Diagnostic Assessment — Right Ankle - Talus Fracture
Example 1 of 1 · fictitious patient (Veteran BL)
Diagnostic Assessment
Right Ankle - Talus Fracture
BOP Code: 63 of 2024 (Fracture)
RH Code: 62 of 2024 (Fracture)
ADF History
Veteran BL, date of birth 22 May 1988, Australian Army, Infantry Soldier and later Commando, enlisted 05 February 2007, medically discharged 11 March 2016. Operational service: Afghanistan, 04 November 2012 to 15 April 2013 (warlike, ended by aeromedical evacuation).
Occupational History
As a commando the veteran carried loads of 35 to 50 kilograms on foot over mountainous terrain, conducted parachute descents, fast-roping and helicopter insertions, and completed long running and loaded pack-marching programmes. Landing from parachutes, ropes, vehicles and hovering aircraft places very high impact forces through the ankle and hindfoot.
Special forces training and operations carry high rates of lower limb fracture, including stress fractures from repetitive loading. Deployed soldiers of the period were exposed to burn-pit smoke and dust, and smoking rates rose on deployment.
History
Veteran BL, a commando in the Australian Army, sustained a displaced fracture of the right talar neck on 14 April 2013 when he jumped from a hovering helicopter under load during warlike service in Afghanistan, through a fatigue stress fracture caused by months of heavy loading on a leg with an uncorrected varus tibial malunion. The fracture went on to non-union, confirmed on 20 January 2014, while he was smoking and had glucocorticoid-induced diabetes, osteoporosis, vitamin D deficiency and a BMI of 40.
Timeline
- 18 Aug 2011 — During peacetime fast-roping training the veteran fell about 4 metres when a rope was released early, landing on his right leg. X-rays showed a displaced fracture of the right tibial shaft, treated the same day with an intramedullary nail. He returned to training after five months. "tibial shaft fracture, IM nail"
- 05 Jun 2012 — Orthopaedic review. The tibial fracture had united, but long-leg standing radiographs showed 8 degrees of varus malunion with a medial shift of the load line through the ankle. Corrective osteotomy was discussed and declined by the unit because of the coming deployment. He was cleared for full commando duties and pre-deployment training. "8 degree varus malunion, uncorrected"
- 02 Mar 2013 — On warlike service in Afghanistan the veteran reported three weeks of aching in the front of the right ankle during and after patrols, worse with load and settling with rest. The patrol medic and the medical officer found tenderness over the dorsal talar neck. No MRI was available in theatre. He was given anti-inflammatories and continued patrolling with 45 kg loads. "load-related ankle pain, no MRI"
- 14 Apr 2013 — During a helicopter insertion the veteran jumped about 2 metres from the hovering aircraft carrying 45 kg and landed on a dorsiflexed right foot. He could not bear weight. CT at the role 3 hospital showed a displaced talar neck fracture (Hawkins type II) with sclerotic margins along the dorsal neck, indicating a pre-existing fatigue stress fracture. He was aeromedically evacuated the next day. "displaced talar neck fracture, Hawkins II"
- 18 Apr 2013 — Open reduction and internal fixation of the right talar neck with two screws was performed in Australia. He was kept non-weight-bearing for 12 weeks. Smoking 20 cigarettes a day, recorded with advice to stop but no cessation support offered. BMI 28.4. "ORIF talar neck, two screws"
- 28 May 2013 — A respiratory physician diagnosed chronic eosinophilic pneumonia after investigation of breathlessness and cough since deployment, with peripheral eosinophilia, bilateral peripheral infiltrates on CT and 38 per cent eosinophils on bronchoalveolar lavage. He attributed it to the veteran's new heavy smoking and burn-pit smoke and dust exposure in Afghanistan. Prednisolone 50 mg a day was commenced, with a slow taper over nine months. "eosinophilic pneumonia, prednisolone 50 mg"
