Right Elbow - Subluxation — DVA claim example

Diagnostic Assessment — Right Elbow - Subluxation

Example 1 of 1 · fictitious patient (Veteran AX)

Diagnostic Assessment

Right Elbow - Subluxation

BOP Code: 56 of 2019 (Dislocation of a Joint and Subluxation of a Joint)
RH Code: 55 of 2019 (Dislocation of a Joint and Subluxation of a Joint)

ADF History

Veteran AX, date of birth 03 November 1970, Australian Army, Logistics Officer, enlisted 15 January 1992, medically discharged 30 June 2011. Operational service: Iraq, 10 January 2006 to 08 May 2006 (warlike, returned early after injury); Middle East Area of Operations, 01 August 2009 to 19 September 2009 (warlike, returned early after injury).

Occupational History

As a logistics officer the veteran planned and accompanied road convoys, supervised the loading of stores and ammunition, and spent long periods in military vehicles on rough roads with whole-body vibration and the risk of rollover and blast. In deployed headquarters she worked long shifts and responded to indirect fire alarms by moving rapidly to hardened shelters over uneven ground, often at night.

Logistics and transport personnel have high rates of musculoskeletal injury from vehicle accidents, falls from vehicles and loading platforms, and manual handling of stores. Upper limb injury from falling onto an outstretched hand is common during rapid movement to shelters, and deployed medical facilities often lack orthopaedic and imaging capability at the point of injury.

History

Veteran AX, a logistics officer in the Australian Army, sustained a right radial head fracture, a left acetabular fracture and a right tibial plateau fracture in a vehicle rollover in Iraq in May 2006, later requiring left total hip and right total knee replacements. On 16 September 2009, on warlike service in the Middle East, she fell onto her outstretched right hand while running to a shelter during an indirect fire attack and sustained a posterolateral subluxation of the right elbow, which persisted and worsened when reduction and imaging were delayed.

Timeline

• 02 May 2006 — On warlike service in Iraq the veteran's protected vehicle rolled over on a convoy route. She sustained a comminuted fracture of the right radial head involving the articular surface, a left posterior wall acetabular fracture and a right lateral tibial plateau fracture. She underwent open reduction and internal fixation at a coalition role 3 hospital and was aeromedically evacuated to Australia on 08 May 2006. "R radial head fracture, rollover"
• 14 Aug 2007 — An orthopaedic surgeon performed a left total hip replacement through a posterior approach for post-traumatic osteoarthritis and collapse following the 2006 acetabular fracture. Her weight had increased from 72 kg in 2005 to 98 kg during more than a year of restricted mobility. She was counselled about hip dislocation precautions. "L THR, post-traumatic OA"
• 20 Mar 2008 — A right total knee replacement was performed for post-traumatic osteoarthritis after the 2006 tibial plateau fracture. Rehabilitation was slow and she remained on restricted duties in a headquarters role. Plain films of the lumbar spine for low back pain showed multilevel spondylosis, worst at L4-5. "R TKR, lumbar spondylosis L4-5"
• 11 Feb 2009 — Review by the orthopaedic surgeon recorded aching in the right elbow with loss of the last 15 degrees of extension. Radiographs showed post-traumatic osteoarthritis of the radiocapitellar joint with a malunited radial head and an osteophyte at the coronoid tip. The elbow was clinically stable. Weight 112 kg, height 1.65 m, BMI 41.1. She was granted a medical waiver to deploy to a headquarters position. "R elbow OA, stable, BMI 41.1"
• 22 Jul 2009 — At her pre-deployment medical the right elbow was stable with no history of giving way, clicking or displacement, and the pivot shift and posterolateral drawer tests were negative. The hip and knee replacements were functioning well. A urinary pregnancy test was negative. "R elbow stable, no instability"
• 16 Sep 2009 — On warlike service in the Middle East, during an indirect fire alarm at night, the veteran tripped on the step of a hardened shelter and fell heavily onto her outstretched right hand with the elbow extended and forearm supinated. She presented to the base medical officer with a deformed, painful right elbow held at 40 degrees of flexion. In the same fall her left total hip prosthesis dislocated posteriorly and her right total knee prosthesis dislocated with lateral displacement of the patella. No imaging or orthopaedic care was available at the base. "R elbow deformity after fall"
• 17 Sep 2009 — After a 26-hour delay awaiting aeromedical transport she reached a role 3 hospital, where radiographs showed posterolateral subluxation of the right elbow with partial loss of contact at the radiocapitellar and ulnohumeral joints and a small coronoid tip fracture fragment. A urinary pregnancy test was positive at about nine weeks' gestation. Closed reduction of the elbow, hip and knee was performed under general anaesthesia, and on emergence she had a right temporomandibular joint subluxation after direct laryngoscopy, which was reduced manually. "posterolateral subluxation, coronoid fragment"
• 02 Oct 2009 — After return to Australia, CT of the right elbow showed persisting posterolateral subluxation of the radial head on the capitellum, despite the earlier reduction, with the coronoid fragment and early heterotopic ossification. MRI showed a complete tear of the lateral ulnar collateral ligament. She now had a 35 degree loss of extension and pain at rest. A lateral ulnar collateral ligament reconstruction was performed on 12 October 2009. "persisting subluxation, LUCL torn"

