being overweight for at least ten years before the clinical onset of osteoarthritis in that joint; (b) for males, having a waist circumference exceeding 102 centimetres for at least ten years before the clinical onset of osteoarthritis in that joint; or (c) for females, having a waist circumference exceeding 88 centimetres for at least ten years before the clinical onset of osteoarthritis in that joint — NOT MET - The thumb IP joint is a hand joint, but his weight is first recorded in early 1981 (89 kg, BMI about 25.5), giving under five years of being overweight before the estimated onset of 5 April 1986, and a waist above 102 cm was first recorded in 1984; ten years is not established.
Factor 9(16): for osteoarthritis of a hip or knee joint only, kneeling or squatting for a cumulative period of at least one hour per day, on more days than not, for a continuous period of at least one year before the clinical onset of osteoarthritis in that joint — NOT MET - This factor applies only to the hip or knee; the veteran's osteoarthritis affects the left thumb IP joint.
Factor 9(17): for osteoarthritis of a knee joint only, having internal derangement of the affected joint before the clinical onset of osteoarthritis in that joint — NOT MET - This factor applies only to the knee; the veteran's osteoarthritis affects the left thumb IP joint.
Factor 9(18): for osteoarthritis of the patello-femoral joint only, having chondromalacia patella before the clinical onset of osteoarthritis in that joint — NOT MET - This factor applies only to the patello-femoral joint; the veteran's osteoarthritis affects the left thumb IP joint.
Factor 9(19): having a disorder associated with loss of pain sensation or proprioception involving the affected joint before the clinical onset of osteoarthritis in that joint — NOT MET - No disorder causing loss of pain sensation or proprioception at the left thumb IP joint is recorded; the left ulnar neuropraxia of late 1981 affected the ulnar side of the hand, which does not supply the thumb IP joint, and settled with splinting and physiotherapy.
Factor 9(20): having Paget's disease of bone of the affected joint before the clinical onset of osteoarthritis in that joint — NOT MET - There is no record of Paget's disease of bone, and no imaging of the thumb has shown it.
Factor 9(21): having acromegaly before the clinical onset of osteoarthritis in that joint — NOT MET - There is no record of acromegaly or growth hormone excess, and nothing in his history suggests it.
Factor 9(22): having joint instability or dislocation of the affected joint, at least one year before the clinical onset of osteoarthritis in that joint — NOT MET - The recorded instability and dislocations were of the MCP joint: the familial recurrent dislocation of both thumb MCP joints and the left MCP dislocation of about 25 February 1984.
No instability or dislocation of the left thumb IP joint, the affected joint, is recorded.
Factor 9(23): for osteoarthritis of a hip joint only, having femoroacetabular impingement syndrome of the affected joint, before the clinical onset of osteoarthritis in that joint — NOT MET - This factor applies only to the hip; the veteran's osteoarthritis affects the left thumb IP joint.
Other Plausible Links to Service The principal link to service lies outside the SOP factors.
The veteran's left thumb MCP joint was dislocated in a motor vehicle (four-wheel-drive) accident near Cooktown on about 25 February 1984, reduced under general anaesthesia on 28 February 1984 and, with the right, fused by tension-band wiring on 28 March 1984.
The left fusion healed angulated in about 30 degrees of flexion, leaving him with difficulty using the thumb (sick bay note of 23 July 1985), and was re-fused in about 10 degrees of flexion on 7 February 1986 with K-wires that were never removed; on the X-rays of January and June 2017 two wires protruded beyond the dorsal cortex of the proximal phalanx, with osteolysis around a wire tract and crepitus on flexion and extension of the IP joint.
All of this treatment was arranged through the Navy's medical services while he was a member, and naval signals sought approval for the surgeon's and hospital fees.
Fusion of the MCP joint transfers the flexion, extension and pinch loads of the thumb to the IP joint, and degeneration of the joint next to an arthrodesis is a recognised long-term consequence, so the IP joint osteoarthritis is an unintended consequence of medical treatment paid for by the Commonwealth within section 6A of the DRCA, and a sequela of the in-service ankylosis of the left thumb MCP joint.
