Diagnostic Assessment — Right Clavicle - Abrasion
Example 1 of 1 · fictitious patient (Veteran B)
Diagnostic Assessment
Right Clavicle - Abrasion
Statement of Principles concerning Cut, Stab, Abrasion and Laceration (Reasonable Hypothesis) (No. 37 of 2025) Statement of Principles concerning Cut, Stab, Abrasion and Laceration (Balance of Probabilities) (No. 38 of 2025)
ADF History
The veteran served in the Australian Army as an Analyst in Intelligence Operations (ECN 002/Linguist) and held the rank of Corporal (CPL). His service records indicate active service from at least 1994 until a separation health examination on 11 Jan 2007.
Occupational History
As an Analyst in Intelligence Operations and a Linguist in the Australian Army, the veteran duties would have primarily involved sedentary work. However, ADF service includes physical training, field exercises, and recreational activities that can carry a risk of superficial injuries such as abrasions from falls, contact with equipment, or navigating rough terrain.
History
The veteran the veteran, while serving as a Corporal in the Australian Army, sustained multiple abrasions, including to the right clavicular region, on 22 July 1999. This injury occurred concurrently with a right clavicle fracture when he fell from a mountain bike.
Timeline
- 22 Jul 1999: The veteran was involved in a mountain bike accident. A medical certificate from a medical officer, at the regional hospital, dated 22 Jul 1999, notes he was suffering from a fracture of the right clavicle OR from information provided by the patient, Multiple abrasions. This indicates the abrasions were a significant injury noted at the time of the accident. He was also treated for a head injury sustained in the same incident.
- 23 Jul 1999: A medical certificate from S.the treating doctor reiterated that the veteran was suffering from a fracture of the right clavicle and Multiple abrasions, rendering him unfit for work. This confirms the presence of abrasions as part of the injuries from the accident.
- 25 Jul 2000: A clinical note, while primarily discussing the past clavicle fracture, also mentions "Injured mountain bike injury R shoulder, laceration & ribs". While "laceration" is used here instead of "abrasion," it refers to a break in the skin in the same region and from the same incident, and it's common for such terms to be used somewhat interchangeably in initial descriptions of multiple superficial injuries or for abrasions to be deep enough to resemble superficial lacerations.
Symptoms
At the time of the injury on 22 Jul 1999, the veteran would have experienced pain, bleeding, and rawness at the sites of the abrasions, including the right clavicular area. Abrasions involve the scraping away of the superficial layers of the skin. Depending on the depth and extent, they can be quite painful and prone to infection if not kept clean. The medical certificate specifically lists Multiple abrasions as one of the conditions he was suffering from. Subsequent entries focus more on the management of the clavicle fracture, and specific ongoing symptoms related solely to the abrasions are not detailed, implying they likely healed uneventfully within the expected timeframe for superficial injuries.
Imaging
No specific imaging would typically be performed for abrasions themselves. The X-ray performed on 22 Jul 1999 was for the suspected clavicle fracture.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis of the condition is Abrasion of the Right Clavicular Region (as part of multiple abrasions).
The DVA SOP that applies is the Statement of Principles concerning Cut, Stab, Abrasion and Laceration (No. 37 of 2025 for Reasonable Hypothesis and No. 38 of 2025 for Balance of Probabilities).
The ICD-10 code for an abrasion of the right upper arm (which would include the clavicular region if not more specifically coded under shoulder) is S40.811A (Abrasion of right upper arm, initial encounter). Given "multiple abrasions" were noted, and one was in the clavicular region, this is an appropriate classification.
An abrasion is an injury that interrupts the continuity of the epidermis or other external or exposed tissue, causing a wound. It may or may not penetrate to the subcutaneous tissues and underlying structures. The SOP definition includes friction burns. It excludes wounds caused by burns other than friction burns, dental abrasion, explosive devices, gunshots, missiles, or traumatic contusions/haematomas. Abrasions are typically caused by friction when the skin rubs or scrapes against a rough or hard surface.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
The veteran first experienced symptoms (pain, broken skin) attributable to the right clavicle abrasion immediately following his fall from a mountain bike on 22 Jul 1999. (Unit Medical Record, page 10)
When did the veteran first present to a health / medical provider for this condition?
