Diagnostic Assessment — Left Wrist - Ulnar Styloid Fracture
Example 1 of 1 · fictitious patient (Veteran BA)
Diagnostic Assessment
Left Wrist - Ulnar Styloid Fracture
BOP Code: 63 of 2024 (Fracture)
RH Code: 62 of 2024 (Fracture)
ADF History
Veteran BA, date of birth 07 May 1979, Royal Australian Air Force, Airfield Defence Guard (later Corporal), enlisted 20 July 1998, medically discharged 15 March 2018. Operational service: East Timor, 25 October 1999 to 20 April 2000 (warlike); Afghanistan, 05 January 2011 to 30 July 2011 (warlike); Middle East Area of Operations, 10 February 2014 to 15 August 2014 (warlike).
Occupational History
As an airfield defence guard the veteran conducted foot and vehicle patrols of airfield perimeters, manned weapon pits and entry control points, and carried a rifle, ammunition, body armour and equipment of 25 to 35 kilograms. Training and fitness requirements involved daily push-ups, weighted dips, pull-ups, weapons drills and climbing obstacles, and on deployment he completed long hours of picket and patrol duty with the weapon held in a firing position.
Airfield defence guards are at risk of falls on uneven ground, vehicle incidents, blast and indirect fire, and of repetitive loading injuries of the wrists and shoulders from weapons handling and upper-body training. Deployed airfields expose members to dust, burn-pit smoke and aviation fuel, and the service culture of the period normalised smoking on deployment.
History
Veteran BA, an airfield defence guard in the Royal Australian Air Force, fractured the base of the left ulnar styloid on 14 May 2011 during warlike service in Afghanistan, when he fell onto his outstretched left hand during a rocket attack, through a fatigue stress fracture caused by repetitive weapons and upper-body loading on a wrist with ulnar-positive variance from an earlier service fracture. The fracture failed to unite, with non-union confirmed on 20 March 2012 while he was smoking heavily and had developed steroid-induced diabetes, osteoporosis, vitamin D deficiency and severe obesity.
Timeline
- 11 Sep 2001 — During a night patrol exercise in northern Australia the veteran fell from a vehicle tailgate onto his outstretched left hand. X-ray showed a dorsally angulated fracture of the distal radius, treated with closed reduction and a cast for six weeks. Follow-up X-rays showed union with 4 mm of radial shortening, leaving the ulna 4 mm longer than the radius at the wrist. "distal radius fracture, closed reduction"
- 20 Jun 2009 — At a periodic health examination the veteran reported intermittent ulnar-sided left wrist ache after push-ups and weapons drills. The Medical Officer noted tenderness over the ulnar head and positive ulnar variance on review of the earlier X-rays, attributed to the malunited radius fracture. No change to duties was made. He was smoking about 15 cigarettes a day. "ulnar wrist ache, ulnar-positive variance"
- 14 May 2011 — During a rocket attack on a deployed airfield in Afghanistan the veteran sprinted for a bunker in full equipment, tripped over a sandbag wall and fell heavily onto his outstretched left hand. He had immediate severe ulnar-sided wrist pain and swelling. X-ray at the role 3 hospital showed a displaced fracture through the base of the left ulnar styloid with sclerotic margins, consistent with completion of a pre-existing stress fracture. A below-elbow cast was applied. "displaced ulnar styloid base fracture"
- 26 May 2011 — At review in Afghanistan the veteran described three months of increasing ulnar wrist pain on push-ups, weighted dips and prolonged weapon holding before the fall. Orthopaedic opinion by telehealth recommended immobilisation in an above-elbow cast and early review in Australia, but he was required to remain in theatre and was returned to light duties in a below-elbow splint. He was now smoking 20 to 25 cigarettes a day. "stress symptoms before fall, splinted"