The underlying familial instability of both thumb MCP joints was assessed by the Medical Boards of 1 June 1984 and 14 September 1984 as constitutional and not caused by naval service, but aggravated by it.
After the fusion the veteran was passed fit for sea on 6 September 1984 and remained an Able Rifleman Rifleman until his discharge on 14 May 1988; as he described them in June 1984, his duties involved working ships' lines, rope work, scrubbing decks and deckheads and operating survey equipment, and in 1985 and 1986 they included ship's husbandry with deck scrubbing and polishing.
Being left- hand dominant, with the MCP joint fused, he took the gripping and pinching in these duties at the IP joint, the only mobile joint of the thumb beyond the carpometacarpal joint, for nearly four years, which is a further contribution by service to the degeneration of that joint.
Conclusion the veteran's left thumb IP joint osteoarthritis is secondary osteoarthritis caused by altered thumb mechanics: his constitutionally unstable left MCP joint was dislocated in February 1984, fused during service in April 1984, healed angulated and was re-fused in February 1986 with K-wires that remain in place, leaving the IP joint to carry loads normally shared with the MCP joint.
Under the SOPs, disordered joint mechanics is met for onset only at the reasonable hypothesis standard, because the fusion preceded the estimated onset by just two years, and for clinical worsening under both standards, together with long-standing overweight and the inability to obtain appropriate clinical management.
The principal connection to service is that the fusion and re-fusion were medical treatment provided and paid for by the Commonwealth (section 6A of the DRCA), for a condition the Medical Boards found aggravated by naval service, followed by Rifleman duties with the dominant left hand until discharge.
The familial MCP instability is a constitutional background factor.
The % contribution of the causes is 100% and significant.
Worsening Factors In the alternative, if the veteran's left thumb IP joint osteoarthritis is found not to have arisen out of his service, the following factors address whether service rendered after its clinical onset (estimated 5 April 1986) aggravated it or contributed to it in a material degree.
About two years of service followed onset, to 14 May 1988, during which he continued Rifleman duties, including ship's husbandry, with the MCP joint of his dominant left thumb fused; the condition later worsened, with thumb pain reported in 1994 and, by 2017, clicking, crepitus and a large dorsal osteophyte.
Worsening Factors — Balance of Probabilities (Statement of Principles concerning Osteoarthritis, No.
62 of 2017) Factor 9(24): having inflammatory joint disease as specified, of the affected joint before the clinical worsening of osteoarthritis in that joint — NOT MET - No inflammatory joint disease as specified has been diagnosed at any time before the clinical worsening of his left thumb IP joint osteoarthritis.
Factor 9(25): having an infection of the affected joint as specified before the clinical worsening of osteoarthritis in that joint — NOT MET - No infection of the left thumb IP joint has been diagnosed; the osteolysis around a retained K-wire tract on the X-ray of 11 May 2017 lies at the MCP fusion hardware rather than within the IP joint, and was not reported as infection.
Factor 9(26): having an intra-articular fracture of the affected joint before the clinical worsening of osteoarthritis in that joint — NOT MET - No fracture involving the articular surface of the left thumb IP joint is recorded at any time, and the X-ray of 11 May 2017 showed no fracture.
Factor 9(27): having haemarthrosis of the affected joint before the clinical worsening of osteoarthritis in that joint — NOT MET - There is no record of bleeding into the left thumb IP joint at any time.
Factor 9(28): having a depositional joint disease as specified, in the affected joint before the clinical worsening of osteoarthritis in that joint — NOT MET - No depositional joint disease as specified, including gout, has been diagnosed at any time.
Factor 9(29): having trauma to the affected joint within the 25 years before the clinical worsening of osteoarthritis in that joint — NOT MET - No discrete injury to the left thumb IP joint is recorded after the estimated onset of 5 April 1986 (the workplace accident of 3 May 2014 injured his face and back), and the earlier dislocation and operations involved the MCP joint, not the IP joint.
