Diagnostic Assessment — Left Wrist - Scaphoid Fracture
Example 1 of 1 · fictitious patient (Veteran EG)
Diagnostic Assessment
Left Wrist - Scaphoid Fracture
BOP Code: 63 of 2024 (Fracture)
RH Code: 62 of 2024 (Fracture)
ADF History
Veteran EG, date of birth 14 June 1987, Australian Army, Rifleman (Infantry), enlisted 03 February 2006, medically discharged 19 October 2014. Operational service: Timor-Leste, 10 October 2007 to 28 April 2008 (non-warlike); Afghanistan, 12 February 2011 to 15 June 2011 (warlike), returned to Australia early for treatment of the injury.
Occupational History
As an infantry rifleman the veteran carried fighting loads of 35 to 45 kilograms on foot over broken ground, climbed compound walls and ditches, handled and maintained individual and crew-served weapons daily, and completed obstacle courses, fire-and-movement drills and close-quarters training in which the hands and wrists repeatedly took his body weight. Physical training in his battalion included daily push-ups, burpees, rope climbs and loaded carries, often several hundred push-ups a day during courses and pre-deployment training.
Falls on to an outstretched hand while patrolling, dismounting vehicles and moving at speed with heavy loads are a recognised hazard of infantry work. Field conditions also limit access to radiography and specialist care, and the culture of the period encouraged soldiers to tape minor-seeming wrist injuries and continue working rather than report them.
History
Veteran EG, an infantry rifleman in the Australian Army, fractured the waist of the left scaphoid when he fell on to his outstretched left hand while patrolling under load in Afghanistan on 06 May 2011, on a background of repetitive loading of the wrist and a malunited distal radius fracture from Timor-Leste. The fracture was missed at first, treatment was delayed by three weeks, and it progressed to a documented non-union on 14 February 2012 while he smoked, had steroid-induced diabetes and osteoporosis, vitamin D deficiency and a BMI above 40.
Timeline
- 03 Mar 2008 — On non-warlike service in Timor-Leste the veteran slipped on wet ground while carrying a 40 kg load during a night patrol and fell on to his left hand. Radiographs at the role 2 facility showed an extra-articular fracture of the left distal radius with dorsal angulation. He was managed in a cast for six weeks and returned to light duties in theatre. "distal radius fracture, cast applied"
- 20 Aug 2008 — Review by an orthopaedic surgeon in Australia recorded a malunited left distal radius fracture with 15 degrees of dorsal tilt and loss of radial inclination. Corrective osteotomy was offered and declined so that he could remain in his battalion. The surgeon noted that the malunion would alter load transmission through the carpus. "malunion, 15 degrees dorsal tilt"
- 16 Nov 2010 — During pre-deployment training in Australia the veteran reported three months of aching in the left wrist on push-ups, weapon handling and rope climbs, worse on the dorsal radial side. The medical officer recorded mild anatomical snuffbox tenderness, attributed it to overuse, and advised activity modification. He continued up to 300 push-ups a day on his pre-deployment course. He was smoking 20 cigarettes a day. "overuse wrist pain, snuffbox tender"
- 06 May 2011 — On warlike service in Afghanistan the veteran slipped down the bank of a dry watercourse while patrolling with a 42 kg load and fell heavily on to his outstretched, dorsiflexed left hand. At the patrol base role 1 facility, where there was no radiography, he was diagnosed with a wrist sprain, strapped and returned to patrolling duties. "FOOSH, wrist sprain, strapped"
- 27 May 2011 — Because of persisting pain, swelling and loss of grip he was sent to a role 2 facility, where scaphoid radiographs and CT showed an undisplaced fracture of the waist of the left scaphoid with sclerotic margins, indicating a preceding stress reaction. A thumb spica cast was applied and he returned to Australia on 15 June 2011 for orthopaedic care. "scaphoid waist fracture, spica cast"
