Diagnostic Assessment — Right Thumb - Fracture
Example 1 of 1 · fictitious patient
Diagnostic Assessment Right Thumb — Fracture BOP Code: 63 of 2024 (Fracture) RH Code: 62 of 2024 (Fracture)
ADF History
The veteran, date of birth [withheld], served in the Royal Australian Navy as a Steward from 8 October 1986 to 24 July 1993
Occupational History
As a Steward, the veteran performed heavy manual handling duties including lifting steel cables and survey equipment.
These duties placed significant loading on the hands and thumbs
History
The veteran sustained an injury to the right thumb requiring bilateral thumb MCP joint arthrodesis performed by the treating doctor on 7 June 1989 during ADF service.
The underlying pathology was severe enough to necessitate excision of both MCP joints and tension band wire fixation.
Following a fall in the shower on 8 August 1989, the right thumb arthrodesis was torn apart with volar angulation.
In a letter dated 9 August 1989, the treating doctor that the thumb was quite tender over the MCP joint, that X-ray showed the arthrodesis displaced about 1 mm, and that he had placed it in a fibreglass thumb spica; on 6 September 1989 he reported to Navy medical staff that the right thumb had been refractured in the fall, and re-arthrodesis was planned; at operation on 13 September 1989, however, the right arthrodesis was found to have joined solidly with no movement, and the treating doctor the fixation from both thumbs and applied plaster for about a month.
The right thumb subsequently achieved solid ankylosis with no residual K-wire, confirmed on X-ray 20 August 2022, with mild IP joint degeneration
Timeline
07 Jun 1989 — Bilateral thumb MCP joint arthrodesis performed by the treating doctor at Calvary Private Hospital, a supply ship.
MCP joints excised and fixed with tension band wire technique.
The severity of the underlying right thumb pathology necessitated excision of the MCP joint, indicating significant structural damage consistent with a fracture or severe dislocation of the right thumb MCP joint. "Arthrodesis both thumb MCP joints" 11 Jul 1989 — Post-operative review.
Both thumbs reasonable.
X-ray confirmed fixation in place with union occurring slowly.
Light duties for another month. "Union occurring slowly" 08 Aug 1989 — Fall in shower at home.
Right thumb arthrodesis torn apart with volar angulation at the arthrodesis site.
Fixation remained intact.
The disruption of the arthrodesis represents a secondary fracture through the fusion site. "Right arthrodesis torn apart" 08 Aug 1989 — X-ray of both thumbs reported to the treating doctor by the treating doctor.H.
Lewis, radiologist, without previous films for comparison.
Fusion of both first metacarpophalangeal joints appeared to be progressing satisfactorily, with no evidence of a recent injury. "progressing satisfactorily following fusion" 09 Aug 1989 — Letter from the treating doctor to the treating doctor, copied to the Medical Officer, a supply ship.
The veteran had recently fallen in a shower at home, injuring his right thumb, and was clinically quite tender over the MCP joint.
X-ray showed the arthrodesis displaced about 1 mm, with the fixation still in place.
Placed in a fibreglass thumb spica for a month, with about 3 months expected before the fusion became really solid. "displaced the arthrodesis about 1 mm" 05 Sep 1989 — X-ray follow-up.
Right thumb fusion with clearly defined gap, union appearing slow.
Left thumb fusion well united.
The treating doctor no evidence of consolidation on the right and proposed re-arthrodesis. "Right thumb fusion with gap" 06 Sep 1989 — Record of telephone conversation between the treating doctor G.
Bayliss (DMS-N) regarding ABSR the veteran, a supply ship.
The right thumb had been refractured after a fall in a shower.
Arthrodesis of the right thumb was scheduled for the following week, with 6 weeks in a cast after the operation, light (clerical) duties after 2 weeks, fitness for sea likely at 2 2½ months and full fitness for heavy manual work at 3 months post-operatively. "refractured his (R) thumb" 13 Sep 1989 — Operation by the treating doctor at Calvary Hospital, a supply ship (admitted 10 14 September 1989).
The right arthrodesis was found to have joined solidly with no movement, so no re-arthrodesis was needed; the fixation was removed from both thumbs and plaster applied for about a month.
He was then held at 4 Camp Hospital, Townsville, 14 20 September 1989. "the arthrodesis had, in fact, joined solidly" September 1989 — Post-operative review; plasters and sutures removed.
Both arthrodeses assessed as "absolutely rock solid" clinically.
Fit to return to light duties. "Rock solid clinically" 20 Aug 2022 — X-ray bilateral thumbs.