- 15 Nov 2013 — Medical officer review after two cancelled imaging appointments due to unit relocation. Persisting pain at the fracture site on walking. HbA1c 7.6 per cent and fasting glucose 9.1 mmol/L, diagnosed as glucocorticoid-induced diabetes mellitus and treated with metformin. Bone densitometry showed osteoporosis (femoral neck T-score -2.6). Serum 25(OH)D 31 nmol/L. Weight 120 kg, BMI 38.7. Smoking 15 to 20 a day. "steroid diabetes, osteoporosis, vitamin D 31"
- 20 Jan 2014 — CT of the right ankle nine months after fixation showed no bridging bone across the talar neck, with a persistent fracture gap, sclerotic fracture margins and lucency around the screws. The orthopaedic surgeon diagnosed an established non-union. Weight 124 kg, BMI 40.0 on 16 January 2014. HbA1c 7.9 per cent and 25(OH)D 34 nmol/L. "established non-union of talar neck"
- 12 Mar 2014 — Revision fixation of the right talar neck with iliac crest bone graft. Union was achieved by October 2014, but with stiffness of the subtalar and ankle joints and early post-traumatic arthritis. He was medically downgraded and could not return to commando duties. "revision fixation, bone graft"
Symptoms
At onset the veteran had sudden severe pain in the right ankle and hindfoot with immediate inability to bear weight, swelling and bruising, preceded by six weeks of load-related aching over the front of the ankle. After fixation he had persisting pain at the fracture site on walking, which did not settle and led to the diagnosis of non-union.
He now reports constant right ankle and hindfoot pain, stiffness, swelling after standing or walking more than 20 minutes, difficulty on uneven ground, slopes and stairs, inability to run, jump or carry loads, and a limp.
Imaging
- 05 Jun 2012 — Long-leg standing radiographs: "United right tibial shaft fracture with intramedullary nail. Varus malunion of 8 degrees with medial deviation of the mechanical axis through the ankle."
- 14 Apr 2013 — CT right ankle and hindfoot: "Displaced fracture of the talar neck with subluxation of the subtalar joint (Hawkins type II). Sclerotic margins along the dorsal cortex of the talar neck at the fracture site, consistent with a pre-existing fatigue stress fracture."
- 15 Nov 2013 — Dual-energy X-ray absorptiometry: "Femoral neck T-score -2.6 (Z-score -2.7) and lumbar spine T-score -2.8 (Z-score -2.9), in the osteoporotic range."
- 20 Jan 2014 — CT right ankle: "No bridging bone across the talar neck fracture nine months after fixation. Persistent fracture gap with sclerotic margins and peri-screw lucency. Established non-union. No collapse of the talar dome."
- 14 Oct 2014 — CT right ankle: "United talar neck fracture after revision fixation and bone grafting. Early degenerative change in the subtalar joint."
Onset Date
The most likely date of onset of this condition is 14 Apr 2013.
At that date the veteran was a commando on warlike service in Afghanistan. On a helicopter insertion he jumped about 2 metres from the hovering aircraft carrying 45 kg and the right talar neck broke through a fatigue stress fracture that had developed over the preceding months. The fracture was confirmed on CT the same day.
This date is appropriate because the fracture itself, an acquired break of bone, occurred at a single identifiable moment, and his ankle was normal at his pre-deployment examination in October 2012. The load-related ankle pain from 02 March 2013 was the warning phase of the fatigue stress fracture, and the bone broke completely on 14 April 2013. It falls within continuous full-time service.
For the force factor, the force was applied at the moment of onset on 14 Apr 2013. For the repetitive loading factor, the loading before onset ran from the start of pre-deployment training in June 2012 through five months of patrolling with 45 kg loads in Afghanistan from 04 Nov 2012 to 14 Apr 2013. For the abnormal force direction factor, the uncorrected 8 degree varus tibial malunion documented on 05 Jun 2012 was present on 14 Apr 2013.