Factor 9(30): having an acute articular cartilage tear of the affected joint within the 25 years before the clinical worsening of osteoarthritis in that joint — NOT MET - There is no record of an acute articular cartilage tear of the left thumb IP joint at any time.
Factor 9(31): having an acute meniscal tear of the affected knee within the 25 years before the clinical worsening of osteoarthritis in that joint — NOT MET - This factor applies only to the knee; the veteran's osteoarthritis affects the left thumb IP joint.
Factor 9(32): having frostbite involving the affected joint before the clinical worsening of osteoarthritis in that joint — NOT MET - There is no record of frostbite at any time.
Factor 9(33): having disordered joint mechanics of the affected joint for at least five years before the clinical worsening of osteoarthritis in that joint — MET - Since 28 March 1984 the veteran's left thumb MCP joint has been rigidly fused, first angulated in about 30 degrees of flexion (sick bay note of 23 July 1985; orthopaedic opinion of 8 November 1985) and, after the re-fusion of 7 February 1986, in about 10 degrees of flexion.
The fused metacarpal and proximal phalanx form an angulation deformity of a joint of the affected limb and of the bones adjacent to the IP joint, abolishing MCP motion and concentrating flexion, extension and pinch loads on the IP joint.
This had lasted five years by April 1989, before the clinical worsening shown by the thumb pain he reported in 1994 and, by 2017, clicking, crepitus on IP movement and degenerative change with a large dorsal osteophyte.
Factor 9(34): having necrosis of the subchondral bone near the affected joint, including that from dysbaric osteonecrosis, before the clinical worsening of osteoarthritis in that joint — NOT MET - No necrosis of the subchondral bone near the left thumb IP joint has been shown; the X-rays of 2017 showed degenerative change and a dorsal osteophyte, not osteonecrosis.
Factor 9(35): for osteoarthritis of a joint of the upper limb only, performing: (a) forceful or repetitive activities involving the affected joint; or (b) tasks involving repeated or sustained pinch grip or hand/power grip; for an average of at least 100 hours per month, for a cumulative period of at least ten years within a continuous period of 15 years, within the 25 years before the clinical worsening of osteoarthritis in that joint — NOT MET - The thumb is a joint of the upper limb, so this factor applies.
The veteran's documented Rifleman duties with his dominant left hand (working ships' lines and rope work, scrubbing decks and deckheads, ship's husbandry and operating survey equipment) are estimated conservatively at about 4 to 5 hours of power or pinch grip on each of about 22 working days a month, or about 90 to 110 hours a month.
Even if every month of his 6.8 years of service reached 100 hours, more than three further years of such work would be needed within the same fifteen-year period, and his recorded post-service roles (office work in the transport sector, managing car yards) did not involve it.
Factor 9(36): for osteoarthritis of a joint of the hand, wrist or elbow joint only, using a hand- held, vibrating percussive tool or object on more days than not, for a cumulative period of at least ten years, within the 25 years before the clinical worsening of osteoarthritis in that joint — NOT MET - No hand-held vibrating percussive tool use on more days than not is recorded at any time; a floor polisher in 1986 and a circular saw in 1987 were occasional and not percussive, and there is no basis for ten years of such use.
Factor 9(37): for osteoarthritis of a joint of the lower limb only: (a) having: (i) an amputation involving either leg; or (ii) an asymmetric gait; for at least five years before the clinical worsening of osteoarthritis in that joint; (b) lifting loads of at least 20 kilograms while bearing weight through the affected joint: (i) to a cumulative total of at least 150 000 kilograms within any ten year period before the clinical worsening of osteoarthritis in that joint; and (ii) where the clinical worsening of osteoarthritis in that joint occurs within the 25 years following that period; (c) carrying loads of at least 20 kilograms while bearing weight through the affected joint: (i) to a cumulative total of at least 3 800 hours within any ten year period before the clinical worsening of osteoarthritis in that joint; and (ii) where the clinical worsening of osteoarthritis in that joint occurs within the 25 years following that period; or (d) ascending or descending at least 150 stairs or rungs of a ladder per day, on more days than not, for a continuous period of at least five years, within the 25 years before the clinical worsening of osteoarthritis in that joint — NOT MET - This factor applies only to joints of the lower limb; the veteran's osteoarthritis affects the left thumb IP joint.
