Diagnostic Assessment — Right Ribs - Fracture
Example 1 of 1 · fictitious patient (Veteran AT)
Diagnostic Assessment
Right Ribs - Fracture
BOP Code: 63 of 2024 (Fracture)
RH Code: 62 of 2024 (Fracture)
ADF History
Veteran AT, date of birth 21 October 1968, Australian Army, Communications and Information Systems Operator (Signaller), later Warrant Officer Class Two, enlisted 13 January 1986, medically discharged 09 June 2011. Operational service: East Timor, 20 September 1999 to 23 February 2000 (warlike); Afghanistan, 10 January 2009 to 30 January 2010 (warlike).
Occupational History
As a signaller the veteran carried a manpack radio and batteries weighing 15 to 18 kilograms on top of body armour and fighting equipment, usually slung from the shoulder, on foot patrols and in vehicles for long periods. He travelled frequently in armoured vehicles over rough ground and was exposed to vehicle accidents, rollovers and blast.
Senior signallers also managed communications in headquarters for 12 to 16 hours a day, often in covered command posts and vehicles with little exposure to sunlight, and shift work disrupted meals and sleep. Signallers are prone to shoulder, neck and chest wall overuse injuries from asymmetric load carriage, and to blunt chest trauma in vehicle incidents. Deployed headquarters staff worked long hours with limited access to follow-up imaging and specialist orthopaedic care.
History
Veteran AT, a signaller and later warrant officer in the Australian Army, sustained fractures of the right first, sixth, seventh and eighth ribs on 04 June 2009 when his vehicle rolled over on warlike service in Afghanistan; the first rib fracture ran through a pre-existing fatigue stress fracture caused by months of carrying a heavy radio on the right shoulder. The first and seventh rib fractures progressed to non-union by December 2009, while he continued to smoke and had diabetes, osteoporosis, vitamin D deficiency and severe obesity.
Timeline
- 18 Sep 2008 — The veteran dislocated his left shoulder on a pre-deployment exercise. A medical officer advised him not to load the left shoulder, and from then on he carried his 18 kg manpack radio slung only over the right shoulder. He smoked about 20 cigarettes a day and had type 2 diabetes, diagnosed in 2006, treated with metformin. Weight 118 kg, height 1.78 m, BMI 37.2. "L shoulder dislocation, offload L"
- 10 Jan 2009 — He deployed to Afghanistan as a headquarters signaller attached to a reconstruction task force. He carried the manpack radio over the right shoulder on foot patrols and in vehicles four to six days a week, typically six to eight hours a day. In April 2009 he reported an ache at the base of the right neck after patrols, recorded as muscular. "radio carried R shoulder only"
- 04 Jun 2009 — His armoured vehicle rolled over on a steep track and he was thrown against the inside of the hull on his right side. At the role 3 hospital he had right chest wall pain and crepitus. CT showed a displaced fracture of the right first rib through a fatigue stress fracture with sclerotic margins and periosteal new bone, and acute fractures of the right sixth, seventh and eighth ribs, with a small haemothorax. "R ribs 1, 6-8 fractured"
- 22 Jun 2009 — After eight days of ward care and analgesia he returned to duties in Afghanistan. The medical officer advised rest from load carriage, smoking cessation and follow-up imaging at six weeks, but no repeat imaging or physiotherapy was available at his location and the operational tempo required him to resume carrying the radio in July 2009. He continued to smoke about 20 cigarettes a day. "return to duty, review six weeks"
- 15 Dec 2009 — He presented with persisting right chest wall pain, a painful click on deep breathing and pain radiating to the right shoulder and neck. X-ray at the role 2 facility showed no bridging callus at the first and seventh rib fractures. Fasting glucose was 11.2 mmol/L and HbA1c 8.9 per cent. Weight 128 kg, BMI 40.4. "painful click, no bridging callus"
- 22 Feb 2010 — After return to Australia, CT of the chest confirmed established non-union of the right first and seventh rib fractures with rounded sclerotic margins, and united sixth and eighth rib fractures. Serum 25-hydroxyvitamin D was 31 nmol/L. DEXA on 01 Mar 2010 showed osteoporosis (lumbar spine T-score minus 2.8) with low testosterone, and coeliac disease was later diagnosed. "non-union R ribs 1 and 7"
- 10 Aug 2010 — A thoracic surgeon performed open reduction and plate fixation of the seventh rib non-union with bone graft and resection of the first rib pseudarthrosis, which was compressing the brachial plexus. Recovery was prolonged and he was medically discharged on 09 Jun 2011 with chronic chest wall pain. "rib plating, first rib resection"
Symptoms
At onset the veteran had severe right chest wall pain worse on breathing, coughing and movement, with crepitus over the lower right ribs and pain at the base of the right neck. After onset the pain eased only partly, and from December 2009 he had a painful click on deep breathing, pain radiating to the shoulder and neck and tingling in the right hand.