For the worsening factors, the clinical worsening is the fracture non-union confirmed on CT on 20 Jan 2014. The period of treatment before it ran from fixation on 18 Apr 2013 to 20 Jan 2014, and he smoked 15 to 20 cigarettes a day throughout. Diabetes mellitus (diagnosed 15 Nov 2013), osteoporosis (15 Nov 2013), vitamin D deficiency (25(OH)D 34 nmol/L on 16 Jan 2014) and a BMI of 40.0 (16 Jan 2014) were each present when the non-union was confirmed.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Right Ankle - Talus Fracture, a displaced fracture of the right talar neck (Hawkins type II) through a fatigue stress fracture, complicated by non-union (ICD-10-AM S92.1), under the Statements of Principles concerning fracture, Balance of Probabilities No. 63 of 2024 and Reasonable Hypothesis No. 62 of 2024.
The talus sits between the tibia and fibula above and the calcaneus below and carries the whole body weight through the ankle. Talar neck fractures are usually caused by forced dorsiflexion of the foot, as in a heavy landing, and they threaten the bone's blood supply, so they carry high rates of non-union, avascular necrosis and post-traumatic arthritis of the ankle and subtalar joints. A fatigue stress fracture develops when repeated loading exceeds the bone's capacity to repair, and it can complete into a displaced fracture under a single heavy force. Non-union is the failure of a fracture to heal and is a clinical worsening of the fracture.
The fracture occurred on 14 April 2013 on warlike service, was confirmed on CT that day and worsened with non-union confirmed on 20 January 2014.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
14 April 2013.
When did the veteran first present to a health / medical provider for this condition?
14 April 2013.
When was the condition confirmed / formally diagnosed?
14 April 2013.
When did the veteran first present to you (or your practice) for this condition?
02 July 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 CT of the right ankle on 14 April 2013, which showed a displaced talar neck fracture with subtalar subluxation (Hawkins type II) and sclerotic margins of a pre-existing fatigue stress fracture at the fracture site. This is an acquired break of bone from a force that ordinarily breaks a healthy bone, and a stress fracture of the fatigue type, both within the Statement of Principles definition. It is not a pathological fracture, an insufficiency fracture, a bone stress injury without fracture or osteonecrosis: the bone was normal before the 2013 deployment and the osteoporosis developed only after the fracture.
The non-union was confirmed by CT on 20 January 2014, which showed no bridging bone nine months after fixation, and by the operative findings at revision fixation on 12 March 2014. Fracture non-union is a clinical worsening of the fracture.
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 April 2013, 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 2011 training accident that left the varus malunion and the 2012 pre-deployment training. The Reasonable Hypothesis instrument applies to the veteran's warlike service in Afghanistan from November 2012 to April 2013, during which the fracture occurred and from which the factors behind the non-union arose.
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 April 2013 the veteran jumped about 2 metres from a hovering helicopter during an insertion, carrying 45 kg of equipment, and landed with his full weight on a dorsiflexed right foot. He felt immediate severe pain and could not bear weight. CT that day showed a displaced fracture of the right talar neck (Hawkins type II). A 2-metre drop under a combined mass of about 133 kg forced the neck of the talus against the anterior lip of the tibia, a force that ordinarily breaks a healthy bone. The force was applied through the affected bone at the time of clinical onset.
Factor 9(2): for stress fracture only, having significant repetitive loading stress to the affected bone prior to clinical onset; — MET
- In the 10 months before onset the veteran completed commando pre-deployment training from June to October 2012 (running 40 to 60 km a week, weekly pack marches of 20 to 30 km with 35 to 45 kg, and parachute and helicopter drills), followed by five months of patrolling on foot with 45 kg loads in mountainous terrain from November 2012. CT of 14 April 2013 showed sclerotic margins along the dorsal talar neck at the fracture site, consistent with a pre-existing fatigue stress fracture, and he had reported load-related right ankle pain from 02 March 2013. This is significant repetitive loading stress to the talus before clinical onset.
