Diagnostic Assessment — Right Hand - Strain
Example 1 of 1 · fictitious patient (Veteran C)
Diagnostic Assessment
Right Hand - Strain
Balance of Probabilities SOP: Sprain and Strain No. 28 of 2020 Reasonable Hypothesis SOP: Sprain and Strain No. 29 of 2020
ADF History
The veteran, Communications and Information Systems Controller, enlisted 28 July 1986, discharged 22 Mar 2003.
Occupational History
As a Communications and Information Systems Controller (CISCON), the veteran was exposed to repetitive hand and wrist movements from equipment handling, keyboard use, and manual manipulation of communication devices. The role involved physical training activities, equipment setup, and manual handling tasks that placed stress on the hands and surrounding musculature. Additionally, workplace activities included handling heavy equipment and manual tasks that could result in acute or repetitive strain injuries.
History
The veteran the veteran a CISCON in the RAAF, sustained a right hand strain initially in December 1989 from striking a wall, with subsequent aggravation from a workplace crush injury to the index finger between a cabinet.
Timeline
- 22 November 1986: The veteran sustained initial right hand injury after striking a wall, resulting in immediate pain and tenderness over multiple areas of the right hand including the snuff box, lateral radial area, and metacarpophalangeal region. The forceful impact caused acute strain to the hand muscles and tendons, preceding the later identification of associated fractures. The mechanism involved high-intensity use of hand musculature during the traumatic impact.
- 25 November 1986: Clinical assessment revealed ongoing pain and functional limitation consistent with acute hand strain, with X-ray imaging subsequently identifying associated fractures. The strain represented the acute soft tissue component of the injury, involving muscles and tendons of the hand that were forcefully stretched during the wall-striking incident.
- 28 November 1986: Orthopedic review noted minimal tenderness with recommendations for conservative management, addressing both the fractures and associated soft tissue strain. The specialist advised activity modification while encouraging normal hand use, indicating recognition of the soft tissue component requiring healing time.
- 19 January 2016: The veteran reported ongoing right hand pain following a crushed between cabinet workplace injury to the index finger, representing a subsequent strain injury superimposed on the previous trauma. The crush injury caused additional soft tissue damage and ongoing pain with limited range of motion, indicating persistent strain effects.
Symptoms
Initially, the veteran experienced acute pain, tenderness, and functional limitation of the right hand following the wall-striking incident. The strain symptoms included muscle pain, stiffness, and reduced grip strength. Following the subsequent workplace crush injury, he experienced persistent pain in the index finger region with limited range of motion and ongoing functional impairment. Current symptoms include chronic pain affecting hand function and grip strength, with particular limitation in activities requiring fine motor control.
Imaging
- 25 November 1986: X-ray examination identified fractures but the underlying strain was a clinical diagnosis based on mechanism of injury and soft tissue symptoms
- 19 January 2016: MRI revealed cortical thickening of the second metacarpal related to the workplace crush injury, with associated soft tissue changes consistent with chronic strain effects
1. What is the formal diagnosis of the condition claimed above?
Right Hand - Strain (S69.9) DVA SOP: Sprain and Strain No. 28 of 2020 (Balance of Probabilities), Sprain and Strain No. 29 of 2020 (Reasonable Hypothesis) ICD-10 Code: S69.9
A strain is an injury involving the tearing or stretching of a muscle or tendon, associated with the onset of pain and tenderness at that site within 24 hours following the injury. Hand strains commonly result from forceful gripping, impact injuries, or overuse activities that stretch or tear the intrinsic muscles and tendons of the hand. These injuries can range from mild muscle fiber stretching to complete tears, and may involve multiple muscle groups depending on the mechanism of injury. Chronic strain effects can result in persistent pain, stiffness, and functional limitation.
The temporal relationship between the diagnoses shows an initial acute traumatic event in 1993 causing simultaneous strain and fractures, followed by a subsequent workplace injury causing additional strain and ossified hematoma formation in the second metacarpal.
