Diagnostic Assessment — Right Lower Leg - Tibial Fracture
Example 1 of 1 · fictitious patient (Veteran BU)
Diagnostic Assessment
Right Lower Leg - Tibial Fracture
BOP Code: 63 of 2024 (Fracture)
RH Code: 62 of 2024 (Fracture)
ADF History
Veteran BU, date of birth 03 November 1986, Australian Army, Infantry Soldier (Rifleman), enlisted 12 February 2005, medically discharged 09 September 2016. Operational service: Solomon Islands, 10 April 2006 to 25 August 2006 (non-warlike); Afghanistan, 18 March 2010 to 23 July 2010 (warlike; deployment ended by aeromedical evacuation after the fracture).
Occupational History
As a rifleman the veteran completed frequent route marches and foot patrols carrying loads of 35 to 45 kilograms, over rough ground, in heat and at night. Training included running, obstacle courses, jumping from vehicles and walls, and parachute descents, all of which place high repetitive and impact loads on the lower limbs.
Infantry soldiers have one of the highest rates of lower limb stress fractures and acute fractures in the ADF, from load carriage, falls and vehicle incidents. Deployed infantry are also exposed to blast, combat trauma and psychological injury, and smoking was common on deployment in the period.
History
Veteran BU, an infantry soldier in the Australian Army, fractured the shaft of the right tibia on 22 July 2010 during warlike service in Afghanistan, when he fell into an irrigation ditch on patrol and completed an anterior cortical fatigue stress fracture caused by heavy load carriage on a leg overloaded by a service-related leg length inequality. The fracture failed to unite, with non-union confirmed on 28 June 2011 while he was smoking heavily and had developed diabetes, osteoporosis, vitamin D deficiency and severe obesity.
Timeline
- 19 Nov 2007 — During a parachute training descent in Australia the veteran landed heavily and sustained a comminuted fracture of the left femoral shaft, treated with an intramedullary nail. The fracture united with 2.2 cm of shortening, confirmed on a CT scanogram on 14 August 2008. A shoe raise was recommended but not supplied, and he returned to full infantry duties in September 2008. "left femur united, 2.2 cm short"
- 28 Jun 2010 — On warlike service in Afghanistan the veteran reported three weeks of aching pain over the front of the right shin during and after patrols carrying about 42 kilograms. The Regimental Medical Officer recorded focal tenderness over the anterior mid-tibia and the uncorrected leg length difference, advised reduced patrolling and simple analgesia, and requested imaging, which was not available at the patrol base. "anterior shin pain, load carriage"
- 22 Jul 2010 — On a night foot patrol the veteran stepped off a bank and fell about 1.5 metres into an irrigation ditch, twisting and landing on his right leg under full load. He had immediate severe pain and could not bear weight. X-ray at the role 3 hospital showed a displaced transverse fracture of the mid-shaft of the right tibia through an anterior cortical stress fracture line with periosteal reaction, and an associated fibular fracture. An external fixator was applied. "displaced tibial shaft fracture, ex-fix"
- 27 Jul 2010 — After aeromedical evacuation the veteran underwent reamed intramedullary nailing of the right tibia, delayed by five days because of evacuation logistics and pin-site contamination. He was smoking 25 cigarettes a day, having increased on deployment. Controlled-release oxycodone was commenced for pain. "tibial IM nail, smoking 25/day"
- 15 Sep 2010 — A psychiatrist diagnosed posttraumatic stress disorder with psychotic features after the death of two section members in an improvised explosive device strike in May 2010. Olanzapine 20 mg daily was commenced. Weight 98 kg, height 1.78 m, BMI 30.9. "PTSD, olanzapine 20 mg"
- 04 Apr 2011 — Blood tests showed an HbA1c of 7.6 per cent, and type 2 diabetes mellitus was diagnosed, attributed to olanzapine-related weight gain, and metformin was started. Serum 25(OH)D was 34 nmol/L. Testosterone was low, attributed to long-term opioid treatment. A DXA scan on 12 May 2011 showed a femoral neck T-score of -2.6, consistent with osteoporosis. "diabetes, vitamin D 34, osteoporosis"
- 28 Jun 2011 — An orthopaedic surgeon confirmed non-union of the right tibial shaft fracture on CT, eleven months after injury, with persistent pain on weight-bearing. Weight 128 kg, BMI 40.4. He was still smoking 25 cigarettes a day. Dynamisation of the nail recommended in February 2011 had been delayed by four months on the surgical waiting list. "tibial non-union, BMI 40.4"
- 19 Sep 2011 — Exchange reamed nailing with autologous bone grafting was performed. The fracture united by May 2012, with residual anterior knee pain, ankle stiffness and a limp, and he was medically downgraded. "exchange nailing, bone graft"
Symptoms
Before onset the veteran had three weeks of aching anterior shin pain with load carriage. At onset he had sudden severe pain, deformity and inability to bear weight on the right leg after the fall. After the fracture failed to unite he had persisting pain on weight-bearing, needed crutches and could not run or march.