Factor 9(3): for stress fracture only, having significant chronic repetitive loading stress to the affected bone due to abnormal force intensity or direction of application, at the time of clinical onset; — MET
- The veteran's right tibial shaft fracture from a peacetime fast-roping accident on 18 August 2011 healed in 8 degrees of varus, confirmed on long-leg radiographs on 05 June 2012. The malunion was not corrected, and he returned to full commando duties. The varus tibia shifted the load line medially and tilted the ankle mortise, concentrating force on the medial and dorsal talar neck with every step, a substantial varus malalignment of the kind the Statement of Principles describes. This abnormal force direction was present at the time of clinical onset on 14 April 2013 and was documented by the orthopaedic surgeon as contributing to the fatigue stress fracture.
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 10 cigarettes a day before deployment, increasing to 20 a day in Afghanistan. Throughout treatment of the fracture, from the internal fixation on 18 April 2013 to the CT confirmation of non-union on 20 January 2014, he smoked 15 to 20 cigarettes a day, recorded at each orthopaedic review. Nicotine and carbon monoxide impair blood flow and osteoblast function, and the talar neck has a fragile blood supply.
Factor 9(5): having diabetes mellitus at the time of the fracture non-union; — MET
- High-dose prednisolone for chronic eosinophilic pneumonia from 28 May 2013 caused glucocorticoid-induced diabetes mellitus, diagnosed on 15 November 2013 with an HbA1c of 7.6 per cent and a fasting glucose of 9.1 mmol/L, and treated with metformin. The diabetes was present at the time of the non-union confirmed on 20 January 2014, with an HbA1c of 7.9 per cent that week.
Factor 9(6): inability to obtain appropriate clinical management for fracture before clinical worsening. — MET
- After the veteran's return from Afghanistan he sought help through his regimental medical officer, but follow-up imaging was cancelled twice because of posting and unit relocation, so the delayed union was not identified until CT on 20 January 2014, nine months after fixation. No smoking cessation support or bone stimulation was offered, his weight-bearing restrictions were not supervised while he was posted away from his treating surgeon, and vitamin D and bone health were not assessed until November 2013. These failures came before the clinical worsening, the non-union.
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 helicopter insertion jump of 14 April 2013, during warlike service in Afghanistan, applied a force through the right talus that ordinarily would break a healthy bone, producing a displaced talar neck fracture at the time of clinical onset.
Factor 9(2): for stress fracture only, having significant repetitive loading stress to the affected bone prior to clinical onset; — MET
- In the five months before onset the veteran patrolled on foot in mountainous terrain in Afghanistan carrying 45 kg, from November 2012 to April 2013, on warlike service, after intensive pre-deployment training. He reported load-related ankle pain from 02 March 2013 and CT showed a pre-existing fatigue stress fracture line at the fracture site. This is significant repetitive loading stress before clinical onset.
Factor 9(3): for stress fracture only, having significant chronic repetitive loading stress to the affected bone due to abnormal force intensity or direction of application, at the time of clinical onset; — MET
- During warlike service in Afghanistan the veteran carried 45 kg loads on a right leg with an uncorrected 8 degree varus tibial malunion, which concentrated abnormal force on the talar neck with every step. This abnormal force direction was present at clinical onset on 14 April 2013.
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 April 2013 to January 2014. His smoking had doubled from 10 a day on warlike service in Afghanistan, where it helped him cope with the stress of patrolling, and did not fall after his evacuation.
Factor 9(5): having diabetes mellitus at the time of the fracture non-union; — MET
- Glucocorticoid-induced diabetes mellitus, diagnosed on 15 November 2013, was present at the non-union on 20 January 2014. It was caused by prednisolone for chronic eosinophilic pneumonia, which his respiratory physician attributed to his new heavy smoking and exposure to burn-pit smoke and dust on warlike service in Afghanistan.