- 25 Aug 2011 — After returning from Afghanistan the veteran was diagnosed with severe asthma related to dust and burn-pit smoke on deployment and commenced prednisolone 50 mg daily, continued at 25 to 50 mg daily through to March 2012 because of repeated exacerbations. Weight 112 kg, height 1.85 m, BMI 32.7. X-ray of the wrist showed the ulnar styloid fragment still displaced with no bridging callus. "prednisolone 50 mg, no callus"
- 16 Jan 2012 — Blood tests showed an HbA1c of 7.9 per cent and a fasting glucose of 9.8 mmol/L, and an endocrinologist diagnosed steroid-induced type 2 diabetes mellitus and commenced metformin. Serum 25(OH)D was 32 nmol/L. On 08 February 2012 a DXA scan showed a lumbar spine T-score of -2.7, confirming glucocorticoid-induced osteoporosis, and alendronate, calcium and vitamin D were started. "steroid diabetes, osteoporosis, vitamin D 32"
- 20 Mar 2012 — An orthopaedic hand surgeon confirmed non-union of the left ulnar styloid base fracture on CT, ten months after injury, with distal radioulnar joint instability and painful clicking on forearm rotation. Weight 139 kg, BMI 40.6. He was still smoking 20 cigarettes a day. Serum 25(OH)D was 41 nmol/L, and HbA1c was 8.2 per cent. "ulnar styloid non-union, DRUJ unstable"
- 14 Aug 2012 — The hand surgeon performed open reduction and internal fixation of the ulnar styloid non-union with a tension band and bone graft, and repaired the foveal attachment of the triangular fibrocartilage complex. Union was achieved by February 2013, with residual reduced grip strength and loss of forearm rotation. "ORIF non-union, TFCC repair"
Symptoms
At onset the veteran had sudden severe pain, swelling and bruising over the ulnar side of the left wrist after the fall, with pain on gripping and forearm rotation, after three months of increasing ulnar-sided wrist ache on push-ups, dips and holding his rifle. After the fracture failed to unite he had persisting pain, a painful clunk on rotating the forearm and weakness of grip.
He now reports ulnar-sided left wrist pain with lifting, gripping, turning door handles and using tools, loss of about a third of grip strength, and stiffness in cold weather. He cannot do push-ups or carry heavy shopping in his left hand and has given up rock fishing and weight training.
Imaging
- 11 Sep 2001 — X-ray left wrist: "Dorsally angulated extra-articular fracture of the distal radius. Ulnar styloid intact."
- 06 Dec 2001 — X-ray left wrist: "United distal radius fracture with 4 mm of radial shortening and positive ulnar variance of +4 mm."
- 14 May 2011 — X-ray left wrist: "Displaced transverse fracture through the base of the ulnar styloid, displaced 3 mm, with sclerotic fracture margins and periosteal new bone indicating a pre-existing fatigue stress fracture. Positive ulnar variance of +4 mm."
- 25 Aug 2011 — X-ray left wrist: "Ulnar styloid base fracture remains displaced with no bridging callus."
- 08 Feb 2012 — DXA bone densitometry: "Lumbar spine T-score -2.7, femoral neck T-score -2.2. Osteoporosis."
- 20 Mar 2012 — CT left wrist: "Established non-union of the ulnar styloid base fracture with sclerotic, rounded fracture ends and a 3 mm gap. Widening of the distal radioulnar joint on rotation views."
Onset Date
The most likely date of onset of this condition is 14 May 2011.
At that date the veteran was on warlike service at a deployed airfield in Afghanistan, conducting perimeter patrols and pickets in full equipment, with a daily programme of push-ups, weighted dips and weapons drills. During a rocket attack he fell onto his outstretched left hand, completing a fatigue stress fracture at the base of the ulnar styloid.
This date is appropriate because his pre-deployment X-ray review and health assessment of 15 November 2010 recorded an intact ulnar styloid with ulnar-positive variance only, and he presented to the role 3 hospital on 14 May 2011, within an hour of the fall, when X-ray showed the fracture. It falls within uninterrupted full-time service and within the deployment.