He now reports aching in the right shin and knee after walking more than a kilometre or standing for long periods, stiffness of the right ankle, a limp on uneven ground and pain at the nail entry site when kneeling. He cannot run or carry heavy loads and has given up football and bushwalking.
Imaging
- 14 Aug 2008 — CT scanogram lower limbs: "United left femoral shaft fracture with intramedullary nail. Left lower limb 2.2 cm shorter than right."
- 22 Jul 2010 — X-ray right tibia and fibula: "Displaced transverse fracture of the right tibial mid-shaft through a horizontal anterior cortical lucency with periosteal reaction, consistent with completion of a fatigue stress fracture. Associated mid-shaft fibular fracture."
- 12 May 2011 — DXA bone densitometry: "Femoral neck T-score -2.6, lumbar spine T-score -2.3. Osteoporosis."
- 28 Jun 2011 — CT right tibia: "Non-union of the tibial shaft fracture with a persisting fracture gap, sclerotic margins and no bridging bone across any cortex. Intramedullary nail intact."
- 14 May 2012 — X-ray right tibia: "United tibial shaft fracture after exchange nailing and bone graft."
Onset Date
The most likely date of onset of this condition is 22 Jul 2010.
At that date the veteran was on warlike service in Afghanistan with an infantry battalion, patrolling daily on foot with loads of about 42 kilograms. He had a 2.2 cm leg length inequality from his 2007 service femoral fracture, which overloaded the longer right leg, and he had three weeks of anterior shin pain from a developing stress fracture. On a night patrol he fell into an irrigation ditch and the tibia fractured completely.
This date is appropriate because his pre-deployment health assessment of 08 February 2010 recorded no lower limb symptoms, and he presented to the role 3 hospital on 22 July 2010, within two hours of the fall, when X-ray showed the fracture. It falls within uninterrupted full-time service and within the deployment.
For the repetitive loading factor, the period before onset relied on runs from the start of the deployment on 18 Mar 2010 to 22 Jul 2010, during which he patrolled on foot for four to eight hours on most days carrying about 42 kilograms. For the abnormal force direction factor, the 2.2 cm leg length inequality was present, uncorrected, on 22 Jul 2010. The force of the fall was applied on that date.
For the worsening factors, the period after onset runs from 22 Jul 2010 to the documented non-union on 28 Jun 2011. Throughout treatment from 22 Jul 2010 to 28 Jun 2011 he smoked about 25 cigarettes a day. Type 2 diabetes mellitus and vitamin D deficiency were diagnosed on 04 Apr 2011 and osteoporosis on 12 May 2011, and his BMI was 40.4 on 28 Jun 2011, so each was present at the time of the non-union. The inability to obtain appropriate clinical management occurred from 22 Jul 2010 to 27 Jul 2010, and again from February to June 2011, before the worsening.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Right Lower Leg - Tibial Fracture (ICD-10-AM S82.2), a displaced transverse fracture of the right tibial shaft completing an anterior cortical fatigue stress fracture, complicated by non-union, under the Statements of Principles concerning fracture, Balance of Probabilities No. 63 of 2024 and Reasonable Hypothesis No. 62 of 2024.
The tibia is the main weight-bearing bone of the lower leg. Repeated loading during marching and running with heavy loads causes microscopic damage that can outpace repair, producing a fatigue stress fracture. Stress fractures of the anterior cortex of the mid-tibia are high-risk because the bone there is under tension and has a poor blood supply, and they can complete with a fall or twist. Abnormal limb mechanics, such as a leg length inequality, concentrate load on one limb. Tibial shaft fractures are prone to non-union, which is made more likely by smoking, diabetes, osteoporosis, vitamin D deficiency, severe obesity and delayed definitive treatment.
The veteran's fracture began on 22 July 2010 on warlike service in Afghanistan, when a fall completed a stress fracture caused by heavy load carriage on a limb overloaded by a leg length inequality. It failed to unite and non-union was confirmed on 28 June 2011.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
22 July 2010.
When did the veteran first present to a health / medical provider for this condition?
22 July 2010.
When was the condition confirmed / formally diagnosed?
22 July 2010.
When did the veteran first present to you (or your practice) for this condition?