Right thumb: solid MCP ankylosis, no residual K-wire, mild IP joint degeneration. "Solid ankylosis"
Symptoms
Following the fall in the shower in August 1989, the veteran was clinically quite tender over the right MCP joint.
He reported ongoing pain and suffering from the thumb operations, as documented in his 2000 letter requesting medical records.
The right thumb has achieved solid ankylosis with mild IP joint degeneration
Imaging
08 Aug 1989 — X-ray both thumbs (the treating doctor.H.
Lewis): "Fusion of both first metacarpo-phalangeal joints appears to be progressing satisfactorily following fusion.
There is no evidence of a recent injury." the treating doctor of 09 Aug 1989 reported that X-ray showed the right arthrodesis displaced about 1 mm.
05 Sep 1989 — X-ray right thumb: "Right thumb fusion with clearly defined gap, union appearing slow." 20 Aug 2022 — X-ray bilateral thumbs: "Right thumb: solid MCP ankylosis, no residual K-wire, mild IP joint degeneration."
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Right Thumb Fracture / MCP Joint Pathology requiring Arthrodesis (ICD-10: S62.501A).
The severity of the right thumb MCP joint pathology necessitated surgical excision and fusion during ADF service, and the subsequent post-operative fracture through the fusion site (August 1989) led to a further operation on 13 September 1989, at which the fusion was found solidly united and the fixation was removed
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition? Prior to 7 June 1989 (date of bilateral MCP arthrodesis) [ [CHART REVIEW document], pages 42, 132; [CHART REVIEW document], Page 23] When did the veteran first present to a health / medical provider for this condition? Prior to 7 June 1989 When was the condition confirmed / formally diagnosed? 7 June 1989 (arthrodesis performed, confirming severe MCP pathology) When did the veteran first present to you (or your practice) for this condition? 18 February 2018
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was confirmed by the treating doctor, orthopaedic surgeon, who performed the bilateral MCP arthrodesis on 7 June 1989.
The severity of the MCP joint pathology was sufficient to warrant excision of the joint and surgical fusion.
The post-operative disruption and the further operation were documented on clinical and radiological grounds [ [CHART REVIEW document], pages 42, 130 132, 140; [CHART REVIEW document], Pages 23, 27 29].
X-ray of both thumbs on 8 August 1989 was reported as showing the fusions progressing satisfactorily with no evidence of a recent injury [CHART REVIEW document]; however, the treating doctor of 9 August 1989 recorded that the right thumb was quite tender over the MCP joint, that X-ray showed the arthrodesis displaced about 1 mm, and that he had applied a fibreglass thumb spica [CHART REVIEW document].
On 6 September 1989 he reported that the right thumb had been refractured after the fall, with re-arthrodesis scheduled [ [CHART REVIEW document], Page 37]; at operation on 13 September 1989 the arthrodesis was found to have joined solidly and the fixation was removed [ [CHART REVIEW document], pages 128, 129]
4. What do you consider to be the cause(s) of the condition in this veteran?
Legislation: The clinical onset of this condition was before 5 January 2007 (see
Date of Clinical Onset
Below), and it did not arise on warlike or non-warlike deployment (the veteran had no deployments).
This is therefore a DRCA claim.
Statements of Principles do not apply to DRCA claims, so there are no binding SOP factors for this condition.
The factors of the relevant Statements of Principles are applied below by analogy, as a guide to the causes of this condition that are recognised in the medical-scientific literature, and every factor of both the Balance of Probabilities and the Reasonable Hypothesis instruments is addressed.
Under the DRCA the question is whether the injury or disease arose out of, or in the course of, the veteran's ADF service, or (for a disease or an aggravation) whether that service contributed to it to a significant degree.
Plausible links to service outside the SOP factors are set out below.
The absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.
Definition: The injury of about 8 August 1989 was a disruption, described as a refracture, through the incompletely united right thumb MCP arthrodesis held by tension band wiring; a fall in a shower might not have broken a healthy, unoperated thumb, but the SOP definition includes fracture of bone contiguous with an orthopaedic implant, and the factors are applied by analogy under the DRCA.
Causative Factors — Balance of Probabilities (Statement of Principles concerning Fracture, No.
63 of 2024) Factor 9(1): having significant physical force applied to or through the affected bone at the time of clinical onset — MET - On about 8 August 1989, during his service and while on light duties after the arthrodesis of 7 June 1989, the veteran fell in the shower at home and injured his right thumb.
The treating doctor of 9 August 1989 records tenderness over the MCP joint and X-ray displacement of the arthrodesis by about 1 mm, and his report of 5 September 1989 states that the fall had 'torn apart' the arthrodesis with volar angulation; the thumb was described on 6 September 1989 as 'refractured'.