Symptoms

At onset the veteran had sudden severe pain, visible deformity and inability to move the right elbow, with swelling over the lateral elbow and pain on any attempt to rotate the forearm. After the delayed reduction she continued to have a painful clunk on rotating the forearm and could not straighten the elbow.

Since October 2009 she has had a persistent loss of elbow extension, pain with lifting more than 2 kg, difficulty pushing up from a chair and weakness of grip on the right. She reports aching in cold weather and when typing for long periods.

Imaging

• 02 May 2006 — Radiographs right elbow, role 3 hospital: "Comminuted fracture of the radial head with displacement of the articular surface."
• 11 Feb 2009 — Radiographs right elbow: "Post-traumatic osteoarthritis of the radiocapitellar joint with a malunited radial head, joint space narrowing and an osteophyte at the coronoid tip. No subluxation."
• 17 Sep 2009 — Radiographs right elbow, role 3 hospital: "Posterolateral subluxation of the elbow with partial loss of contact at the radiocapitellar and ulnohumeral articulations. Small coronoid tip fracture fragment."
• 02 Oct 2009 — CT right elbow: "Persisting posterolateral subluxation of the radial head relative to the capitellum. Coronoid tip fragment. Early heterotopic ossification anterior to the joint."
• 02 Oct 2009 — MRI right elbow: "Complete tear of the lateral ulnar collateral ligament with oedema of the lateral joint capsule and common extensor origin."

Onset Date

The most likely date of onset of this condition is 16 Sep 2009.

At that date the veteran was on warlike service in the Middle East Area of Operations, working night shifts in a deployed headquarters. During an indirect fire alarm she ran to a hardened shelter, tripped on its step and fell onto her outstretched right hand, and presented to the base medical officer the same night with a deformed right elbow.

This date is appropriate because her pre-deployment medical of 22 July 2009 recorded a stable right elbow with no displacement or instability, and the subluxation was first recorded within hours of the fall on 16 September 2009 and confirmed on radiographs on 17 September 2009. It falls within her warlike service and within uninterrupted full-time service.

The trauma, ligament damage, coronoid fracture, osteoarthritis, obesity and lumbar spondylosis factors are each to be present at the time of onset, and each was present on 16 Sep 2009: the fall occurred that day, the coronoid fragment and the lateral ulnar collateral ligament tear arose in the fall, the radiocapitellar osteoarthritis was documented on 11 Feb 2009, her BMI was 41.1 on 11 Feb 2009 and remained above 40, and the lumbar spondylosis was documented on 20 Mar 2008. For the pregnancy factor, the six weeks before onset run from 05 Aug 2009 to 16 Sep 2009; she conceived shortly before deployment and was pregnant throughout that period, about nine weeks' gestation when the pregnancy was confirmed on 17 Sep 2009. The temporomandibular joint subluxation occurred on 17 Sep 2009 at direct laryngoscopy.