Factor 9(38): for osteoarthritis of a joint of the lower limb or hand joint only: (a) being overweight for at least ten years before the clinical worsening of osteoarthritis in that joint; (b) for males, having a waist circumference exceeding 102 centimetres for at least ten years before the clinical worsening of osteoarthritis in that joint; or (c) for females, having a waist circumference exceeding 88 centimetres for at least ten years before the clinical worsening of osteoarthritis in that joint — MET - The left thumb IP joint is a hand joint, so this factor applies.
The veteran weighed 89 kg in June 1981 (BMI about 25.5), was in the obese range from September 1984 (BMI 32.9) and at discharge in May 1988 (BMI 35.7, waist 115 cm), and was heavier later (about BMI 48.6 before bariatric surgery in 2016; 41.5 in January 2022).
He had therefore been overweight for more than ten years before the clinical worsening shown by his thumb pain in 1994 and the degenerative change with a large dorsal osteophyte in 2017.
Most of that period falls after discharge, and the Medical Board of 16 August 1985 did not relate his obesity to service.
Factor 9(39): for osteoarthritis of a hip or knee joint only: (a) kneeling or squatting for a cumulative period of at least one hour per day, on more days than not, for a continuous period of at two years before the clinical worsening of osteoarthritis in that joint; and (b) where the clinical worsening of osteoarthritis in that joint occurs within the 25 years following that period — NOT MET - This factor applies only to the hip or knee; the veteran's osteoarthritis affects the left thumb IP joint.
Factor 9(40): for osteoarthritis of a knee joint only, having internal derangement of the affected joint before the clinical worsening of osteoarthritis in that joint — NOT MET - This factor applies only to the knee; the veteran's osteoarthritis affects the left thumb IP joint.
Factor 9(41): for osteoarthritis of the patello-femoral joint only, having chondromalacia patella before the clinical worsening of osteoarthritis in that joint — NOT MET - This factor applies only to the patello-femoral joint; the veteran's osteoarthritis affects the left thumb IP joint.
Factor 9(42): having a disorder associated with loss of pain sensation or proprioception involving the affected joint before the clinical worsening of osteoarthritis in that joint — NOT MET - No disorder causing loss of pain sensation or proprioception at the left thumb IP joint is recorded; no diabetic neuropathy is recorded, and the mild ulnar-innervated left hand weakness found in 2021 does not affect sensation at the thumb IP joint.
Factor 9(43): having Paget's disease of bone of the affected joint before the clinical worsening of osteoarthritis in that joint — NOT MET - There is no record of Paget's disease of bone at any time.
Factor 9(44): having acromegaly before the clinical worsening of osteoarthritis in that joint — NOT MET - There is no record of acromegaly at any time, and nothing in his history suggests it.
Factor 9(45): having joint instability or dislocation of the affected joint, at least one year before the clinical worsening of osteoarthritis in that joint — NOT MET - No instability or dislocation of the left thumb IP joint is recorded at any time; the recorded dislocations and instability involved the MCP joint, which has been fused since April 1984.
Factor 9(46): for osteoarthritis of a hip joint only, having femoroacetabular impingement syndrome of the affected joint, before the clinical worsening of osteoarthritis in that joint — NOT MET - This factor applies only to the hip; the veteran's osteoarthritis affects the left thumb IP joint.
Factor 9(47): inability to obtain appropriate clinical management for osteoarthritis — MET - Under Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), inability is assessed objectively and subjectively and includes psychological or emotional incapacity and the threat of sanctions that make seeking treatment unrealistic.