Although the radiologist, without earlier films for comparison, reported no recent injury, the surgeon's findings establish significant physical force applied through the bones of the right first MCP fusion at the time of clinical onset.
Factor 9(2): for stress fracture only, having significant repetitive loading stress to the affected bone prior to clinical onset — NOT MET - This factor applies only to stress fracture; the veteran's right thumb fracture was an acute traumatic disruption of the healing arthrodesis in a fall on about 8 August 1989.
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 — NOT MET - This factor applies only to stress fracture; the right thumb fracture resulted from a single fall on about 8 August 1989, not from chronic repetitive loading stress.
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 — NOT MET - Fracture non-union did not occur: although the X-ray of 5 September 1989 showed a gap and a transfer summary recorded 'non union', at operation on 13 September 1989 the surgeon found the right arthrodesis 'had, in fact, joined solidly', so this factor does not arise, whatever his smoking at the time.
Factor 9(5): having diabetes mellitus at the time of the fracture non-union — NOT MET - Fracture non-union did not occur, the right arthrodesis being found solidly united at operation on 13 September 1989, and his diabetes mellitus was not diagnosed until 2023.
Causative Factors — Reasonable Hypothesis (Statement of Principles concerning Fracture, No.
62 of 2024) the veteran had no operational deployments.
The Reasonable Hypothesis standard applies only to operational service, so these factors are assessed for completeness and, like the Balance of Probabilities factors, by analogy only.
Factor 9(1): having significant physical force applied to or through the affected bone at the time of clinical onset — MET - On about 8 August 1989, while on light duties after the arthrodesis of 7 June 1989, the veteran fell in the shower at home and injured his right thumb.
His orthopaedic surgeon found tenderness over the MCP joint and X-ray displacement of the arthrodesis by about 1 mm, later describing it as 'torn apart' by the fall with volar angulation, and the thumb was recorded on 6 September 1989 as 'refractured'.
This establishes significant physical force applied through the bones of the right first MCP fusion at the time of clinical onset.
Factor 9(2): for stress fracture only, having significant repetitive loading stress to the affected bone prior to clinical onset — NOT MET - This factor applies only to stress fracture; the right thumb fracture was an acute traumatic disruption of the healing arthrodesis in a fall on about 8 August 1989.
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 — NOT MET - This factor applies only to stress fracture; the right thumb fracture followed a single fall on about 8 August 1989, not chronic repetitive loading stress.
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 — NOT MET - Fracture non-union did not occur: despite the gap on the X-ray of 5 September 1989, at operation on 13 September 1989 the surgeon found the right arthrodesis solidly joined with no movement, so this factor does not arise, whatever his smoking at the time.
Factor 9(5): having diabetes mellitus at the time of the fracture non-union — NOT MET - Fracture non-union did not occur, the right arthrodesis being found solidly united at operation on 13 September 1989, and his diabetes mellitus was diagnosed only in 2023.
Factor 9(6): having osteoporosis at the time of the fracture non-union — NOT MET - Fracture non-union did not occur, the right arthrodesis being found solidly united at operation on 13 September 1989, and osteoporosis has never been diagnosed in the veteran, who was then 19.
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 — NOT MET - Fracture non-union did not occur, the right arthrodesis being found solidly united at operation on 13 September 1989, and no vitamin D level was measured; nothing suggests deficiency in a young man then serving in tropical a supply ship.
Factor 9(8): having a Body Mass Index (BMI) of 40 or greater at the time of the fracture non-union — NOT MET - Fracture non-union did not occur, the right arthrodesis being found solidly united at operation on 13 September 1989, and his BMI at the time was about 33 (115 kg at 187 cm on 23 November 1989), below 40.
Other Plausible Links to Service The fracture is an unintended consequence of medical treatment paid for by the Commonwealth (section 6A of the DRCA).
It broke through the fusion site created by the bilateral thumb MCP arthrodesis performed during service on 7 June 1989 by the treating doctor at Calvary Hospital, a supply ship, arranged and paid for through the Navy; union was still 'occurring slowly' on 11 July 1989, and the fall of about 8 August 1989 disrupted a healing fusion that would not otherwise have existed.
The further operation on 13 September 1989 (exploration, removal of the fixation from both thumbs and a further month in plaster), for which the Navy approved the admission and the hospital, theatre, anaesthetic and surgical fees, followed directly from it.
The arthrodesis treated a condition accepted as aggravated by service.
After the dislocation of his left thumb in a motor vehicle accident near Cooktown during his service in late 1989, his surgeon recommended fusion of both thumb MCP joints for familial recurrent dislocation, and the Medical Boards of Survey of 11 August 1989 and 24 November 1989 found the fusion of both first MCP joints to be constitutional but aggravated by naval service.