For the clinical management factor, the elbow remained subluxated for 26 hours until reduction on 17 Sep 2009, and the documented worsening followed on 02 Oct 2009, when CT confirmed persisting subluxation with heterotopic ossification and the loss of extension had increased from 15 degrees to 35 degrees.

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

The formal diagnosis is Right Elbow - Subluxation (ICD-10-AM S53.10), a posterolateral subluxation of the right elbow, under the Statements of Principles concerning dislocation of a joint and subluxation of a joint, Balance of Probabilities No. 56 of 2019 and Reasonable Hypothesis No. 55 of 2019.

Subluxation of a joint is an episode of displacement in which there is partial loss of contact between the articulating surfaces of the bones. At the elbow it usually follows a fall onto the outstretched hand, in which axial load, supination and valgus force rotate the forearm away from the humerus. The lateral ulnar collateral ligament is the primary restraint to posterolateral rotation and is torn first, followed by the capsule, and a small fracture of the coronoid tip is common. Pre-existing radial head malunion and osteoarthritis reduce the bony stability of the joint. Untreated or delayed reduction leads to stiffness, heterotopic ossification and persisting displacement.

The condition began on warlike service in the Middle East on 16 September 2009, was confirmed on radiographs on 17 September 2009, and worsened after the delayed reduction, as shown on CT on 02 October 2009.

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

When did the veteran first experience symptoms attributable to this condition?

16 September 2009.

When did the veteran first present to a health / medical provider for this condition?

16 September 2009.

When was the condition confirmed / formally diagnosed?

17 September 2009.

When did the veteran first present to you (or your practice) for this condition?

07 May 2025.

3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?

The diagnosis was confirmed on radiographs at a role 3 hospital on 17 September 2009, which showed posterolateral subluxation of the right elbow with partial loss of contact between the articulating surfaces of the radial head and capitellum and of the ulnohumeral joint, without complete loss of contact. This meets the Statement of Principles definition of subluxation of a joint. The veteran had a clear traumatic mechanism, immediate deformity, a fixed flexed posture and pain on forearm rotation.

The subluxation was not congenital, did not result from a prosthesis and was not recurrent displacement due to pre-existing instability: the elbow was documented as stable on 11 February 2009 and 22 July 2009. CT on 02 October 2009 confirmed persisting subluxation and MRI confirmed a complete lateral ulnar collateral ligament tear. An orthopaedic surgeon confirmed the diagnosis and reconstructed the ligament on 12 October 2009.

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 16 September 2009, after 1 July 2004, during warlike service in the Middle East Area of Operations. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim and the Statements of Principles apply. The Reasonable Hypothesis instrument applies to the veteran's warlike service in Iraq in 2006, where the vehicle rollover caused the radial head, acetabular and tibial plateau fractures, and in the Middle East in 2009, where the subluxation occurred. The Balance of Probabilities instrument applies to her peacetime service in Australia from 2006 to 2009, during which the joint replacements, the weight gain and the osteoarthritis developed.

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 Dislocation of a Joint and Subluxation of a Joint, No. 56 of 2019

Causative factors

Factor 9(1): having physical trauma to the affected joint at the time of the clinical onset of dislocation of a joint or subluxation of a joint; — MET

- On 16 September 2009 the veteran fell heavily onto her outstretched right hand while running to a hardened shelter during an indirect fire alarm, transmitting axial and rotational force directly to the right elbow. The subluxation occurred at the moment of the fall and the deformity was recorded by the base medical officer the same night. Movement to shelter on alarm was an ordered duty.