Between December 2009 and his surgery in August 2010 he could not carry a radio or body armour, run or lift more than 10 kilograms, and he was placed on restricted duties. He now reports chronic right chest wall pain, pain on lifting and carrying, reduced exercise tolerance and difficulty lying on his right side.
Imaging
- 04 Jun 2009 — CT chest (role 3 hospital, Afghanistan): "Displaced fracture of the right first rib through a fatigue-type stress fracture with sclerotic margins and periosteal new bone. Acute fractures of the right sixth, seventh and eighth ribs posterolaterally. Small right haemothorax."
- 15 Dec 2009 — X-ray chest and ribs (role 2 facility, Afghanistan): "No bridging callus across the right first and seventh rib fractures. Healing sixth and eighth rib fractures."
- 22 Feb 2010 — CT chest: "Established non-union of the right first and seventh rib fractures with rounded sclerotic margins and pseudarthrosis. United sixth and eighth rib fractures."
- 01 Mar 2010 — DEXA bone densitometry: "Lumbar spine T-score minus 2.8 and femoral neck T-score minus 2.6, consistent with osteoporosis."
Onset Date
The most likely date of onset of this condition is 04 Jun 2009.
At that date the veteran was on warlike service in Afghanistan as a headquarters signaller, carrying a manpack radio over the right shoulder on patrols and in vehicles. His armoured vehicle rolled over that day and he was thrown against the hull on his right side.
This date is appropriate because the fractures were caused by the rollover and confirmed on CT the same day. His pre-deployment medical examination of 20 Nov 2008 recorded no chest wall symptoms, and the neck ache of April 2009 was not associated with any loss of function. It falls within continuous full-time service.
For the significant physical force factor, the force was applied at the time of the rollover on 04 Jun 2009. For the stress fracture factors, the repetitive loading of the right first rib ran from 18 Sep 2008, when he began carrying the radio only on the right shoulder, to the onset on 04 Jun 2009, and the abnormal direction of loading was present on that date.
For the worsening factors, the documented clinical worsening is non-union, first recorded on 15 Dec 2009 and confirmed on CT on 22 Feb 2010. Treatment of the fractures ran from 04 Jun 2009 to 15 Dec 2009, and he smoked about 20 cigarettes a day throughout that period. Diabetes, osteoporosis, vitamin D deficiency and a BMI over 40 were each present at the time of the non-union.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Fractures of the Right Ribs, first, sixth, seventh and eighth (ICD-10-AM S22.4), the first rib fracture occurring through a fatigue stress fracture, complicated by non-union of the first and seventh rib fractures, under the Statements of Principles concerning fracture, Balance of Probabilities No. 63 of 2024 and Reasonable Hypothesis No. 62 of 2024.
A fracture is an acquired break of bone from a force that would ordinarily break a healthy bone. A stress fracture of the fatigue type develops when repeated loading exceeds the bone's capacity to repair, and it can be completed by a single further force. Most rib fractures heal within six to twelve weeks; non-union is the failure of a fracture to unite and is a clinical worsening of the fracture. Smoking, diabetes, osteoporosis, vitamin D deficiency, severe obesity and continued loading of the fracture all impair healing.
