Diagnostic Assessment — Right 4th Toe - Soft Tissue Injury
Example 1 of 1 · fictitious patient
Diagnostic Assessment Right 4th Toe — Soft Tissue Injury BOP Code: 44 of 2024 (Traumatic Contusion or Haematoma) RH Code: 43 of 2024 (Traumatic Contusion or Haematoma)
ADF History
The veteran, date of birth [withheld], served in the Royal Australian Navy as a Marine Technician from 9 March 1981 to 24 December 1987
Occupational History
As a naval serviceman at a frigate, the veteran performed duties that included working with maritime equipment such as outboard motors.
These duties involved the risk of crush and stub injuries to the feet from heavy equipment
History
The veteran sustained a stub injury to the 4th toe of the right foot on 5 November 1987 when he kicked his toe on an outboard motor at a frigate, approximately seven weeks before his discharge from the Navy on 24 December 1987.
X-ray of the right fourth toe that day, reported by radiologist the treating doctor on 9 November 1987, showed no evidence of a fracture
Timeline
05 Nov 1987 — ABSR the veteran, as a young adult, kicked his toe on an outboard motor at a frigate.
He sustained a stub injury to the 4th toe of the right foot.
An X-ray was performed which showed no fracture.
The wound was cleaned with Savlon antiseptic solution.
Daily dressings were ordered for the wound.
He was returned to duty.
This injury occurred at a time when his right foot had already undergone bilateral toe straightening surgery (approximately September 1985) with IP joint fusion, making the toes more rigid and vulnerable to stub injuries. "Stubb injury, 4th toes" 09 Nov 1987 — Rayscan
Imaging
Report by radiologist the treating doctor (Surgeon Commander RANR) on the X-ray of the right fourth toe taken on 05 Nov 1987 for a frigate.
Fusions were noted across the proximal interphalangeal joints of the right third and fourth toes, described as presumably congenital in origin.
No other bony abnormality was seen and there was no evidence of a fracture. "I see no evidence of a fracture"
Symptoms
At the time of injury, the veteran experienced pain at the right 4th toe following the stub injury against the outboard motor.
The wound required daily dressings, indicating a significant soft tissue injury with skin disruption
Imaging
05 Nov 1987 — X-ray right fourth toe (reported 9 November 1987, the treating doctor): "Fusions are noted across the proximal interphalangeal joint of the right third and fourth toes.
These are presumably congenital in origin.
No other bony abnormality is seen within either toe.
I see no evidence of a fracture."
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Right 4th Toe Soft Tissue Injury / Contusion (ICD-10: S90.12XA).
The relevant Statements of Principles are those concerning Traumatic Contusion or Haematoma (Balance of Probabilities No.
44 of 2024; Reasonable Hypothesis No.
43 of 2024), applied by analogy as this is a DRCA claim.
A stub injury to the toe involves direct impact of the toe against a hard object, causing soft tissue damage including bruising, laceration, and potential damage to the nail bed, periosteum, and underlying structures.
In the veteran's case, the right 4th toe had previously undergone IP joint fusion surgery approximately two years prior, making the toe rigid and more susceptible to injury from direct impact
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition? 5 November 1987 [ [CHART REVIEW document], pages 1 2] When did the veteran first present to a health / medical provider for this condition? 5 November 1987 When was the condition confirmed / formally diagnosed? 5 November 1987 When did the veteran first present to you (or your practice) for this condition? 20 July 2022
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was confirmed on clinical and radiological grounds by the attending medical officer at a frigate.
The key symptoms were right 4th toe pain following a stub injury against an outboard motor.
The key signs were a wound requiring antiseptic cleaning and daily dressings.
X-ray excluded fracture [ [CHART REVIEW document], pages 1 2]; the formal report of the right fourth toe X-ray by radiologist the treating doctor (9 November 1987) found no evidence of a fracture and no bony abnormality other than fusions across the proximal interphalangeal joints of the right third and fourth toes [CHART REVIEW document]
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 6 June 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.
Definition: The Daily Injury Record of 5 November 1987 describes a stub injury of the right fourth toe with a wound that was cleaned and dressed daily; bruising is not expressly recorded, but a blunt impact of this kind causes bleeding into the soft tissues of the toe, and the x-ray taken that day showed no fracture, so the exclusion of blood collections associated with a fracture does not apply.
The skin wound itself falls under the Statements of Principles concerning cut, stab, abrasion and laceration.
Causative Factors — Balance of Probabilities (Statement of Principles concerning Traumatic Contusion or Haematoma, No.
44 of 2024) Factor 9(1): having trauma involving the affected site within the 24 hours before clinical onset — MET - At about 1.00 pm on 5 November 1987 the veteran kicked his right fourth toe on an outboard motor at a frigate, and the Daily Injury Record of that day records a stub injury of the right fourth toe with a query fracture and a wound that was cleaned with Savlon and dressed daily.