Factor 9(2): having damage to a soft tissue structure as specified at the time of the clinical onset of dislocation of a joint or subluxation of a joint; — MET

- MRI on 02 October 2009 showed a complete tear of the lateral ulnar collateral ligament with injury to the lateral joint capsule. The lateral ulnar collateral ligament and capsule are structures that contribute to stability of the elbow, and they were torn in the fall of 16 September 2009, at the time of onset.

Factor 9(3): having a fracture, avulsion or bony abnormality involving the articulating surfaces of the affected joint, at the time of the clinical onset of dislocation of a joint or subluxation of a joint; — MET

- At onset the veteran had a malunited radial head involving the articular surface from the fracture of 02 May 2006, documented on radiographs on 11 February 2009, and the fall of 16 September 2009 produced a coronoid tip fracture, shown on radiographs on 17 September 2009. Both involve the articulating surfaces of the right elbow and were present at onset.

Factor 9(4): having a disease process as specified affecting the normal structural or functional relationship between the articulating surfaces of the affected joint at the time of the clinical onset of dislocation of a joint or subluxation of a joint; — MET

- Post-traumatic osteoarthritis of the right radiocapitellar joint, with joint space narrowing and a coronoid osteophyte, was documented on 11 February 2009 and was present at onset on 16 September 2009. Osteoarthritis is a degenerative condition within the specified list, and it followed the radial head fracture sustained in the service vehicle rollover.

Factor 9(5): for dislocation of a temporomandibular joint or subluxation of a temporomandibular joint only, undertaking an activity or undergoing a medical procedure that involves wide opening of the mouth at the time of the clinical onset of dislocation of a joint or subluxation of a joint; — MET

- During the general anaesthetic for reduction of the service elbow injury on 17 September 2009 the veteran underwent direct laryngoscopy, which involves wide opening of the mouth, and the anaesthetist recorded a right temporomandibular joint subluxation on emergence, reduced manually. The subluxation arose from the Defence-provided procedure at the time of the laryngoscopy.

Factor 9(6): for dislocation of a tibiofemoral joint or subluxation of a tibiofemoral joint only, having morbid obesity at the time of the clinical onset of dislocation of a joint or subluxation of a joint; — MET

- In the same fall on 16 September 2009 the veteran's right total knee replacement dislocated at the tibiofemoral articulation, confirmed on radiographs at the role 3 hospital on 17 September 2009. Her BMI was 41.1 (112 kg at 1.65 m) on 11 February 2009 and was unchanged at onset, which is morbid obesity. The weight gain of 40 kg followed the prolonged immobility and restricted duties caused by her 2006 service injuries.

Factor 9(7)(a): for dislocation of a total hip joint prosthesis only: being obese at the time of the clinical onset of dislocation of a joint; — MET

- The fall of 16 September 2009 also caused a posterior dislocation of the veteran's left total hip prosthesis, implanted on 14 August 2007 for post-traumatic osteoarthritis after the service acetabular fracture. Her BMI was 41.1 at the time, well above the threshold of 30, and the obesity arose from the immobility caused by her service injuries.

Factor 9(7)(b): for dislocation of a total hip joint prosthesis only: having lumbar spondylosis, lumbar intervertebral disc prolapse, lumbar spondylolisthesis, lumbar spinal stenosis or lumbar spinal fusion at the time of the clinical onset of dislocation of a joint; — MET

- Multilevel lumbar spondylosis, worst at L4-5, was documented on radiographs on 20 March 2008 and was present when the left total hip prosthesis dislocated on 16 September 2009. The spondylosis followed years of whole-body vibration in military vehicles and the 2006 rollover, and the resulting stiffness of the lumbar spine alters pelvic tilt and increases the risk of prosthetic hip dislocation.

Worsening factors

Factor 9(8): inability to obtain appropriate clinical management for dislocation of a joint or subluxation of a joint. — MET

- No radiography or orthopaedic capability was available at the base and the elbow remained subluxated for 26 hours until aeromedical transfer and reduction on 17 September 2009. The prolonged displacement led to persisting subluxation, heterotopic ossification and an increase in the loss of extension from 15 to 35 degrees, confirmed on CT on 02 October 2009. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.