In service, a command signal of September 1984 suspected him of malingering over his thumb surgery, no follow-up of the physiotherapy requested on 1 March 1986 to mobilise the IP joint is recorded, the re-fusion K-wires were never removed, and his medical record was lost in June 1987.
His letter received by Defence on 26 January 1995, reporting pain and suffering from the thumb operation, was redirected to Veterans' Affairs, and the IP joint was not imaged until May 2017, more than 22 years later, by which time a large dorsal osteophyte had formed.
Worsening Factors — Reasonable Hypothesis (Statement of Principles concerning Osteoarthritis, No.
61 of 2017) the veteran had no operational deployments.
The Reasonable Hypothesis standard applies only to operational service, so these factors are assessed for completeness and, like the Balance of Probabilities factors, by analogy only.
Factor 9(24): having inflammatory joint disease as specified, of the affected joint before the clinical worsening of osteoarthritis in that joint — NOT MET - No inflammatory joint disease as specified has been diagnosed at any time before the clinical worsening of his left thumb IP joint osteoarthritis.
Factor 9(25): having an infection of the affected joint as specified before the clinical worsening of osteoarthritis in that joint — NOT MET - No infection of the left thumb IP joint has been diagnosed; the osteolysis around a retained K-wire tract on the X-ray of 11 May 2017 lies at the MCP fusion hardware rather than within the IP joint, and was not reported as infection.
Factor 9(26): having an intra-articular fracture of the affected joint before the clinical worsening of osteoarthritis in that joint — NOT MET - No fracture involving the articular surface of the left thumb IP joint is recorded at any time, and the X-ray of 11 May 2017 showed no fracture.
Factor 9(27): having haemarthrosis of the affected joint before the clinical worsening of osteoarthritis in that joint — NOT MET - There is no record of bleeding into the left thumb IP joint at any time.
Factor 9(28): having a depositional joint disease as specified, in the affected joint before the clinical worsening of osteoarthritis in that joint — NOT MET - No depositional joint disease as specified, including gout, has been diagnosed at any time.
Factor 9(29): having trauma to the affected joint before the clinical worsening of osteoarthritis in that joint — NOT MET - No discrete injury to the left thumb IP joint is recorded after the estimated onset of 5 April 1986 (the workplace accident of 3 May 2014 injured his face and back), and the earlier dislocation and operations involved the MCP joint, not the IP joint.
Factor 9(30): having an acute articular cartilage tear of the affected joint before the clinical worsening of osteoarthritis in that joint — NOT MET - There is no record of an acute articular cartilage tear of the left thumb IP joint at any time.
Factor 9(31): having an acute meniscal tear of the affected knee before the clinical worsening of osteoarthritis in that joint — NOT MET - This factor applies only to the knee; the veteran's osteoarthritis affects the left thumb IP joint.
Factor 9(32): having frostbite involving the affected joint before the clinical worsening of osteoarthritis in that joint — NOT MET - There is no record of frostbite at any time.
Factor 9(33): having disordered joint mechanics of the affected joint for at least three years before the clinical worsening of osteoarthritis in that joint — MET - Since 28 March 1984 the veteran's left thumb MCP joint has been rigidly fused, first angulated in about 30 degrees of flexion (sick bay note of 23 July 1985; orthopaedic opinion of 8 November 1985) and, after the re-fusion of 7 February 1986, in about 10 degrees of flexion.
The fused metacarpal and proximal phalanx form an angulation deformity of a joint of the affected limb and of the bones adjacent to the IP joint, abolishing MCP motion and concentrating flexion, extension and pinch loads on the IP joint.
This had lasted three years by April 1987, before the clinical worsening shown by his thumb pain in 1994 and, by 2017, clicking, crepitus and a large dorsal osteophyte.