- 22 Aug 2011 — A respiratory physician commenced prolonged high-dose prednisolone, 50 mg daily tapering to 25 mg, for severe persistent asthma that had deteriorated in the dust of Afghanistan. The course continued, with repeated escalations, to February 2012. He remained in a cast and continued to smoke 15 to 20 cigarettes a day despite advice. "prednisolone 50 mg, severe asthma"
- 10 Jan 2012 — Investigations for weight gain and fatigue showed steroid-induced diabetes mellitus with an HbA1c of 7.4 per cent, first confirmed on 12 December 2011, osteoporosis on dual-energy X-ray absorptiometry, and a serum 25-hydroxyvitamin D level of 36 nmol/L. Weight 128 kg, height 1.78 m, BMI 40.4. Metformin, vitamin D and calcium were commenced. "diabetes, osteoporosis, 25(OH)D 36"
- 14 Feb 2012 — CT of the left wrist, nine months after injury, showed no bridging trabeculae across the scaphoid waist, a persistent 1.5 mm fracture gap, sclerosis and a resorption cyst, with early humpback deformity. A hand surgeon diagnosed non-union of the left scaphoid fracture and performed open reduction, internal fixation and iliac crest bone grafting on 20 March 2012. "established scaphoid non-union, ORIF planned"
- 12 Sep 2013 — MRI after surgery showed only partial union with reduced proximal pole signal and early radioscaphoid degenerative change. The hand surgeon recorded persistent pain, grip strength of 22 kg on the left against 48 kg on the right, and permanent restrictions on weapon handling and load carriage. He was medically discharged on 19 October 2014. "partial union, grip 22 kg"
Symptoms
At onset the veteran had immediate radial-sided left wrist pain, swelling over the anatomical snuffbox, pain on gripping and on axial loading of the thumb, and an inability to take weight through the hand for push-ups or to hold his rifle in a firing position. In the three weeks before the fracture was diagnosed he continued patrolling with the wrist strapped and the pain increased.
After the non-union was diagnosed he had constant aching pain in the left wrist, stiffness, reduced wrist extension and flexion, weakness of grip and pain when lifting, carrying, pushing up from a chair and using tools. He now reports daily pain of 4 to 6 out of 10, worse in cold weather and after use, difficulty with fine and heavy tasks with the left hand, and night pain.
Imaging
- 03 Mar 2008 — X-ray left wrist: "Extra-articular fracture of the distal radius with dorsal angulation. Carpus intact."
- 20 Aug 2008 — X-ray left wrist: "Healed distal radius fracture with malunion, 15 degrees of dorsal tilt and reduced radial inclination."
- 27 May 2011 — X-ray left scaphoid series: "Undisplaced fracture of the waist of the scaphoid with sclerotic margins."
- 27 May 2011 — CT left wrist: "Undisplaced transverse scaphoid waist fracture. Marginal sclerosis and endosteal thickening consistent with a preceding stress reaction. Malunited distal radius."
- 10 Jan 2012 — Dual-energy X-ray absorptiometry: "Lumbar spine T-score -2.7, Z-score -2.8. Total hip T-score -2.5. Osteoporosis."
- 14 Feb 2012 — CT left wrist: "Established non-union of the scaphoid waist with a 1.5 mm gap, sclerosis, a 4 mm resorption cyst and early humpback deformity."
- 12 Sep 2013 — MRI left wrist: "Partial union across the scaphoid waist. Reduced signal in the proximal pole. Early radioscaphoid degenerative change."
Onset Date
The most likely date of onset of this condition is 06 May 2011.
At that date the veteran was on warlike service in Afghanistan, patrolling on foot from a patrol base with a 42 kg load. He slipped down the bank of a dry watercourse and fell on to his outstretched, dorsiflexed left hand, with immediate pain and swelling in the anatomical snuffbox.
This date is appropriate because the fracture is an injury with a defined moment of onset. The last record before it, a medical officer review on 16 November 2010, recorded overuse pain and snuffbox tenderness but no fracture and full function, and he patrolled without restriction until the fall. He presented to the role 1 facility on the day of the fall, 06 May 2011, and the fracture was confirmed on radiographs and CT on 27 May 2011. It falls within warlike service.