Reasonable Hypothesis — Statement of Principles concerning Dislocation of a Joint and Subluxation of a Joint, No. 55 of 2019

Causative factors

Factor 9(1): having physical trauma to the affected joint at the time of the clinical onset of dislocation of a joint or subluxation of a joint; — MET

- The fall onto the outstretched right hand occurred on warlike service in the Middle East Area of Operations on 16 September 2009, while the veteran was moving to a shelter during an indirect fire attack, and caused the subluxation at that moment.

Factor 9(2): having damage to a soft tissue structure as specified at the time of the clinical onset of dislocation of a joint or subluxation of a joint; — MET

- The complete tear of the lateral ulnar collateral ligament and the lateral capsular injury, confirmed on MRI on 02 October 2009, occurred in the fall on warlike service on 16 September 2009 and were present at onset.

Factor 9(3): having a fracture, avulsion or bony abnormality involving the articulating surfaces of the affected joint, at the time of the clinical onset of dislocation of a joint or subluxation of a joint; — MET

- The malunited radial head followed the articular fracture sustained in the vehicle rollover on warlike service in Iraq on 02 May 2006, and the coronoid tip fracture occurred in the fall on warlike service on 16 September 2009. Both were present at onset.

Factor 9(4): having a disease process as specified affecting the normal structural or functional relationship between the articulating surfaces of the affected joint at the time of the clinical onset of dislocation of a joint or subluxation of a joint; — MET

- Post-traumatic osteoarthritis of the right radiocapitellar joint developed after the radial head fracture sustained on warlike service in Iraq in 2006, was documented on 11 February 2009 and was present at onset on 16 September 2009.

Factor 9(5): being pregnant within the six weeks before the clinical onset of dislocation of a joint or subluxation of a joint; — MET

- A urinary pregnancy test at the role 3 hospital on 17 September 2009 was positive, with ultrasound dating the pregnancy at about nine weeks' gestation. The veteran conceived shortly before deploying and was pregnant, unaware, throughout the six weeks before onset, from 05 August 2009 to 16 September 2009, while on warlike service. The hormonal ligamentous laxity of early pregnancy reduced the restraint of the elbow ligaments.

Factor 9(6): for dislocation of a temporomandibular joint or subluxation of a temporomandibular joint only, undertaking an activity or undergoing a medical procedure that involves wide opening of the mouth at the time of the clinical onset of dislocation of a joint or subluxation of a joint; — MET

- Direct laryngoscopy for the general anaesthetic to reduce the elbow injury sustained on warlike service caused a right temporomandibular joint subluxation on 17 September 2009, recorded by the anaesthetist at the role 3 hospital.

Factor 9(7): for dislocation of a patellofemoral joint only, being obese at the time of the clinical onset of dislocation of a joint; — MET

- The fall on warlike service on 16 September 2009 dislocated the patellofemoral articulation of the veteran's right total knee replacement laterally, confirmed on radiographs on 17 September 2009. Her BMI was 41.1 at the time, following the weight gain that accompanied immobility after her 2006 Iraq injuries.

Factor 9(8): for dislocation of a tibiofemoral joint or subluxation of a tibiofemoral joint only, being severely obese at the time of the clinical onset of dislocation of a joint or subluxation of a joint; — MET

- The tibiofemoral articulation of the right knee replacement dislocated in the same fall on warlike service on 16 September 2009. Her BMI of 41.1 exceeded the threshold of 35 for severe obesity.

Factor 9(9)(a): for dislocation of a total hip joint prosthesis only: being obese at the time of the clinical onset of dislocation of a joint; — MET

- The left total hip prosthesis, implanted for osteoarthritis following the acetabular fracture sustained on warlike service in Iraq, dislocated in the fall on warlike service on 16 September 2009, when her BMI was 41.1.

