Diagnostic Assessment — Right Hand - Metacarpal Injury/Strain
Example 1 of 1 · fictitious patient (Veteran N)
Diagnostic Assessment
Right Hand - Metacarpal Injury/Strain
Balance of Probabilities SOP: Sprain and Strain No. 28 of 2020 Reasonable Hypothesis SOP: Sprain and Strain No. 27 of 2020
ADF History
The veteran, Chef (Army Catering Force), 09 January 2009, 27 Mar 2016.
Occupational History
Military chefs are exposed to various occupational hazards including heavy lifting, equipment handling, and significant psychological stressors from military hierarchy and workplace demands. The combination of physical demands and psychological pressures in military environments can lead to acute stress reactions that manifest in physical self-harm behaviors, as well as direct occupational injuries from kitchen duties and training activities.
History
The veteran the veteran a Chef in the Australian Defence Force, sustained a right hand metacarpal injury in September 2013 when he punched a wall in frustration during an acute stress episode related to workplace harassment and excessive duty assignments as punishment.
Timeline
- September 2013 - the veteran punched a wall in frustration during an acute stress episode related to workplace pressures. He had been reprimanded by a sergeant for attending a medical appointment that had been changed without proper notification, and was being required to work an extra shift that night and over the weekend as punishment. Physical examination revealed tenderness over right 5th metacarpal head with no obvious deformity noted. X-ray was planned to exclude fracture of the 5th metacarpal bone following the wall-punching incident. He admitted it was "silly" to do but stated it was "better" than hitting a person and having resultant charges. This incident occurred during a documented period of acute stress reaction when he felt unable to cope with workplace pressures and was experiencing service-related mental health deterioration.
Symptoms
At the time of injury, the veteran experienced tenderness over the right 5th metacarpal head following the wall-punching incident, with no obvious deformity noted on examination. The injury occurred during an acute psychological crisis related to workplace harassment and excessive punitive duty assignments. From the current assessment, the veteran has potential long-term effects from this traumatic incident that was directly caused by service-related psychological stressors and workplace harassment.
Imaging
September 2013 - X-ray was planned to exclude fracture of the 5th metacarpal bone following the wall-punching incident, with physical examination revealing tenderness over right 5th metacarpal head.
1. What is the formal diagnosis of the condition claimed above?
Right Hand 5th Metacarpal Injury/Strain with query fracture. DVA SOP: Sprain and Strain No. 28 of 2020 (Balance of Probabilities). ICD-10 code: S62.3.
Metacarpal injury involves trauma to the long bones of the hand that connect the wrist to the fingers. The 5th metacarpal is commonly injured in "boxer's fractures" typically resulting from punching a hard object. The injury can range from soft tissue strain to complete fracture of the bone. Such injuries result from significant physical force applied to the hand, often in the context of striking a solid object with a closed fist.
The temporal relationship shows an acute traumatic injury in September 2013 that occurred as a direct consequence of service-related psychological stress and workplace harassment, representing a manifestation of underlying mental health conditions caused by military service stressors.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition? September 2013 during acute stress episode at work. [Chart Review - STEPHAN MACKENZIE.docx, Right Hand timeline]
When did the veteran first present to a health / medical provider for this condition? September 2013 to Military Medical Personnel for assessment following the wall-punching incident. [Chart Review - STEPHAN MACKENZIE.docx, Right Hand timeline]
When was the condition confirmed / formally diagnosed? September 2013 by Military Medical Personnel through physical examination revealing tenderness over right 5th metacarpal head, with X-ray planned to exclude fracture. [Chart Review - STEPHAN MACKENZIE.docx, Right Hand timeline]
When did the veteran first present to you (or your practice) for this condition? 12 Jun 2018
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 by Military Medical Personnel through physical examination revealing tenderness over right 5th metacarpal head with no obvious deformity noted following the wall-punching incident. X-ray imaging was planned to exclude fracture of the 5th metacarpal bone. The injury occurred during a documented acute stress episode related to workplace harassment and excessive punitive duty assignments. [Chart Review - STEPHAN MACKENZIE.docx, Right Hand timeline]
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.
Factor 9(2) - forceful stretching or high intensity use of a muscle or tendon at the time of the clinical onset of a strain to that muscle or tendon - MET
- The wall-punching incident involved forceful and high intensity use of the hand and metacarpal structures through the impact force generated when striking the wall with a closed fist during the acute stress episode.
This injury is directly causally related to military service through the documented workplace harassment and excessive punitive duty assignments that precipitated the acute psychological crisis. The veteran was being punished with extra shifts for attending a medical appointment that had been changed without proper notification, demonstrating the service-related psychological stressors that led to this manifestation of physical self-harm. As per the Full Federal Court in Brew v Repatriation Commission, psychological or emotional incapacity can make certain behaviors something the veteran could not avoid, and workplace sanctions created a reality where normal stress management was not possible.
Sequelae
This condition is a sequelae of service-related mental health conditions including anxiety disorder and major depressive disorder, manifesting as physical self-harm during acute stress reaction to workplace harassment.
Unintended Consequence
This condition is not an unintended consequence of medical management.
Inability to Attain Appropriate Medical Management
There is no evidence of inability to obtain appropriate clinical management for this specific injury. The condition was appropriately assessed with physical examination and imaging planned. However, the underlying mental health conditions that precipitated this incident may not have received adequate management at the time, contributing to the acute stress reaction. The factor is NOT MET for this specific injury.
The % contribution of the causes is 100% and significant.
5. Please provide a Health Summary and a medication / prescribing history.
-see attached report