02 September 2025.
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was confirmed by X-ray at the role 3 hospital on 22 July 2010, which showed a displaced transverse fracture of the right tibial mid-shaft through a horizontal anterior cortical lucency with periosteal reaction, the appearance of a pre-existing fatigue stress fracture, together with a fibular fracture. This is an acquired break of bone from an applied force that would ordinarily break healthy bone and includes a stress fracture of the fatigue type, meeting the Statement of Principles definition of fracture. The bone was healthy at the time, so it is not a pathological or insufficiency fracture.
Non-union was confirmed by CT on 28 June 2011, eleven months after injury, with a persisting fracture gap, sclerotic margins and no bridging bone, and by an orthopaedic surgeon. Fracture non-union is a clinical worsening of the fracture under the Statements of Principles. The osteoporosis developed after the fracture, during opioid and immobility-related bone loss, and did not cause it.
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 22 July 2010, after 1 July 2004, during continuous full-time service. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim and the Statements of Principles apply. The Balance of Probabilities instrument applies to peacetime service, including the treatment period in Australia when the fracture failed to unite and the 2007 training injury that caused the leg length inequality. The Reasonable Hypothesis instrument applies to the veteran's warlike service in Afghanistan in 2010, where the stress fracture developed, the fracture occurred and the trauma underlying his posttraumatic stress disorder took place.
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 Fracture, No. 63 of 2024
Causative factors
Factor 9(1): having significant physical force applied to or through the affected bone at the time of clinical onset; — MET
- On 22 July 2010 the veteran fell about 1.5 metres into an irrigation ditch carrying about 42 kilograms, twisting and landing on his right leg. The combined body and load weight, falling from height with rotation, applied a significant force through the right tibia, which fractured completely, as shown on X-ray the same day.
Factor 9(2): for stress fracture only, having significant repetitive loading stress to the affected bone prior to clinical onset; — MET
- The fracture completed an anterior cortical fatigue stress fracture, shown by the horizontal lucency and periosteal reaction on X-ray. Before onset the veteran patrolled on foot for four to eight hours on most days from 18 March 2010, carrying about 42 kilograms, and had anterior shin pain recorded on 28 June 2010. His earlier training included route marches of up to 30 kilometres with loads of 35 kilograms.
Factor 9(3): 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; — MET
- The left femoral fracture from a parachute descent on 19 November 2007 united with 2.2 cm of shortening, confirmed on CT scanogram on 14 August 2008. The shoe raise recommended was never supplied, and the uncorrected substantial leg length inequality concentrated force on the longer right limb with every step. It was present at onset on 22 July 2010.
Worsening factors
Factor 9(4): smoking at least 5 cigarettes per day, or the equivalent thereof in other tobacco products, during treatment for fracture prior to fracture non-union; — MET
- The veteran smoked about 25 cigarettes a day throughout treatment of the fracture, from 22 July 2010 to the non-union on 28 June 2011, as recorded on admission on 27 July 2010 and at review on 28 June 2011. His smoking had increased from 10 a day during his deployment.
Factor 9(5): having diabetes mellitus at the time of the fracture non-union; — MET
- Type 2 diabetes mellitus was diagnosed on 04 April 2011, with an HbA1c of 7.6 per cent, caused by weight gain on olanzapine prescribed by Defence-funded psychiatrists for his service-related posttraumatic stress disorder. It was present on metformin at the non-union on 28 June 2011.
Factor 9(6): inability to obtain appropriate clinical management for fracture before clinical worsening. — MET
- In February 2011 the orthopaedic surgeon recommended dynamisation of the intramedullary nail for delayed union, but the procedure was delayed four months on the surgical waiting list, and by 28 June 2011 the fracture had progressed to non-union. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management before the clinical worsening.
Reasonable Hypothesis — Statement of Principles concerning Fracture, No. 62 of 2024
Causative factors
Factor 9(1): having significant physical force applied to or through the affected bone at the time of clinical onset; — MET
- On a night foot patrol on warlike service in Afghanistan on 22 July 2010 the veteran fell about 1.5 metres into an irrigation ditch under a load of about 42 kilograms, twisting and landing on his right leg, applying significant force through the tibia and causing a displaced shaft fracture.
Factor 9(2): for stress fracture only, having significant repetitive loading stress to the affected bone prior to clinical onset; — MET
- From 18 March 2010 on warlike service in Afghanistan the veteran conducted foot patrols of four to eight hours on most days carrying about 42 kilograms over rough ground. The resulting anterior tibial fatigue stress fracture produced shin pain recorded on 28 June 2010 and was visible on the X-ray of 22 July 2010.
Factor 9(3): 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; — MET
- The uncorrected 2.2 cm leg length inequality from his 2007 service femoral fracture overloaded the right tibia with every step during patrols on warlike service in Afghanistan, and it was present at onset on 22 July 2010.