For the repetitive loading factor, the period before onset relied on runs from the start of the deployment on 05 Jan 2011 to 14 May 2011, during which he performed at least 150 push-ups and 60 weighted dips a day and held his rifle in a firing position for six to eight hours a shift; his ulnar wrist pain on loading began in February 2011. For the abnormal force direction factor, the positive ulnar variance of +4 mm from the 2001 radius malunion was present on 14 May 2011. The force of the fall was applied at that date.
For the worsening factors, the period after onset runs from 14 May 2011 to the documented non-union on 20 Mar 2012. Throughout treatment from 14 May 2011 to 20 Mar 2012 he smoked 20 to 25 cigarettes a day. Steroid-induced diabetes mellitus was diagnosed on 16 Jan 2012, osteoporosis on 08 Feb 2012 and vitamin D deficiency on 16 Jan 2012, and his BMI was 40.6 on 20 Mar 2012, so each was present at the time of the non-union. The inability to obtain appropriate clinical management occurred from 26 May 2011 to 30 Jul 2011, before the worsening.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Left Wrist - Ulnar Styloid Fracture (ICD-10-AM S52.8), a displaced fracture through the base of the left ulnar styloid completing a fatigue stress fracture, complicated by non-union, under the Statements of Principles concerning fracture, Balance of Probabilities No. 63 of 2024 and Reasonable Hypothesis No. 62 of 2024.
The ulnar styloid is the small bony projection at the end of the ulna on the little-finger side of the wrist, to which the triangular fibrocartilage complex attaches. Fractures through its base can destabilise the distal radioulnar joint, which allows forearm rotation. The ulnar styloid is overloaded when the ulna is longer than the radius, as after a shortened, malunited radius fracture, and repetitive weight-bearing through the hand can cause a fatigue stress fracture that completes with a fall. Non-union is more likely with displacement, inadequate immobilisation, smoking, diabetes, osteoporosis, vitamin D deficiency, severe obesity and glucocorticoid treatment.
The veteran's fracture began on 14 May 2011 on warlike service in Afghanistan, when a fall completed a stress fracture caused by repetitive loading of a wrist with ulnar-positive variance. It failed to unite and non-union was confirmed on 20 March 2012.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
14 May 2011.
When did the veteran first present to a health / medical provider for this condition?
14 May 2011.
When was the condition confirmed / formally diagnosed?
14 May 2011.
When did the veteran first present to you (or your practice) for this condition?
23 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 X-ray at the role 3 hospital on 14 May 2011, which showed a displaced transverse fracture through the base of the left ulnar styloid. The sclerotic margins and periosteal new bone showed that a fatigue stress fracture was present before the fall, consistent with the three months of loading pain the veteran described. This is an acquired break of bone from an applied force that would ordinarily break healthy bone, and it includes a stress fracture of the fatigue type, meeting the Statement of Principles definition of fracture. The bone was healthy at the time of the fracture, so it is not a pathological or insufficiency fracture.
Non-union was confirmed by CT on 20 March 2012, ten months after injury, with sclerotic, rounded fracture ends, a persisting gap and distal radioulnar joint instability, and by an orthopaedic hand surgeon. Fracture non-union is a clinical worsening of the fracture under the Statements of Principles. The subsequent osteoporosis developed during glucocorticoid treatment after the fracture and did not cause it.
4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.
Legislation: the clinical onset of this condition was on 14 May 2011, after 1 July 2004, during continuous full-time service. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim and the Statements of Principles apply. The Balance of Probabilities instrument applies to peacetime service, including the treatment period in Australia when the fracture failed to unite. The Reasonable Hypothesis instrument applies to the veteran's warlike service in Afghanistan in 2011, where the stress fracture developed and the fracture occurred, and where appropriate treatment could not be obtained.
Each factor must be related to the person's relevant service. Under the beneficial approach required by the legislation, the absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.