Factor 9(34): having necrosis of the subchondral bone near the affected joint, including that from dysbaric osteonecrosis, before the clinical worsening of osteoarthritis in that joint — NOT MET - No necrosis of the subchondral bone near the left thumb IP joint has been shown; the X-rays of 2017 showed degenerative change and a dorsal osteophyte, not osteonecrosis.
Factor 9(35): for osteoarthritis of a joint of the upper limb only: (a) performing: (i) forceful or repetitive activities involving the affected joint; or (ii) tasks involving repeated or sustained pinch grip or hand/power grip; for an average of at least 100 hours per month, for a cumulative period of at least ten years within a continuous period of 15 years, before the clinical worsening of osteoarthritis in that joint; or (b) using a hand-held, vibrating percussive tool or object on more days than not, for a cumulative period of at least ten years, before the clinical worsening of osteoarthritis in that joint — NOT MET - For limb (a), the veteran's documented Rifleman duties with his dominant left hand (ships' lines and rope work, scrubbing decks and deckheads, ship's husbandry, survey equipment) are estimated at about 90 to 110 hours of power or pinch grip a month, but even if every month of his 6.8 years of service qualified, more than three further years would be needed within fifteen years, and his recorded post-service work was office work and car-yard management.
For limb (b), no hand-held vibrating percussive tool use on more days than not is recorded.
Factor 9(36): for osteoarthritis of a joint of the lower limb only: (a) having: (i) an amputation involving either leg; or (ii) an asymmetric gait; for at least three years before the clinical worsening of osteoarthritis in that joint; (b) lifting loads of at least 20 kilograms while bearing weight through the affected joint to a cumulative total of at least 100 000 kilograms within any ten year period before the clinical worsening of osteoarthritis in that joint; (c) carrying loads of at least 20 kilograms while bearing weight through the affected joint to a cumulative total of at least 3 800 hours within any ten year period before the clinical worsening of osteoarthritis in that joint; (d) ascending or descending at least 150 stairs or rungs of a ladder per day, on more days than not, for a continuous period of at least two years, before the clinical worsening of osteoarthritis in that joint; or (e) having osteoporosis before the clinical worsening of osteoarthritis in that joint — NOT MET - This factor applies only to joints of the lower limb; the veteran's osteoarthritis affects the left thumb IP joint.
Factor 9(37): for osteoarthritis of a joint of the lower limb or hand joint only: (a) being overweight for at least ten years before the clinical worsening of osteoarthritis in that joint; (b) for males, having a waist circumference exceeding 102 centimetres for at least ten years before the clinical worsening of osteoarthritis in that joint; or (c) for females, having a waist circumference exceeding 88 centimetres for at least ten years before the clinical worsening of osteoarthritis in that joint — MET - The left thumb IP joint is a hand joint.
The veteran was overweight from at least June 1981 (BMI about 25.5), obese from September 1984 (BMI 32.9) to discharge in May 1988 (BMI 35.7, waist 115 cm) and heavier afterwards (about BMI 48.6 before bariatric surgery in 2016; 41.5 in January 2022), so he had been overweight for more than ten years before the clinical worsening shown by thumb pain in 1994 and a large dorsal osteophyte in 2017.
Most of that period is after discharge, and the Medical Board of 16 August 1985 did not relate his obesity to service.
Factor 9(38): for osteoarthritis of a hip or knee joint only, kneeling or squatting for a cumulative period of at least one hour per day, on more days than not, for a continuous period of at least one year before the clinical worsening of osteoarthritis in that joint — NOT MET - This factor applies only to the hip or knee; the veteran's osteoarthritis affects the left thumb IP joint.
Factor 9(39): for osteoarthritis of a knee joint only, having internal derangement of the affected joint before the clinical worsening of osteoarthritis in that joint — NOT MET - This factor applies only to the knee; the veteran's osteoarthritis affects the left thumb IP joint.
Factor 9(40): for osteoarthritis of the patello-femoral joint only, having chondromalacia patella before the clinical worsening of osteoarthritis in that joint — NOT MET - This factor applies only to the patello-femoral joint; the veteran's osteoarthritis affects the left thumb IP joint.