Worsening factors
Factor 9(4): smoking at least 5 cigarettes per day, or the equivalent thereof in other tobacco products, during treatment for fracture prior to fracture non-union; — MET
- The veteran's smoking increased to about 25 cigarettes a day during his warlike service in Afghanistan, as a way of coping with combat stress and the deaths of section members, and continued at that level throughout treatment from 22 July 2010 to the non-union on 28 June 2011.
Factor 9(5): having diabetes mellitus at the time of the fracture non-union; — MET
- Type 2 diabetes mellitus, diagnosed on 04 April 2011, resulted from weight gain on olanzapine prescribed for posttraumatic stress disorder arising from the deaths of two section members in an improvised explosive device strike on warlike service in Afghanistan in May 2010. It was present at the non-union on 28 June 2011.
Factor 9(6): having osteoporosis at the time of the fracture non-union; — MET
- A DXA scan on 12 May 2011 showed a femoral neck T-score of -2.6, confirming osteoporosis, caused by opioid-induced hypogonadism from oxycodone prescribed for the fracture sustained on warlike service and by prolonged immobility. It was present at the non-union on 28 June 2011.
Factor 9(7): having vitamin D deficiency, with a serum 25(OH)D level of less than 50 nanomoles per litre at the time of the fracture non-union; — MET
- Serum 25(OH)D was 34 nmol/L on 04 April 2011 and 38 nmol/L on 28 June 2011, at the time of the non-union. The deficiency followed months of housebound recovery from the fracture sustained on warlike service in Afghanistan.
Factor 9(8): having a Body Mass Index (BMI) of 40 or greater at the time of the fracture non-union; — MET
- The veteran's weight rose from 98 kg in September 2010 to 128 kg on 28 June 2011, a BMI of 40.4 at a height of 1.78 m, at the time of the non-union. The weight gain was caused by olanzapine for his deployment-related posttraumatic stress disorder and by immobility from the fracture sustained on warlike service.
Factor 9(9): inability to obtain appropriate clinical management for fracture before clinical worsening. — MET
- After the fracture on warlike service on 22 July 2010, definitive intramedullary fixation was delayed for five days by evacuation logistics, with the fracture held in an external fixator and pin sites contaminated in the field. Dynamisation recommended in February 2011 was then delayed four months on a waiting list. The fracture progressed to non-union. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management before the clinical worsening.
The % contribution of the causes is 100% and significant.
Sequelae
The right tibial fracture is a sequela of the veteran's accepted left femoral fracture of 2007, which united with a 2.2 cm leg length inequality that overloaded the right tibia. The non-union is in turn a sequela of his accepted posttraumatic stress disorder, whose olanzapine treatment caused diabetes and severe obesity. Residual anterior knee pain and ankle stiffness are sequelae of the fracture and its treatment.
Unintended Consequence
Met. The non-union is in part an unintended consequence of treatment provided by the Commonwealth while the veteran was serving: olanzapine for his posttraumatic stress disorder, which caused weight gain to a BMI above 40 and type 2 diabetes, and long-term oxycodone, which caused hypogonadism and osteoporosis (section 6A of the DRCA and the equivalent provisions of the MRCA).
Inability to Attain Appropriate Medical Management
MET. After the fracture on warlike service in Afghanistan on 22 July 2010, definitive fixation was delayed for five days by evacuation logistics, and dynamisation of the nail recommended in February 2011 was delayed for four months on a surgical waiting list. The fracture progressed to an established non-union requiring exchange nailing and bone graft. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), operational and system constraints that delay recommended fracture care amount to an inability to obtain appropriate clinical management. The failure to supply the recommended shoe raise after the 2007 femoral fracture is also indicative of barriers to care.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 19 Nov 2007, Operation report, Orthopaedic surgeon
- 14 Aug 2008, CT scanogram report, Radiologist
- 08 Feb 2010, Pre-deployment health assessment, Medical Officer
- 28 Jun 2010, Deployed health record, Regimental Medical Officer, Afghanistan
- 22 Jul 2010, Emergency record and X-ray report, Role 3 hospital, Afghanistan
- 27 Jul 2010, Operation report, Orthopaedic surgeon
- 15 Sep 2010, Psychiatric assessment, Consultant psychiatrist
- 04 Apr 2011, General practice record and pathology, Medical Officer
- 12 May 2011, DXA bone densitometry report, Radiologist
- 28 Jun 2011, Specialist consultation and CT report, Orthopaedic surgeon
- 19 Sep 2011, Operation report, Orthopaedic surgeon
- Statement of Principles concerning Fracture (Balance of Probabilities) No. 63 of 2024, Repatriation Medical Authority
- Statement of Principles concerning Fracture (Reasonable Hypothesis) No. 62 of 2024, Repatriation Medical Authority