Balance of Probabilities — Statement of Principles concerning Fracture, No. 63 of 2024
Causative factors
Factor 9(1): having significant physical force applied to or through the affected bone at the time of clinical onset; — MET
- On 14 May 2011 the veteran, carrying about 30 kilograms of equipment, tripped while sprinting for cover and fell with his full body weight onto his outstretched left hand. The impact transmitted a significant force through the wrist and the ulnar styloid, and the role 3 X-ray the same day showed a displaced fracture through its base.
Factor 9(2): for stress fracture only, having significant repetitive loading stress to the affected bone prior to clinical onset; — MET
- The fracture completed a fatigue stress fracture, shown by sclerotic margins and periosteal new bone on X-ray. Before onset the veteran performed at least 150 push-ups and 60 weighted dips a day as part of the required fitness programme and held his rifle in a firing position for six to eight hours a shift, loading the ulnar side of the wrist repeatedly. Ulnar wrist pain on loading began in February 2011 and increased until the fall.
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 left distal radius fracture sustained on a service exercise on 11 September 2001 united with 4 mm of radial shortening, leaving positive ulnar variance of +4 mm. This uncorrected malalignment directed an abnormally high share of axial load through the ulnar head and styloid during push-ups, dips and weapon holding, and was present at onset on 14 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 20 to 25 cigarettes a day throughout treatment of the fracture, from 14 May 2011 to the non-union confirmed on 20 March 2012, as recorded at his reviews of 26 May 2011 and 20 March 2012. His smoking had increased from 15 a day during his deployment, where cigarettes were cheap and widely used to cope with long pickets.
Factor 9(5): having diabetes mellitus at the time of the fracture non-union; — MET
- An endocrinologist diagnosed type 2 diabetes mellitus on 16 January 2012, with an HbA1c of 7.9 per cent, induced by prednisolone prescribed from 25 August 2011 for asthma caused by dust and burn-pit smoke on deployment. The HbA1c was 8.2 per cent on 20 March 2012, when the non-union was confirmed.
Factor 9(6): inability to obtain appropriate clinical management for fracture before clinical worsening. — MET
- On 26 May 2011 an orthopaedic surgeon advised above-elbow cast immobilisation and early specialist review in Australia, but the veteran was required to remain in Afghanistan until 30 July 2011 and was managed in a below-elbow splint on light duties, without specialist follow-up or repeat imaging. When reviewed in Australia on 25 August 2011 there was no callus, and non-union followed. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management before the clinical worsening.
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
- During a rocket attack on warlike service in Afghanistan on 14 May 2011 the veteran fell heavily onto his outstretched left hand while running for a bunker in about 30 kilograms of equipment, applying significant force through the ulnar styloid and causing a displaced fracture through its base.
Factor 9(2): for stress fracture only, having significant repetitive loading stress to the affected bone prior to clinical onset; — MET
- From 05 January 2011 on warlike service in Afghanistan the veteran performed a daily programme of at least 150 push-ups and 60 weighted dips and held his rifle in a firing position for six to eight hours each picket shift, repeatedly loading the ulnar side of the left wrist. The resulting fatigue stress fracture produced pain from February 2011 and was visible on the X-ray of 14 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
- Positive ulnar variance of +4 mm from the malunited 2001 service radius fracture caused an abnormal concentration of force through the ulnar styloid during the push-ups, dips and weapons handling performed on warlike service in Afghanistan, and was present at onset on 14 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's smoking increased to 20 to 25 cigarettes a day during his warlike service in Afghanistan, as a way of coping with long night pickets and indirect fire, and continued at that level throughout treatment of the fracture from 14 May 2011 to the non-union on 20 March 2012.
Factor 9(5): having diabetes mellitus at the time of the fracture non-union; — MET
- Steroid-induced type 2 diabetes mellitus was diagnosed on 16 January 2012. It followed prolonged high-dose prednisolone for asthma caused by dust and burn-pit smoke during warlike service in Afghanistan, and it was present, with an HbA1c of 8.2 per cent, at the non-union on 20 March 2012.