Factor 9(41): having a disorder associated with loss of pain sensation or proprioception involving the affected joint before the clinical worsening of osteoarthritis in that joint — NOT MET - No disorder causing loss of pain sensation or proprioception at the left thumb IP joint is recorded; no diabetic neuropathy is recorded, and the mild ulnar-innervated left hand weakness found in 2021 does not affect sensation at the thumb IP joint.
Factor 9(42): having Paget's disease of bone of the affected joint before the clinical worsening of osteoarthritis in that joint — NOT MET - There is no record of Paget's disease of bone at any time.
Factor 9(43): having acromegaly before the clinical worsening of osteoarthritis in that joint — NOT MET - There is no record of acromegaly at any time, and nothing in his history suggests it.
Factor 9(44): having joint instability or dislocation of the affected joint, at least one year before the clinical worsening of osteoarthritis in that joint — NOT MET - No instability or dislocation of the left thumb IP joint is recorded at any time; the recorded dislocations and instability involved the MCP joint, which has been fused since April 1984.
Factor 9(45): for osteoarthritis of a hip joint only, having femoroacetabular impingement syndrome of the affected joint, before the clinical worsening of osteoarthritis in that joint — NOT MET - This factor applies only to the hip; the veteran's osteoarthritis affects the left thumb IP joint.
Factor 9(46): inability to obtain appropriate clinical management for osteoarthritis — MET - Applying Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), which assesses inability objectively and subjectively and includes psychological or emotional incapacity and the threat of sanctions that make seeking treatment unrealistic, this factor is met.
In service he had been suspected of malingering over his thumb surgery (command signal of September 1984), his medical record was lost in June 1987, and no follow- up of the physiotherapy requested on 1 March 1986 to mobilise the IP joint is recorded; after discharge, his 1994 complaint of thumb pain was redirected to Veterans' Affairs, and the joint was not imaged until May 2017, more than 22 years later, by which time the retained K-wires protruded and a large dorsal osteophyte had formed
Sequelae
Left thumb IP joint osteoarthritis is a sequela of the ankylosis of the left thumb MCP joint produced by the arthrodesis of 28 March 1984 and the re-fusion of 7 February 1986, both performed during ADF service
Unintended Consequence
This condition is an unintended consequence of medical treatment provided and paid for by the Commonwealth while the veteran was a member.
The MCP arthrodesis of 28 March 1984 healed angulated and was re-fused on 7 February 1986 with K-wires that were never removed; fusion of the MCP joint transfers flexion, extension and pinch loads to the IP joint, accelerating its degeneration — MET under section 6A of the DRCA
Inability to Attain Appropriate Medical Management
Not applicable
Date of Clinical Onset
Left thumb osteoarthritis is a chronic condition.
Its date of clinical onset is the date on which the condition first manifested clinically.
It is not the date on which the condition was first imaged or formally diagnosed
Imaging
And specialist diagnosis record when an established condition was confirmed; a chronic condition is present, and usually symptomatic, for a considerable period before it is investigated, so the date of imaging must not be taken as the date of clinical onset.
First documented presentation with pain in the left thumb: 25 February 1984 — dislocation of the left thumb in a motor vehicle accident near Cooktown, followed by MCP arthrodesis on 28 March 1984 [ [CHART REVIEW document], pages 143 144].
End of ADF service: 14 May 1988.
First imaging / formal diagnosis (confirmation, not onset): 11 May 2017 (X-ray of the left thumb).
The precise date of clinical onset cannot be determined from the records.
It is therefore estimated as the midpoint between the first documented presentation with pain in the left thumb (25 February 1984) and the end of the veteran's ADF service (14 May 1988).
Estimated date of clinical onset: 5 April 1986.
This date falls within the veteran's ADF service (29 July 1981 14 May 1988).
In-service events and exposures before this date relate to clinical onset, and those after it to clinical worsening