For the significant physical force factor, the force was applied at the moment of onset, 06 May 2011, when his body weight and a 42 kg load came down through the outstretched hand. For the repetitive loading factors, the period before onset runs from his pre-deployment training in Australia from August to December 2010, when he did up to 300 push-ups a day with rope climbs and weapon drills, through his warlike service from 12 February 2011 to 06 May 2011, when he climbed compound walls, handled weapons and continued daily push-ups. The abnormal force direction from the malunited distal radius was present continuously from 20 August 2008 to the onset and beyond.
For the worsening factors, non-union is the clinical worsening of a fracture. The treatment period runs from the cast applied on 27 May 2011 to the documented non-union on 14 February 2012. Throughout that period he smoked 15 to 20 cigarettes a day. Steroid-induced diabetes was confirmed on 12 December 2011, osteoporosis on 10 January 2012, the vitamin D level was 36 nmol/L on 10 January 2012 and the BMI was 40.4 on 10 January 2012, and each was present on 14 February 2012. The three-week delay in diagnosis, from 06 May 2011 to 27 May 2011, came before that worsening.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is fracture of the waist of the left scaphoid (ICD-10 S62.0), progressing to non-union, under the Statements of Principles concerning fracture, Balance of Probabilities No. 63 of 2024 and Reasonable Hypothesis No. 62 of 2024.
The scaphoid is the largest bone of the proximal row of the carpus and links the proximal and distal rows. It is fractured most often by a fall on to the outstretched, dorsiflexed hand, which loads the waist of the bone across the radius. Its blood supply enters distally, so fractures of the waist and proximal pole are prone to delayed union, non-union and avascular necrosis of the proximal fragment, particularly when diagnosis and immobilisation are delayed. Untreated or ununited fractures lead to carpal collapse and progressive degenerative arthritis of the wrist (scaphoid non-union advanced collapse).
In this veteran the fracture followed a fall under load on warlike service on 06 May 2011, on a background of repetitive loading and a malunited distal radius from earlier operational service. It was confirmed on 27 May 2011 and worsened to an established non-union on 14 February 2012.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
06 May 2011.
When did the veteran first present to a health / medical provider for this condition?
06 May 2011.
When was the condition confirmed / formally diagnosed?
27 May 2011.
When did the veteran first present to you (or your practice) for this condition?
18 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 scaphoid radiographs and CT on 27 May 2011, which showed an undisplaced transverse fracture of the waist of the left scaphoid. The fracture was produced by a force that would ordinarily break a healthy bone, a heavy fall under load on to the outstretched hand, and meets the Statement of Principles definition of fracture. The marginal sclerosis on CT showed that repetitive loading had produced a stress reaction at the same site beforehand, which is consistent with a stress fracture of the fatigue type completed by the fall.
The worsening was confirmed by CT on 14 February 2012, nine months after injury, which showed no bridging trabeculae, a persistent fracture gap, sclerosis, a resorption cyst and early humpback deformity. A hand surgeon diagnosed established non-union and performed internal fixation and bone grafting. MRI on 12 September 2013 confirmed only partial union with proximal pole changes and early degenerative arthritis.
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 06 May 2011, after 1 July 2004, during warlike service in Afghanistan. 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 Afghanistan in 2011, where the fracture occurred, and to his non-warlike service in Timor-Leste in 2008, where the distal radius malunion arose. The Balance of Probabilities instrument applies to his peacetime service, including pre-deployment training in 2010 and the period in Australia from June 2011 to February 2012 in which the fracture went on to non-union.
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 06 May 2011 the veteran fell down the bank of a watercourse on to his outstretched, dorsiflexed left hand while carrying a 42 kg load, so that more than 120 kg came down through the wrist. This is a force that ordinarily breaks a healthy scaphoid. The repetitive loading that weakened the bone beforehand was imposed during peacetime pre-deployment training from August to December 2010, and the force at onset was applied in the course of his duties.