The right thumb fracture through that fusion is therefore also a consequence of a service-aggravated condition and its treatment.
The fracture and the operations left permanent sequelae: solid ankylosis of the right thumb MCP joint with mild degenerative change of the interphalangeal joint on the X-ray of 20 August 2022, and in 2000 the veteran wrote that the thumb operations were causing him considerable pain and suffering.
Conclusion the veteran's right thumb fracture was caused by a fall in the shower on about 8 August 1989, during his service, which broke through the incompletely united right MCP arthrodesis performed on 7 June 1989; the significant-force factor is met, and no non-union followed, the fusion being found solidly united at operation on 13 September 1989.
The fracture occurred through the healing fusion site left by the Commonwealth-funded arthrodesis, undertaken for a thumb condition the Navy's Medical Boards found aggravated by naval service, and it required a further Commonwealth-funded operation; it is therefore an unintended consequence of that treatment and related to his service.
The % contribution of the causes is 100% and significant.
Worsening Factors In the alternative, if the veteran's right thumb fracture is found not to have arisen out of his service, the following factor addresses whether events after its clinical onset (8 August 1989) aggravated it or contributed to it in a material degree.
The SOP treats fracture non- union as a clinical worsening, but no non-union occurred: the fusion was found solidly united at operation on 13 September 1989.
Worsening Factors — Balance of Probabilities (Statement of Principles concerning Fracture, No.
63 of 2024) Factor 9(6): inability to obtain appropriate clinical management for fracture before clinical worsening — NOT MET - The fracture was managed promptly and appropriately: his orthopaedic surgeon X-rayed it and applied a thumb spica on 8 August 1989, reviewed it on 5 September 1989 and, with Navy approval, operated on 13 September 1989, finding the fusion solidly united.
The November 1989 signal suspecting malingering followed union.
Worsening Factors — Reasonable Hypothesis (Statement of Principles concerning Fracture, No.
62 of 2024) the veteran had no operational deployments.
The Reasonable Hypothesis standard applies only to operational service, so these factors are assessed for completeness and, like the Balance of Probabilities factors, by analogy only.
Factor 9(9): inability to obtain appropriate clinical management for fracture before clinical worsening — NOT MET - His orthopaedic surgeon treated the fracture in a thumb spica from 8 August 1989, reviewed it with X-ray on 5 September 1989 and operated on 13 September 1989 with Navy approval, when the fusion was found solidly united; the command's suspicion of malingering in November 1989 followed union and did not impede this management
Sequelae
The right thumb fracture and the operations left permanent solid ankylosis of the right thumb MCP joint with mild degenerative change of the interphalangeal joint (X-ray 20 August 2022); in 2000 the veteran wrote that the thumb operations were causing him considerable pain and suffering.
These are sequelae of the in-service fracture and surgery
Unintended Consequence
The fracture is an unintended consequence of medical treatment paid for by the Commonwealth (section 6A of the DRCA): it broke through the incompletely united fusion site created by the arthrodesis of 7 June 1989, performed during service and arranged and paid for through the Navy, and it led to the further Navy-funded operation of 13 September 1989.
The mild interphalangeal joint degeneration is a further consequence of the MCP fusion.
The arthrodesis treated a condition that the Medical Boards of 5 February and 24 November 1989 found aggravated by naval service
Inability to Attain Appropriate Medical Management
NOT MET.
The fracture was promptly and appropriately managed: the treating doctor it and applied a thumb spica on 8 August 1989, reviewed it on 5 September 1989 and, with Navy approval, operated on 13 September 1989, finding the fusion solidly united.
The command signal of November 1989 suspecting malingering came after union and did not prevent this treatment
Date of Clinical Onset
Right thumb fracture is an acute condition.
Its date of clinical onset is the date of the injury or illness itself, as recorded in the contemporaneous service record.
Later investigations, reviews and imaging record the investigation, treatment or confirmation of the condition; they are not the date of clinical onset.
Date of injury / illness: 8 August 1989 — fall in the shower at home in which he "refractured his (R) thumb" after the right thumb MCP arthrodesis of 7 June 1989; he was re-operated on 13 September 1989 [ [CHART REVIEW document], pages 132, 135].
The underlying right thumb MCP joint pathology that required arthrodesis was present before 7 June 1989.
The later records, including the X-ray of both thumbs on 20 August 2022, concern investigation or follow-up and do not alter the date of clinical onset.
Date of clinical onset: 8 August 1989.
This date falls within the veteran's ADF service (8 October 1986 24 July 1993).
In-service events and exposures before this date relate to clinical onset, and those after it to clinical worsening