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 strain symptoms on 22 November 1986 when he struck a wall, causing immediate pain and tenderness in the right hand. [MR. ALAN NICHOLLS FRACS FAORTHA, UMR - 200 - 400.pdf, Page 24]
When did the veteran first present to a health / medical provider for this condition? The veteran first presented for medical assessment on 22 November 1986 following the injury, with clinical evaluation documenting the acute hand strain symptoms. [MR. ALAN NICHOLLS FRACS FAORTHA, UMR - 200 - 400.pdf, Page 24]
When was the condition confirmed / formally diagnosed? The strain was clinically diagnosed on 22 November 1986 based on the mechanism of injury and immediate onset of pain and tenderness following the traumatic impact. [MR. ALAN NICHOLLS FRACS FAORTHA, UMR - 200 - 400.pdf, Page 24]
When did the veteran first present to you (or your practice) for this condition? 31 July 2015.
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 strain diagnosis was confirmed through clinical assessment based on the mechanism of injury and immediate onset of symptoms. Key symptoms included immediate pain and tenderness over multiple areas of the right hand following forceful impact against a wall. Clinical examination on 22 November 1986 revealed tenderness over the snuff box, lateral radial area, and metacarpophalangeal region. The diagnosis was supported by the typical presentation of acute strain following high-intensity muscle use during trauma. Subsequent workplace crush injury in 2022 caused additional strain effects confirmed by clinical symptoms and MRI findings showing chronic changes. [MR. ALAN NICHOLLS FRACS FAORTHA, UMR - 200 - 400.pdf, Page 24] [IMAGING.pdf, Pages 4, 5]
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.
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 - This factor requires forceful stretching or high intensity use of hand muscles or tendons causing the strain.
- MET: The veteran struck a wall with his fist on 22 November 1986, involving forceful and high-intensity use of the hand muscles and tendons. This mechanism directly caused acute stretching and strain of the intrinsic hand musculature. The subsequent workplace crush injury also involved forceful compression of hand structures, causing additional strain.
Forceful stretching or high intensity use of a muscle or tendon at the time of the clinical worsening of a strain to that muscle or tendon - This factor addresses clinical worsening of existing strain.
- MET: The workplace crush injury between a cabinet represented a subsequent episode of forceful compression and stretching of hand muscles and tendons, causing clinical worsening of the pre-existing strain condition with development of chronic changes including ossified hematoma formation.
Inability to obtain appropriate clinical management for sprain or strain - This factor examines whether appropriate clinical management was available for the strain condition.
- MET: While initial acute management was provided in 1993, the chronic strain effects and subsequent workplace injury appear to have received delayed or inadequate management. The condition progressed to chronic changes including ossified hematoma formation, suggesting insufficient ongoing clinical management for the strain component of the injury. The gap between initial injury and comprehensive imaging assessment represents inability to obtain appropriate ongoing clinical management.
Sequelae
This condition represents both a primary traumatic injury from the 1993 incident and subsequent aggravation from workplace trauma. The ossified hematoma formation may be considered a sequelae of the chronic strain effects.
Unintended Consequence
The condition is not considered an unintended consequence of medical management, as it resulted from traumatic incidents rather than medical intervention.
Inability to Attain Appropriate Medical Management
While the veteran received initial assessment for the acute fractures in 1993, there appears to have been inadequate ongoing management of the soft tissue strain component. The condition progressed to chronic changes with development of ossified hematoma formation following the workplace injury, suggesting insufficient clinical management of the underlying strain condition. The significant time gap between the initial injury and comprehensive assessment of chronic changes represents an inability to obtain appropriate ongoing clinical management. As established in Brew v Repatriation Commission (19 July 1990), the inability encompasses circumstances where ongoing management of chronic conditions is not adequately provided. This has resulted in permanent worsening with development of structural changes and persistent functional limitation.
The % contribution of the causes is 100% and significant.
5. Please provide a Health Summary and a medication / prescribing history. -see attached report