The x-ray of the toe taken that day, reported on 9 November 1987, showed no fracture.
The impact against the outboard motor was trauma involving the right fourth toe, the affected site, on the day the injury began, and so within the 24 hours before clinical onset.
Causative Factors — Reasonable Hypothesis (Statement of Principles concerning Traumatic Contusion or Haematoma, No.
43 of 2024) 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): having trauma involving the affected site within the 24 hours before clinical onset — MET - Kicking the right fourth toe on an outboard motor at a frigate on 5 November 1987 was trauma involving the affected site on the day the soft tissue injury began, and so within the 24 hours before clinical onset; the x-ray taken that day showed no fracture.
Other Plausible Links to Service The injury occurred at a frigate at about 1.00 pm on a working day, Friday 5 November 1987, when the veteran kicked his toe on an outboard motor; it was treated by the service medical record staff and recorded on the Navy's Daily Injury Record, and he was returned to duty.
The record does not state whether he was on duty, but outboard motors are small-boat equipment of the kind a Marine Technician works with, and the time and place point to his duties; on that basis the injury arose out of, or in the course of, his employment as a member.
The right fourth toe had been operated on in service, with a flexor-to-extensor tendon transfer on 19 June 1983 and fusion of its interphalangeal joint on 18 September 1985, both arranged through the Navy and paid for by the Commonwealth; the x-ray of 5 November 1987 showed fusion across the proximal interphalangeal joints of the right third and fourth toes, which the radiologist presumed congenital but which correspond to those in-service fusions.
A fused, rigid toe cannot flex away from an impact and is more exposed to stubbing, and this toe had remained painful over its dorsum after surgery (15 January 1986), so the earlier in- service treatment contributed to its vulnerability to this injury.
Conclusion The soft tissue injury (contusion) of the veteran's right fourth toe was caused by kicking the toe on an outboard motor at a frigate on 5 November 1987, which is trauma involving the affected site at the onset of the injury and meets factor 9(1) of both Statements of Principles; fracture was excluded by x-ray.
The circumstances point to his duties as a Marine Technician, and the rigidity of the toe after its in-service fusion made it more vulnerable to the injury, so the condition is attributable to his service.
The % contribution of the causes is 100% and significant.
Worsening Factors In the alternative, if the soft tissue injury of the veteran's right fourth toe is found not to have arisen out of his service, the following factor addresses whether it was worsened after its clinical onset on 5 November 1987.
He returned to duty the same day and served for a further seven weeks, until his discharge on 24 December 1987.
Worsening Factors — Balance of Probabilities (Statement of Principles concerning Traumatic Contusion or Haematoma, No.
44 of 2024) Factor 9(2): inability to obtain appropriate clinical management for traumatic contusion or haematoma before clinical worsening — NOT MET - Assessed objectively and subjectively as Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J) requires, there was no inability: the toe was treated on the day of injury and x-rayed the same day, with a radiologist's report excluding fracture on 9 November 1987, the wound was cleaned and dressed daily, and a review was arranged.
Worsening Factors — Reasonable Hypothesis (Statement of Principles concerning Traumatic Contusion or Haematoma, No.
43 of 2024) 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(2): inability to obtain appropriate clinical management for traumatic contusion or haematoma before clinical worsening — NOT MET - Applying Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), there was no objective or subjective inability: the toe was treated, dressed and x- rayed on the day of injury, and a review was arranged
Sequelae
The right 4th toe had previously undergone IP joint fusion surgery during service (September 1985).
The stub injury represents additional trauma to an already-compromised toe
Unintended Consequence
This condition is not an unintended consequence of medical management per se, however the rigidity of the right 4th toe following the in-service IP joint fusion surgery may have contributed to the vulnerability of the toe to stub injuries
Inability to Attain Appropriate Medical Management
There was no inability to obtain appropriate clinical management.
The toe was treated on the day of injury and X-rayed the same day, with a radiologist's report excluding fracture on 9 November 1987; the wound was cleaned and dressed daily and a review was arranged.
Assessed objectively and subjectively as required by Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), this factor is NOT MET
Date of Clinical Onset
Right 4th toe soft tissue injury is an acute condition.
Its date of clinical onset is the date of the injury or illness itself, as recorded in the contemporaneous service record.
Later investigations, reviews and imaging record the investigation, treatment or confirmation of the condition; they are not the date of clinical onset.
Date of injury / illness: 5 November 1987 — stub injury to the right 4th toe on an outboard motor at a frigate [ [CHART REVIEW document], pages 1 2].
The later records, including the X-ray of the toe reported on 9 November 1987, concern investigation or follow-up and do not alter the date of clinical onset.
Date of clinical onset: 5 November 1987.
This date falls within the veteran's ADF service (9 March 1981 24 December 1987).
In-service events and exposures before this date relate to clinical onset, and those after it to clinical worsening
