Right Elbow - Radial Collateral Ligament Injury with Ossification — DVA claim example (Diagnostic Assessment)

Example document — fictitious patient. Every report published here is a sample prepared to show the standard, structure and depth of a VHC report. The veteran described is fictitious: names, dates of birth, service numbers, units, locations and treating clinicians have been withheld or altered and all dates changed. It must not be relied upon as a record of any real claim.

Diagnostic Assessment — Right Elbow - Radial Collateral Ligament Injury with Ossification

Example 1 of 1 · fictitious patient (Veteran P)

Example document — fictitious patient. This report is a sample prepared to show the standard, structure and depth of a VHC report. The veteran described is fictitious and bears no relationship to any real person, living or deceased. Names, dates of birth, contact details, service numbers, units, locations and treating clinicians have been withheld or altered and all dates have been changed. It must not be relied upon as a record of any real claim.

Diagnostic Assessment

Right Elbow - Radial Collateral Ligament Injury with Ossification

SOP Codes for Balance of Probabilities: Sprain and Strain No. 28 of 2020 SOP Codes for Reasonable Hypothesis: Sprain and Strain No. 29 of 2020

ADF History

Name: The veteran, Date of Birth: [withheld] Occupation: Warehouse Operator, Enlistment date: 15/08/2012, Discharge date: 16/06/2015.

Occupational History

As a Warehouse Operator in the Australian Army, the veteran was exposed to activities involving lateral stress on the elbow joint through lifting, carrying, and manual handling of equipment, repetitive arm movements that stressed the lateral elbow structures, and activities that required elbow stability during forceful gripping and manipulation tasks.

History

The veteran a Warehouse Operator with the Australian Army, sustained a radial collateral ligament injury on 08 July 2011 during the same traumatic event that caused his elbow fractures, with subsequent development of ossification within the ligament structure during his military service due to ongoing occupational stresses and inadequate rehabilitation.

Timeline

08 Jul 2011 - Initial traumatic injury when arm became caught in rope causing hyperextension mechanism that damaged the radial collateral ligament. The CT imaging suggested "avulsion fracture from the radial side potentially his radial collateral ligament" indicating ligament involvement in the original trauma.
31 Jul 2011 - Orthopedic specialist Mr M. Sharland confirmed the "avulsion fracture from the radial side potentially his radial collateral ligament" establishing the relationship between the bony injury and ligament damage. The specialist noted the complex nature of the injury involving multiple structures including the lateral stabilizing ligament.
13 Jan 2013 - Physiotherapy assessment documented ongoing functional limitations and "persistant weakness and dull ache following use" suggesting incomplete healing and ongoing instability of the lateral elbow structures including the radial collateral ligament.
20 Dec 2021 - MRI imaging demonstrated "Evidence of previous radial collateral ligament injury with ossification" and "Evidence of previous radial collateral ligament injury with an associated ossicle". This confirmed chronic changes in the ligament with calcification representing the body's attempt to stabilize the damaged structure through ossification.

Symptoms

At the time of injury, the veteran experienced severe elbow pain, instability, and functional limitation. Following the injury, he developed ongoing lateral elbow pain, sense of elbow instability, and functional difficulties with activities requiring lateral elbow stability.

Currently, the veteran experiences chronic elbow discomfort, functional limitations with activities requiring elbow stability, and ongoing effects from the ligament injury with ossification that affects his elbow mechanics and function.

Imaging

18 Jul 2011 - Avulsion fracture involving the posterior base of capitellum/inferior margin of lateral epicondyle likely reflecting avulsion fracture possibly associated with the proximal attachment of radial collateral ligament.

20 Dec 2021 - Evidence of previous radial collateral ligament injury with ossification. Evidence of previous radial collateral ligament injury with an associated ossicle.

1. What is the formal diagnosis of the condition claimed above?

Radial Collateral Ligament Injury with Ossification - DVA SOP Code: Sprain and Strain No. 28 of 2020, ICD-10 Code: S53.21XA

The radial collateral ligament is the primary lateral stabilizer of the elbow joint, preventing excessive varus angulation and posterolateral rotation. Injury to this ligament can result from acute trauma or chronic stress. Ossification within the ligament represents heterotopic bone formation as a healing response to injury, creating a calcified or bony structure within the soft tissue. This can result in altered elbow mechanics, stiffness, and ongoing functional limitations.

2. For each diagnosis identified, please also provide the following dates:

When did the veteran first experience symptoms attributable to this condition? 08 July 2011 [IMAGING - OCR.pdf page 1, CHART REVIEW.docx page 67]

When did the veteran first present to a health / medical provider for this condition? 08 July 2011 to Royal the base city Hospital Emergency Department [IMAGING - OCR.pdf page 1, CHART REVIEW.docx page 67]

When was the condition confirmed / formally diagnosed? 20 December 2021 by MRI imaging and radiologist the treating doctor [IMAGING - OCR.pdf page 6]

When did the veteran first present to you (or your practice) for this condition? 14 January 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 was confirmed through MRI imaging on 20 December 2021 which demonstrated clear evidence of previous radial collateral ligament injury with associated ossification and ossicle formation [IMAGING - OCR.pdf page 6]. The original CT imaging in 2013 suggested the involvement of the radial collateral ligament attachment site with the avulsion fracture [IMAGING - OCR.pdf page 1]. Orthopedic specialist assessment confirmed the relationship between the fracture and ligament injury [CHART REVIEW.docx page 69].

Key symptoms included lateral elbow pain, instability, and functional limitations. Clinical signs showed altered elbow mechanics and ongoing dysfunction consistent with lateral ligament injury.

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.

Experiencing a significant physical force applied to or through the affected joint at the time of clinical onset of a sprain – MET (not related to service)

The hyperextension mechanism when the veteran' arm became caught in the rope created significant physical force through the elbow joint, exceeding the physiological tolerance of the radial collateral ligament and resulting in ligament injury.

Experiencing a significant physical force applied to or through the affected joint at the time of clinical worsening of a sprain - MET

Ongoing occupational activities during military service involving lifting, carrying, and manual handling created repetitive stress on the injured ligament, contributing to ongoing damage and the development of ossification as a healing response.

Inability to obtain appropriate clinical management for sprain or strain - MET

The ligament injury was not properly diagnosed or managed during service, as established by the precedent in Brew v Repatriation Commission. The lack of appropriate early intervention, specific ligament rehabilitation, and monitoring for complications constitutes inability to obtain appropriate clinical management. This resulted in permanent worsening with ossification and ongoing functional limitations.

Unintended Consequence

The condition does not represent an unintended consequence of medical management but rather a natural progression from inadequate treatment of the original ligament injury.

Inability to Attain Appropriate Medical Management

There was clear inability to attain appropriate medical management as established in Brew v Repatriation Commission. The ligament injury was not properly recognized or treated during service despite ongoing symptoms and functional limitations. The lack of specific ligament rehabilitation, absence of follow-up imaging to assess healing, and conservative management without addressing the underlying ligament instability constitutes barriers to healthcare. This inability resulted in permanent worsening with ossification formation and chronic functional limitations.

The % contribution of the causes is 100% and significant.

5. Please provide a Health Summary and a medication / prescribing history. -see attached report

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