Right Index Finger - Crush Injury with Osteoarthritis — 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 Index Finger - Crush Injury with Osteoarthritis

Example 1 of 1 · fictitious patient (Veteran D)

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 Index Finger - Crush Injury with Osteoarthritis

Fracture SOP (Reasonable Hypothesis) No. 62 of 2024, Fracture SOP (Balance of Probabilities) No. 63 of 2024

ADF History

The veteran, Airfield Defence Guard, enlisted 29 July 1993, currently serving (employment status listed as "Active" with no termination date specified).

Occupational History

As an Airfield Defence Guard in the Royal Australian Air Force, the veteran duties involve providing security and ground defence for RAAF assets, personnel, and installations. This occupation is physically demanding and exposes personnel to various hazards including manual handling of heavy equipment, weapons, ammunition, and field gear. Physical stressors include lifting, carrying, and pack marching, often over uneven terrain and for extended durations. Duties may involve operation of vehicles and equipment with potential for crush injuries and other trauma to extremities.

History

The veteran an Airfield Defence Guard in the RAAF, sustained a crush injury to his right index finger in late January/early December 2019 while working on the fire section, when a tank crushed his finger. He initially did not seek medical attention as he believed it would resolve naturally.

Timeline

Late Jan/Early Dec 2019. The veteran sustained a crush injury to the base of his right index finger while on the fire section at work, when a tank belonging to another person crushed his finger. He reported soreness at the time but did not seek immediate medical help as he thought it would resolve. when a tank crushed his finger
22 Nov 2017. The veteran presented to sick parade reporting that his right index finger was weak and he was finding it difficult to open things like jars, approximately 7 weeks after the crush injury. He stated there was no pain on movement and no restriction of movement. On examination, the finger looked normal, was not red, hot, or swollen, and had a full range of motion. He was referred for X-ray and ultrasound to assess for potential ligamentous or small bony injury. weak and finding it difficult to open
26 Nov 2017. An ultrasound of the right index finger was performed. The report stated: "The metacarpophalangeal and interphalangeal joints of the index finger are unremarkable. No effusion. Collateral ligaments intact. The extensor and flexor tendons and pulleys are intact and unremarkable." The conclusion was "No acute injury identified." An X-ray of the right hand was also performed on this date. The report noted: "Mild degenerative change of the interphalangeal joint of the thumb. No other significant arthropathy identified. No fracture or dislocation." No acute injury identified
04 Dec 2018. An MRI of the Right Index Finger was performed. The findings included: "No acute bone marrow oedema or fracture. There is reduction in the joint space within the DIPJ of the right index finger which suggests early OA changes." The collateral ligaments, flexor and extensor tendons, and pulley mechanism appeared normal. The conclusion was "Very minor degeneration at the DIPJ." reduction in the joint space within the DIPJ

Symptoms

At the time of the injury, the veteran experienced soreness in his right index finger. He did not seek immediate medical attention as he believed the injury would resolve on its own. Approximately 7 weeks later, he reported persistent weakness in the right index finger and difficulty with functional activities such as opening jars. Notably, he experienced no pain on movement and no restriction of range of motion at that time.

Currently, the veteran continues to experience weakness in his right index finger affecting his grip strength. Despite the functional impairment, clinical examinations show a normal-appearing digit with full range of motion. Imaging studies have revealed early degenerative changes at the distal interphalangeal joint (DIPJ) without evidence of acute injury to soft tissues or ligamentous structures.

Imaging

26 Nov 2017: Ultrasound Right Index Finger: "The metacarpophalangeal and interphalangeal joints of the index finger are unremarkable. No effusion. Collateral ligaments intact. The extensor and flexor tendons and pulleys are intact and unremarkable." Conclusion: "No acute injury identified."

26 Nov 2017: X-ray Right Hand (clinical indication for right index finger): "Mild degenerative change of the interphalangeal joint of the thumb. No other significant arthropathy identified. No fracture or dislocation."

04 Dec 2018: MRI Right Index Finger: "No acute bone marrow oedema or fracture. There is reduction in the joint space within the DIPJ of the right index finger which suggests early OA changes." The collateral ligaments, flexor and extensor tendons, and pulley mechanism appeared normal. Conclusion: "Very minor degeneration at the DIPJ."

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

The formal diagnosis is Right Index Finger Crush Injury with secondary early Osteoarthritis of the Distal Interphalangeal Joint (DIPJ).

The applicable DVA SOP codes are:

Fracture SOP (Reasonable Hypothesis) No. 62 of 2024 (used by analogy for crush injury)
Fracture SOP (Balance of Probabilities) No. 63 of 2024 (used by analogy for crush injury)
ICD-10 codes: S67.8X1A (Crushing injury of other specified part of right wrist, hand and fingers, initial encounter) and M19.041 (Primary osteoarthritis, right hand)

A crush injury occurs when pressure is applied to part of the body, resulting in compression of tissues, blood vessels, and potentially underlying structures including bones. While no fracture was identified in this case, crush injuries can cause soft tissue damage, vascular compromise, and over time, degenerative changes to joints. The compression forces can damage articular cartilage leading to post-traumatic osteoarthritis.

In the veteran case, the crush injury occurred in late January/early December 2019, and subsequent imaging has revealed early osteoarthritic changes in the distal interphalangeal joint of the right index finger by February 2021. This temporal relationship suggests that the early osteoarthritis is a consequence of the initial crush injury, representing a post-traumatic degenerative process that has developed over the course of approximately 14 months.