The fractures followed months of asymmetric radio carriage on the right shoulder and a vehicle rollover on warlike service in Afghanistan on 04 June 2009. They were confirmed on CT that day and progressed to non-union by 15 December 2009.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
04 June 2009.
When did the veteran first present to a health / medical provider for this condition?
04 June 2009.
When was the condition confirmed / formally diagnosed?
04 June 2009.
When did the veteran first present to you (or your practice) for this condition?
26 August 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 CT of the chest on 04 June 2009, which showed a displaced fracture of the right first rib through a fatigue-type stress fracture with sclerotic margins and periosteal new bone, and acute fractures of the right sixth, seventh and eighth ribs. This meets the Statement of Principles definition of fracture, which includes stress fracture of the fatigue type.
Non-union was confirmed by the absence of bridging callus on X-ray on 15 December 2009 and by CT on 22 February 2010, which showed rounded sclerotic margins and pseudarthrosis at the first and seventh rib fractures, and by the operative findings on 10 August 2010.
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 04 June 2009, 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. The Reasonable Hypothesis instrument applies to the veteran's warlike service in Afghanistan from January 2009 to January 2010, where the fractures occurred and progressed to non-union.
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 04 June 2009 the veteran's armoured vehicle rolled over and he was thrown against the inside of the hull on his right side, applying significant physical force to the right chest wall. CT the same day showed fractures of the right first, sixth, seventh and eighth ribs at the points of impact and loading, with a small haemothorax. A rollover of a heavy armoured vehicle delivers a force well beyond that needed to break healthy ribs, and the pattern of four fractures on one side matches the direction of impact recorded in the incident report.
Factor 9(2): for stress fracture only, having significant repetitive loading stress to the affected bone prior to clinical onset; — MET
- CT on 04 June 2009 showed that the right first rib fracture ran through a fatigue-type stress fracture with sclerotic margins and periosteal new bone. Before onset the veteran had carried an 18 kg manpack radio over his right shoulder six to eight hours a day, four to six days a week, from September 2008, a significant repetitive loading stress transmitted through the strap to the right first rib, where the scalene muscles insert. The neck ache he reported after patrols in April 2009 was the early symptom of this bone stress. The first rib is a recognised site of fatigue stress fracture in soldiers carrying heavy shoulder-slung loads.
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
- After his left shoulder dislocation on 18 September 2008 he was medically advised not to load the left shoulder, and he carried the radio only on the right. This concentrated the full strap load on the right first rib in an abnormal direction and intensity, and the asymmetric loading was continuing at onset on 04 June 2009. This is the kind of changed force intensity and direction the instrument describes, comparable to an uncorrected limb length inequality in the lower limb.
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 20 cigarettes a day throughout the treatment of the fractures, from 04 June 2009 to the non-union recorded on 15 December 2009, despite medical advice to stop. Nicotine and carbon monoxide reduce blood flow and oxygen delivery to the healing bone and impair callus formation. Smoking cessation support was not available at his deployed location.
Factor 9(5): having diabetes mellitus at the time of the fracture non-union; — MET
- Type 2 diabetes, diagnosed in 2006, was poorly controlled at the time of the non-union, with a fasting glucose of 11.2 mmol/L and an HbA1c of 8.9 per cent on 15 December 2009. Hyperglycaemia impairs osteoblast function and the vascular supply of the fracture callus, and the poor control coincided with irregular meals and long shifts on deployment.
Factor 9(6): inability to obtain appropriate clinical management for fracture before clinical worsening. — MET
- On 22 June 2009 the medical officer advised rest from load carriage and follow-up imaging at six weeks, but no repeat imaging or physiotherapy was available at the veteran's location, and the operational tempo required him to resume carrying the radio in July 2009. The fractures were not reviewed for six months and 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
- The significant physical force was applied when the veteran's armoured vehicle rolled over on warlike service in Afghanistan on 04 June 2009 and he was thrown against the hull on his right side.