The veteran first presented to a health/medical provider for this condition (as part of multiple injuries) on 22 Jul 1999 at the regional hospital, where he was attended to by a medical officer. (Unit Medical Record, page 10)
When was the condition confirmed / formally diagnosed?
The presence of Multiple abrasions was confirmed/formally diagnosed on 22 Jul 1999 by a medical officer, at the regional hospital, as documented on the medical certificate issued on that day. (Unit Medical Record, page 10)
When did the veteran first present to you (or your practice) for this condition?
19 June 2021.
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions? Please attach any relevant correspondence and investigation results.
The diagnosis of abrasion of the right clavicular region (as part of multiple abrasions) was confirmed by:
- Key symptoms and signs: Following the fall from a mountain bike, the veteran would have had visible scraping of the skin over the right clavicle, associated with pain, and possible minor bleeding. The medical certificate from 22 Jul 1999 explicitly lists Multiple abrasions as a condition from which he was suffering. (Unit Medical Record, page 10)
- Clinical Examination: The diagnosis of an abrasion is typically made by visual inspection of the affected skin by a medical professional.
- Investigation results: No specific investigations are usually required for abrasions unless complications like infection are suspected. None are noted in relation to the abrasion itself.
- Specialist opinions: No specialist opinion is typically required for simple abrasions. The diagnosis was made by the attending medical officer in the emergency department.
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.
The cause of the veteran right clavicle abrasion was direct physical trauma. The onset of the abrasion was 22 July 1999, which is before 29 February 2001. Therefore, this claim falls under the provisions of the Safety, Rehabilitation and Compensation (Defence-related Claims) Act 1987 (DRCA). Under DRCA, the primary consideration is whether the injury arose out of, or in the course of, his employment with the ADF. As noted for the concurrent clavicle fracture, if the mountain biking activity was sanctioned or encouraged as part of maintaining fitness for service, or occurred in a context linked to his employment, the injury could be considered service-related. We will analyze against the SOP factors for completeness.
The relevant Statement of Principles is the Statement of Principles concerning Cut, Stab, Abrasion and Laceration (No. 37 of 2025 - RH and No. 38 of 2025 - BoP). The key factor for the clinical onset of an abrasion is:
Factor 9(1) (RH) / 9(1) (BoP): having direct physical trauma to the affected site at the time of the cut, stab, abrasion or laceration;
- Status: MET
- the veteran sustained Multiple abrasions when he Fell off cycle 22/09/01. This fall would have involved direct physical trauma (friction/scraping) to the skin over his right clavicle and other areas. (Unit Medical Record, page 10, page 72)
Sequelae
Superficial abrasions typically heal without significant long-term sequelae, although there can sometimes be minor scarring or pigment changes depending on the depth and healing process. The provided records do not detail any specific chronic sequelae from the abrasions sustained on 22 Jul 1999.
Unintended Consequence
There is no indication in the provided medical records that the veteran right clavicle abrasion was an unintended consequence of medical treatment paid for by the Commonwealth. The abrasion was the result of a traumatic accident.
Inability to Attain Appropriate Medical Management
Following the injury on 22 July 1999, the veteran received medical attention at the regional hospital for his multiple injuries, including the abrasions. Standard wound care for abrasions (cleaning, dressing if necessary) would have been part of this acute management. There is no evidence to suggest an inability to obtain appropriate clinical management for the abrasions that led to a permanent worsening. The Full Federal Court in Brew v Repatriation Commission (09 May 1996) is noted, but no objective or subjective barriers to obtaining care for the abrasions are apparent from the records.
The % contribution of the causes is 100% and significant.
5. Please provide a Health Summary and a medication / prescribing history.
-see attached report