Factor 9(6): having osteoporosis at the time of the fracture non-union; — MET
- A DXA scan on 08 February 2012 showed a lumbar spine T-score of -2.7, and glucocorticoid-induced osteoporosis was diagnosed. It resulted from the prednisolone prescribed for asthma arising from his warlike service in Afghanistan, and it was present at the non-union on 20 March 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
- Serum 25(OH)D was 32 nmol/L on 16 January 2012 and 41 nmol/L on 20 March 2012, at the time of the non-union. The deficiency followed months of night-shift pickets and indoor work in Afghanistan and housebound recovery from his deployment-related asthma.
Factor 9(8): having a Body Mass Index (BMI) of 40 or greater at the time of the fracture non-union; — MET
- The veteran's weight rose from 112 kg in August 2011 to 139 kg on 20 March 2012, a BMI of 40.6 at a height of 1.85 m, at the time the non-union was confirmed. The weight gain followed high-dose prednisolone for asthma arising from his warlike service and the inactivity of his wrist injury.
Factor 9(9): inability to obtain appropriate clinical management for fracture before clinical worsening. — MET
- While on warlike service in Afghanistan from 14 May 2011 to 30 July 2011 the veteran could not obtain the above-elbow immobilisation, specialist orthopaedic review and repeat imaging recommended on 26 May 2011, because he was required to remain in theatre. The fracture showed no healing on his return and progressed to non-union. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management before the clinical worsening.
The % contribution of the causes is 100% and significant.
Sequelae
The left ulnar styloid fracture is a sequela of the veteran's accepted malunited left distal radius fracture of 2001, which left the ulna 4 mm longer than the radius. The non-union is in turn a sequela of his accepted deployment-related asthma, whose glucocorticoid treatment caused diabetes, osteoporosis and severe obesity. Distal radioulnar joint instability and a triangular fibrocartilage complex tear are sequelae of the fracture.
Unintended Consequence
Met. The non-union is in part an unintended consequence of treatment provided by the Commonwealth while the veteran was serving: the prolonged high-dose prednisolone prescribed for his service-related asthma, which caused steroid-induced diabetes, glucocorticoid-induced osteoporosis and weight gain to a BMI above 40 (section 6A of the DRCA and the equivalent provisions of the MRCA).
Inability to Attain Appropriate Medical Management
MET. After the fracture on 14 May 2011 an orthopaedic surgeon advised above-elbow immobilisation and early specialist review in Australia, but the veteran was required to remain on warlike service in Afghanistan until 30 July 2011 and was managed in a below-elbow splint on light duties without specialist follow-up or repeat imaging. No callus had formed by 25 August 2011 and the fracture progressed to non-union. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), operational requirements that prevent recommended fracture care amount to an inability to obtain appropriate clinical management. The further delay from March to August 2012 before surgical fixation is also indicative of barriers to care.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 11 Sep 2001, Emergency record and X-ray report, Base health centre
- 06 Dec 2001, Fracture clinic review and X-ray report, Orthopaedic registrar
- 20 Jun 2009, Periodic health examination, Medical Officer, Base health centre
- 15 Nov 2010, Pre-deployment health assessment, Medical Officer
- 14 May 2011, Emergency record and X-ray report, Role 3 hospital, Afghanistan
- 26 May 2011, Deployed health record and telehealth orthopaedic advice, Medical Officer, Afghanistan
- 25 Aug 2011, Respiratory consultation and X-ray report, Respiratory physician
- 16 Jan 2012, Endocrinology consultation and pathology, Endocrinologist
- 08 Feb 2012, DXA bone densitometry report, Radiologist
- 20 Mar 2012, Specialist consultation and CT report, Orthopaedic hand surgeon
- 14 Aug 2012, Operation report, Orthopaedic 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