Factor 9(2): for stress fracture only, having significant repetitive loading stress to the affected bone prior to clinical onset; — MET
- From August to December 2010, during peacetime pre-deployment training, the veteran did up to 300 push-ups a day, rope climbs and repeated weapon-handling drills, which load the scaphoid with the wrist extended. He reported three months of activity-related left wrist pain with snuffbox tenderness on 16 November 2010, and the CT of 27 May 2011 showed marginal sclerosis and endosteal thickening at the fracture site, confirming a stress reaction of the fatigue type before the fall completed the fracture.
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 distal radius fracture of 03 March 2008 healed with 15 degrees of dorsal tilt and loss of radial inclination, documented by an orthopaedic surgeon on 20 August 2008, who recorded that the malunion would alter load transmission through the carpus. This uncorrected malalignment redirected and concentrated the load of every push-up and weapon drill on to the scaphoid waist, and it was present at the onset on 06 May 2011. The training that applied that load was peacetime training in Australia in 2010.
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 treatment of the fracture, from the cast applied on 27 May 2011 until non-union was diagnosed on 14 February 2012, as recorded at each orthopaedic and medical review. He took up smoking at the 1st Recruit Training Battalion in 2006, and smoking was heavily normalised in his unit. Smoking reduces blood flow and osteoblast activity at the fracture site and is a recognised cause of scaphoid non-union.
Factor 9(5): having diabetes mellitus at the time of the fracture non-union; — MET
- Steroid-induced diabetes mellitus was confirmed on 12 December 2011, with an HbA1c of 7.4 per cent, and metformin was commenced on 10 January 2012. It was caused by the high-dose prednisolone prescribed from 22 August 2011 for severe asthma that deteriorated on service, and it was present when non-union was diagnosed on 14 February 2012.
Factor 9(6): inability to obtain appropriate clinical management for fracture before clinical worsening. — MET
- When the veteran fell on 06 May 2011 there was no radiography at his patrol base. He was diagnosed with a sprain, strapped and returned to patrolling, and the fracture was not immobilised until 27 May 2011, three weeks later. In the period before the non-union of 14 February 2012 he continued to load the wrist on patrol for three weeks. Delay in immobilising a scaphoid waist fracture is a recognised cause of 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
- The fracture occurred on warlike service in Afghanistan on 06 May 2011, when the veteran fell down a watercourse bank on patrol and his body weight and a 42 kg fighting load came down through his outstretched left hand. The fall arose directly from patrolling duties on operational service.
Factor 9(2): for stress fracture only, having significant repetitive loading stress to the affected bone prior to clinical onset; — MET
- On warlike service in Afghanistan from 12 February 2011 to 06 May 2011 the veteran climbed compound walls and ditches several times a day, handled his rifle and a machine gun for hours on each patrol, and continued daily push-ups and loaded physical training at the patrol base. This repetitive loading continued the stress reaction recorded in November 2010 and is shown by the marginal sclerosis on the CT of 27 May 2011.
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 malunited left distal radius, with 15 degrees of dorsal tilt, resulted from the fall on non-warlike service in Timor-Leste on 03 March 2008. The uncorrected malalignment concentrated load on the scaphoid waist throughout his warlike service in Afghanistan and was present at onset on 06 May 2011.
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 from the time the cast was applied in Afghanistan on 27 May 2011, while still on warlike service, through to the non-union diagnosed on 14 February 2012. His smoking increased on deployment, when cigarettes were cheap and used to cope with the stress of patrolling.
Factor 9(5): having diabetes mellitus at the time of the fracture non-union; — MET
- Steroid-induced diabetes, confirmed on 12 December 2011, was present at the non-union on 14 February 2012. It resulted from prednisolone for severe asthma that deteriorated with dust exposure on warlike service in Afghanistan in 2011.