Factor 9(9)(b): for dislocation of a total hip joint prosthesis only: having lumbar spondylosis, lumbar intervertebral disc prolapse, lumbar spondylolisthesis, lumbar spinal stenosis or lumbar spinal fusion at the time of the clinical onset of dislocation of a joint; — MET

- Lumbar spondylosis, documented on 20 March 2008 and contributed to by the 2006 vehicle rollover on warlike service, was present when the left hip prosthesis dislocated on 16 September 2009.

Factor 9(10): for dislocation of a total knee joint prosthesis only, having morbid obesity at the time of the clinical onset of dislocation of a joint; — MET

- The right total knee prosthesis, implanted on 20 March 2008 for osteoarthritis following the tibial plateau fracture sustained on warlike service in Iraq, dislocated in the fall on warlike service on 16 September 2009. Her BMI of 41.1 at that time is morbid obesity.

Worsening factors

Factor 9(11): inability to obtain appropriate clinical management for dislocation of a joint or subluxation of a joint. — MET

- On warlike service in the Middle East there was no imaging or orthopaedic care at the base, and the elbow remained subluxated for 26 hours awaiting aeromedical transport. The delay led to persisting subluxation, heterotopic ossification and a loss of extension that increased from 15 to 35 degrees, confirmed on CT on 02 October 2009.

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

Sequelae

The right elbow subluxation is a sequela of the veteran's accepted right radial head fracture from the 2006 vehicle rollover, through the resulting radial head malunion and post-traumatic osteoarthritis, and of the obesity that followed the prolonged immobility after her accepted acetabular and tibial plateau fractures. The elbow stiffness and heterotopic ossification are in turn sequelae of the subluxation.

Unintended Consequence

Met. The right temporomandibular joint subluxation is an unintended consequence of the direct laryngoscopy performed during the Defence-provided general anaesthetic for reduction of the elbow on 17 September 2009, and the left hip and right knee replacements that dislocated in the same fall were Defence-funded treatment of her service injuries (section 6A of the DRCA and the equivalent provisions of the MRCA).

Inability to Attain Appropriate Medical Management

MET. On warlike service in the Middle East on 16 September 2009 the base had no radiography, no orthopaedic surgeon and no capacity for reduction under anaesthesia, and the veteran waited 26 hours for aeromedical transport with her elbow subluxated. The prolonged displacement allowed haematoma and soft tissue contracture, and CT on 02 October 2009 showed persisting subluxation, heterotopic ossification and a loss of extension that had increased from 15 to 35 degrees. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), operational constraints that delay the reduction of a displaced joint amount to an inability to obtain appropriate clinical management.

5. Please provide a Health Summary and a medication / prescribing history.

See attached report.

References

1. 02 May 2006, Trauma admission and operation report, Role 3 hospital, Iraq
2. 14 Aug 2007, Operation report, left total hip replacement, Orthopaedic surgeon
3. 20 Mar 2008, Operation report, right total knee replacement, Orthopaedic surgeon
4. 20 Mar 2008, Radiographs lumbar spine, Radiologist
5. 11 Feb 2009, Orthopaedic review and radiographs right elbow, Orthopaedic surgeon
6. 22 Jul 2009, Pre-deployment medical, Medical Officer
7. 16 Sep 2009, Field medical record, Base Medical Officer, Middle East Area of Operations
8. 17 Sep 2009, Radiographs, anaesthetic record and operation note, Role 3 hospital
9. 02 Oct 2009, CT and MRI right elbow, Radiologist
10. 12 Oct 2009, Operation report, lateral ulnar collateral ligament reconstruction, Orthopaedic surgeon
11. Statement of Principles concerning Dislocation of a Joint and Subluxation of a Joint (Balance of Probabilities) No. 56 of 2019, Repatriation Medical Authority
12. Statement of Principles concerning Dislocation of a Joint and Subluxation of a Joint (Reasonable Hypothesis) No. 55 of 2019, Repatriation Medical Authority