Factor 9(2): for stress fracture only, having significant repetitive loading stress to the affected bone prior to clinical onset; — MET
- The fatigue stress fracture of the right first rib resulted from carrying an 18 kg manpack radio over the right shoulder, including six to eight hours a day on patrols and in vehicles on warlike service in Afghanistan from 10 January 2009, before onset.
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
- On warlike service in Afghanistan the veteran carried the radio only on the right shoulder because of his left shoulder dislocation, an abnormal direction and intensity of loading on the right first rib that was present at onset on 04 June 2009.
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
- He smoked about 20 cigarettes a day while on warlike service in Afghanistan throughout the treatment of the fractures, from 04 June 2009 to the non-union on 15 December 2009.
Factor 9(5): having diabetes mellitus at the time of the fracture non-union; — MET
- Poorly controlled type 2 diabetes, with an HbA1c of 8.9 per cent on 15 December 2009, was present at the non-union on warlike service in Afghanistan. His diet and medication routine were disrupted by the deployed working pattern of long shifts and irregular meals.
Factor 9(6): having osteoporosis at the time of the fracture non-union; — MET
- DEXA on 01 March 2010 showed osteoporosis, with a lumbar spine T-score of minus 2.8, due to hypogonadism and coeliac disease. Osteoporosis is a slowly developing state, and it was present at the non-union in December 2009.
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-hydroxyvitamin D was 31 nmol/L on 22 February 2010, below 50 nmol/L, after a year of working in covered headquarters and vehicles in Afghanistan with coeliac malabsorption. The deficiency was present at the time of the non-union.
Factor 9(8): having a Body Mass Index (BMI) of 40 or greater at the time of the fracture non-union; — MET
- The veteran weighed 128 kg at a height of 1.78 m on 15 December 2009, a BMI of 40.4, at the non-union on warlike service in Afghanistan. He had gained 10 kg since the fractures, when pain stopped him exercising and the deployed diet was high in energy. Severe obesity increases the mechanical load on the healing chest wall with every breath and is associated with impaired fracture healing.
Factor 9(9): inability to obtain appropriate clinical management for fracture before clinical worsening. — MET
- On warlike service in Afghanistan the veteran could not obtain the advised follow-up imaging, physiotherapy or rest from load carriage after his fractures, and he resumed carrying the radio in July 2009. The fractures progressed to non-union by 15 December 2009.
The % contribution of the causes is 100% and significant.
Sequelae
The right rib fractures are in part a sequela of the veteran's accepted left shoulder dislocation of September 2008, which forced him to carry his radio only on the right shoulder and produced the fatigue stress fracture of the right first rib. The non-union has itself caused chronic chest wall pain and brachial plexus irritation.
Unintended Consequence
Not applicable on the present evidence. The non-union followed the absence of follow-up care rather than any treatment provided.
Inability to Attain Appropriate Medical Management
MET. After the fractures of 04 June 2009 the medical officer advised rest from load carriage, smoking cessation support and follow-up imaging at six weeks, but on warlike service in Afghanistan none of this was available, and the operational tempo required the veteran to resume carrying an 18 kg radio in July 2009. The fractures were not imaged again until 15 December 2009, by which time the first and seventh rib fractures had failed to unite. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), operational constraints that prevent appropriate treatment amount to an inability to obtain appropriate clinical management.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 18 Sep 2008, Outpatient health record, Medical Officer, Garrison health centre
- 20 Nov 2008, Pre-deployment medical examination, Medical Officer
- 04 Jun 2009, Trauma admission and CT chest report, Role 3 hospital, Afghanistan
- 22 Jun 2009, Discharge summary and outpatient record, Medical Officer, Afghanistan
- 15 Dec 2009, Outpatient health record and X-ray report, Role 2 facility, Afghanistan
- 22 Feb 2010, CT chest report, Radiologist
- 01 Mar 2010, DEXA report and endocrinology consultation, Endocrinologist
- 10 Aug 2010, Operation report, Thoracic 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