Factor 9(6): having osteoporosis at the time of the fracture non-union; — MET
- Dual-energy X-ray absorptiometry on 15 November 2013 showed glucocorticoid-induced osteoporosis, with a T-score of -2.6 at the femoral neck and -2.8 at the lumbar spine (Z-scores -2.7 and -2.9), caused by six months of high-dose prednisolone combined with prolonged non-weight-bearing after the fracture. The osteoporosis was present at the non-union on 20 January 2014. Both its causes followed his warlike service in Afghanistan.
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 31 nmol/L on 15 November 2013 and 34 nmol/L on 16 January 2014, below 50 nanomoles per litre at the time of the non-union confirmed on 20 January 2014. The deficiency developed during months confined indoors in a cast and on crutches after the fracture sustained on 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's weight rose from 88 kg at deployment to 124 kg in January 2014 (height 1.76 m, BMI 40.0 on 16 January 2014) because of high-dose prednisolone and immobility after the fracture. His BMI was 40.0 at the time of the non-union on 20 January 2014.
Factor 9(9): inability to obtain appropriate clinical management for fracture before clinical worsening. — MET
- After his evacuation from warlike service in Afghanistan the veteran's follow-up imaging was cancelled twice because of service relocation, the delayed union was not identified until nine months after fixation, and no smoking cessation support, bone stimulation or bone health assessment was provided before November 2013. In theatre, his load-related ankle pain from 02 March 2013 could not be investigated because no MRI was available, and he kept patrolling until the fracture completed. These came before the clinical worsening, the non-union.
The % contribution of the causes is 100% and significant.
Sequelae
The talar neck fracture and its non-union have resulted in post-traumatic arthritis of the right subtalar and ankle joints, chronic hindfoot pain and stiffness, and an altered gait that has caused right knee and lower back pain. These are sequelae of the accepted fracture and can be claimed in their own right when diagnosed.
Unintended Consequence
Met. The non-union was contributed to by glucocorticoid-induced diabetes mellitus and osteoporosis, which were adverse effects of high-dose prednisolone prescribed and paid for by the Commonwealth for chronic eosinophilic pneumonia, and the iliac crest bone graft at revision surgery left chronic donor-site pain. Each is an unintended consequence of treatment provided by the Commonwealth (section 6A of the DRCA and the equivalent provisions of the MRCA).
Inability to Attain Appropriate Medical Management
MET. On warlike service in Afghanistan the veteran's load-related ankle pain from 02 March 2013 could not be investigated because no MRI was available, so the fatigue stress fracture was not found and he kept patrolling until it completed. After evacuation, follow-up imaging was cancelled twice because of unit relocation, the delayed union was not recognised until nine months after fixation, and he was not offered smoking cessation support, bone stimulation or bone health assessment until November 2013. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), investigation and follow-up that were unavailable or delayed because of operational and service circumstances 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
- 18 Aug 2011, Training accident report and operation report, Orthopaedic surgeon
- 05 Jun 2012, Orthopaedic review and long-leg radiographs, Orthopaedic surgeon
- 02 Mar 2013, Role 2 consultation, Medical Officer, Afghanistan
- 14 Apr 2013, Role 3 hospital trauma record and CT report, Afghanistan
- 18 Apr 2013, Operation report, Orthopaedic surgeon
- 28 May 2013, Specialist consultation and bronchoscopy report, Respiratory physician
- 15 Nov 2013, Outpatient health record, pathology and bone densitometry, Medical Officer
- 16 Jan 2014, Pathology report, Medical Officer
- 20 Jan 2014, CT right ankle and orthopaedic review, Orthopaedic surgeon
- 12 Mar 2014, Operation report, Orthopaedic surgeon
- 14 Oct 2014, CT right ankle, Radiologist
- 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