Factor 9(6): having osteoporosis at the time of the fracture non-union; — MET
- Dual-energy X-ray absorptiometry on 10 January 2012 showed a lumbar spine T-score of -2.7 and Z-score of -2.8 and a total hip T-score of -2.5, confirming osteoporosis, attributed by the endocrinologist to more than four months of high-dose prednisolone. The asthma requiring the steroid was aggravated on warlike service in Afghanistan. The osteoporosis was present at the non-union on 14 February 2012.
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
- The serum 25-hydroxyvitamin D level was 36 nmol/L on 10 January 2012, five weeks before the non-union was diagnosed on 14 February 2012, and a repeat level on 13 February 2012 was 39 nmol/L. The deficiency followed months of limited sun exposure while he was in a cast and largely housebound with severe asthma after his return from warlike service.
Factor 9(8): having a Body Mass Index (BMI) of 40 or greater at the time of the fracture non-union; — MET
- The veteran weighed 128 kg at a height of 1.78 m on 10 January 2012, a BMI of 40.4, and 129 kg on 14 February 2012, a BMI of 40.7. His weight rose from 110 kg in May 2011 because of high-dose prednisolone and the inactivity imposed by the wrist injury sustained on warlike service.
Factor 9(9): inability to obtain appropriate clinical management for fracture before clinical worsening. — MET
- On warlike service in Afghanistan there was no radiography at the patrol base, and the fracture was misdiagnosed as a sprain on 06 May 2011 and not immobilised until 27 May 2011. The delay was imposed by operational conditions and he continued to load the wrist on patrol, which contributed to the non-union documented on 14 February 2012.
The % contribution of the causes is 100% and significant.
Sequelae
Met. The non-union is a recognised sequela of the scaphoid fracture, and it has led to early radioscaphoid degenerative arthritis of the left wrist shown on MRI on 12 September 2013, with chronic pain, stiffness and weakness of grip. The osteoporosis and steroid-induced diabetes present at the non-union are themselves sequelae of treatment for asthma aggravated on service, and should be considered for separate claims.
Unintended Consequence
Met. The steroid-induced diabetes, osteoporosis and weight gain that contributed to the non-union are unintended consequences of high-dose prednisolone prescribed by Defence-funded specialists from 22 August 2011 while the veteran was serving (section 6A of the DRCA and the equivalent provisions of the MRCA). The three-week delay in diagnosis at the role 1 facility was also an unintended consequence of the medical treatment provided on service.
Inability to Attain Appropriate Medical Management
MET. When the veteran fell on 06 May 2011 he was at a patrol base in Afghanistan with no radiography. He was diagnosed with a sprain, strapped and returned to patrolling, and the scaphoid fracture was not identified or immobilised until 27 May 2011. A delay of more than two weeks in immobilising a scaphoid waist fracture substantially increases the risk of non-union, and non-union was established on 14 February 2012. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), the absence of imaging in the operational setting and the resulting misdiagnosis amount to an inability to obtain appropriate clinical management before the clinical worsening.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 03 Mar 2008, Trauma presentation and X-ray report, Role 2 facility, Timor-Leste
- 20 Aug 2008, Orthopaedic consultation and X-ray report, Orthopaedic surgeon
- 16 Nov 2010, Outpatient health record, Medical Officer, Garrison health centre
- 06 May 2011, Patrol base treatment record, Medical Officer, Role 1 facility, Afghanistan
- 27 May 2011, X-ray and CT reports, Radiologist, Role 2 facility, Afghanistan
- 15 Jun 2011, Aeromedical evacuation summary, Medical Officer
- 22 Aug 2011, Specialist consultation, Respiratory physician
- 12 Dec 2011, Pathology report, HbA1c
- 10 Jan 2012, Dual-energy X-ray absorptiometry report and endocrinology consultation, Endocrinologist
- 14 Feb 2012, CT report and hand surgery consultation, Hand surgeon
- 20 Mar 2012, Operation report, Hand surgeon
- 12 Sep 2013, MRI report and hand surgery review, Hand 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