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 attributable to this condition in late January/early December 2019, when he sustained the crush injury to his right index finger while working on the fire section. At that time, he experienced immediate soreness.

When did the veteran first present to a health / medical provider for this condition? The veteran first presented to a health provider on 22 November 2017, approximately 7 weeks after the initial injury, when he reported to sick parade with complaints of weakness in his right index finger and difficulty opening jars.

When was the condition confirmed / formally diagnosed? The condition was formally diagnosed as a result of the clinical presentation on 22 November 2017, supported by subsequent imaging. The MRI on 04 December 2018 provided confirmation of early osteoarthritic changes in the DIPJ of the right index finger, establishing the secondary diagnosis of osteoarthritis.

When did the veteran first present to you (or your practice) for this condition? 13 December 2017

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 right index finger crush injury with secondary early osteoarthritis was confirmed through a combination of clinical history, physical examination findings, and diagnostic imaging results:

Clinical History: The veteran provided a clear history of a crush injury to his right index finger in late January/early December 2019, when a tank crushed his finger while working on the fire section. He subsequently reported persistent weakness and functional difficulties approximately 7 weeks later.
Physical Examination: On examination at sick parade on 22 November 2017, the finger appeared normal with no redness, heat, or swelling. There was full range of motion. The key sign was functional weakness affecting grip strength, particularly when opening jars, despite normal appearance.
Diagnostic Imaging:
Ultrasound (26 November 2017): No acute injury identified, with intact collateral ligaments, tendons, and pulleys.
X-ray (26 November 2017): No fracture or dislocation identified.
MRI (04 December 2018): Revealed reduction in the joint space within the DIPJ of the right index finger suggestive of early osteoarthritic changes. No acute bone marrow edema or fracture was seen.

The diagnosis is supported by the temporal relationship between the traumatic event and the development of symptoms, the persistent functional deficit despite normal appearance, and the eventual demonstration of early degenerative changes on advanced imaging, consistent with post-traumatic osteoarthritis.

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.

having significant physical force applied to or through the affected bone at the time of clinical onset

MET. The veteran experienced a crush injury to his right index finger when a tank crushed his finger during his duties on the fire section in late January/early December 2019. This constitutes significant physical force applied to the affected digit.

for stress fracture only, having significant repetitive loading stress to the affected bone prior to clinical onset

NOT MET. This is not a stress fracture; it is a crush injury with subsequent development of early osteoarthritis.

for stress fracture only, having significant chronic repetitive loading stress to the affected bone due to abnormal force intensity or direction of application, at the time of clinical onset

NOT MET. This is not a stress fracture; it is a crush injury with subsequent development of early osteoarthritis.

smoking at least 5 cigarettes per day, or the equivalent thereof in other tobacco products, during treatment for fracture prior to fracture non-union

NOT MET. While this factor is listed for consideration, it only relates to fracture non-union. The veteran's medical records consistently indicate he has never smoked, and there is no fracture or fracture non-union in this case.

having diabetes mellitus at the time of the fracture non-union

NOT MET. There is no documentation of diabetes mellitus in the veteran medical records, and this case does not involve a fracture or fracture non-union.

inability to obtain appropriate clinical management for fracture before clinical worsening

MET. The veteran did not seek immediate medical attention for his crush injury, delaying presentation by approximately 7 weeks. During this period, the injury was not clinically managed, which may have contributed to the development of early osteoarthritic changes. According to the Full Federal Court in Brew v Repatriation Commission (14 May 1993), "inability" includes subjective barriers to seeking treatment. The veteran decision not to seek immediate care because he believed the injury would resolve constitutes such a barrier. This delay in obtaining appropriate clinical management likely allowed the initial soft tissue damage to progress without intervention, resulting in the early degenerative changes observed on later imaging.

Sequelae

The early osteoarthritis of the distal interphalangeal joint (DIPJ) of the veteran right index finger is considered a sequela of the initial crush injury. The traumatic compression of the joint structures likely caused damage to the articular cartilage and underlying bone, initiating a degenerative process that has manifested as early osteoarthritis. This temporal and causal relationship is supported by the absence of any documented pre-existing condition affecting this joint prior to the crush injury, and the development of degenerative changes within approximately 14 months of the initial trauma.

Unintended Consequence

This condition does not appear to be an unintended consequence of medical management, as the initial injury occurred during occupational duties rather than as a result of medical treatment.

Inability to Attain Appropriate Medical Management

There was an inability to attain appropriate medical management for this condition as evidenced by the 7-week delay between injury occurrence and first medical presentation. The veteran did not seek immediate medical attention for his crush injury as he believed it would resolve on its own. According to the Full Federal Court in Brew v Repatriation Commission (14 May 1993), "inability" can include subjective barriers that prevent a veteran from seeking treatment. In this case, the veteran belief that his injury would spontaneously resolve constituted such a barrier.

This delay in obtaining appropriate clinical assessment and management likely allowed the initial crush injury to progress without proper intervention, potentially leading to the early degenerative changes that were later observed. Timely intervention with appropriate rest, possibly immobilization, anti-inflammatory treatment, and structured rehabilitation might have reduced the long-term impact on the joint. Instead, continued use of the injured finger without medical guidance likely contributed to the development of early osteoarthritis.

The delay in diagnosis and management represents a significant factor in the permanent worsening of the condition, satisfying the requirements for inability to attain appropriate medical management as a causative factor.

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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