Right Wrist - Chronic Sprain/TFCC Tear — 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 Wrist - Chronic Sprain/TFCC Tear

Example 1 of 1 · fictitious patient (Veteran H)

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 Wrist - Chronic Sprain/TFCC Tear

SOP Codes: Balance of Probabilities: Sprain and Strain No. 28 of 2020 Reasonable Hypothesis: Sprain and Strain No. 27 of 2020

ADF History

The veteran, M113 Crewman/RAAC Assistant Instructor, 06 November 1988, Continuous Full Time Service ended 30 Apr 1992, General Reserves until approximately 2001, Army Standby Reserve separated 10 May 2007.

Occupational History

As an M113 Crewman in the Royal Australian Armoured Corps, the veteran service involved significant physical demands and environmental exposures. Duties included lifting and carrying heavy equipment, repetitive movements, working on armoured vehicles in potentially awkward postures, physical training including pack marches and battle PT, and manual handling tasks. His role required extensive use of tools and equipment during vehicle maintenance, which placed considerable stress on the upper limbs and wrists.

History

Mr John the veteran an M113 Crewman, sustained an acute right wrist injury on 19 November 1991 while working on a service vehicle during his deployment to an overseas deployment. The injury progressed to chronic sprain with partial TFCC tear over subsequent years.

Timeline

19 November 1991 - Presented with right wrist pain that had developed after working on a service vehicle approximately 1.5 days prior to presentation. Clinical examination revealed slight pain on movement but no swelling, bruising, or significant range of motion restriction. The injury was diagnosed as '?Muscle strain' and treated with Metsal topical analgesic and rest, with advice to return if pain continued.
16 August 2015 - First consulted Dr Thomas Perkins who completed a DVA Diagnosis Form for 'Right Upper Limb - Pain', formally addressing his chronic wrist symptoms for compensation purposes. This represented his first formal presentation of the chronic consequences of his 1998 service-related wrist injury.
08 January 2016 - MRI referral was made, specifically noting his history as an M113 crewman with the 'Right injured while working on a service vehicle ? sprain'. The referral documented ongoing symptoms of pain, restricted range of motion, and functional limitation stemming from the original 1998 injury.
16 January 2016 - MRI of the right wrist confirmed the chronic consequences of his 1998 injury, revealing 'High signal intensity at the ulnar styloid attachment of the TFCC with some cystic changes within the ulnar styloid' suggesting an old degenerative partial thickness tear of the TFCC, along with minor DRUJ osteoarthritic changes with positive ulnar variance.

Symptoms

At the time of the initial injury in December 1994, the veteran experienced acute right wrist pain with slight pain on movement but no swelling or bruising. Following the injury, he developed chronic wrist pain, restricted range of motion, and functional limitation that persisted over more than two decades. From the current medical documentation, he continues to experience ongoing right wrist pain, stiffness, and reduced functional capacity that significantly impacts his daily activities and quality of life.

Imaging

16 January 2016 - MRI Right Wrist revealed: 'High signal intensity at the ulnar styloid attachment of the TFCC with some cystic changes within the ulnar styloid. This may suggest old degenerative partial thickness small tear of the TFCC. TFCC complex is intact. Minor DRUJ OA changes with positive ulnar variance but no evidence of ulnar lunate impaction.'

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

The formal diagnoses are Right Wrist Chronic Sprain (ICD-10: S63.5) and Right Wrist TFCC Tear (ICD-10: S63.5), applicable under SOP No. 28 of 2020 (Balance of Probabilities) and SOP No. 27 of 2020 (Reasonable Hypothesis) for Sprain and Strain.

A chronic sprain represents a long-term consequence of ligamentous injury where the initial acute tearing or stretching of joint ligaments progresses to chronic instability, pain, and functional impairment. The TFCC (Triangular Fibrocartilage Complex) is a crucial stabilizing structure of the wrist that, when partially torn, can lead to chronic pain, instability, and degenerative changes. This condition typically develops from acute traumatic injury and progresses over time with continued use and mechanical stress.

The temporal relationship demonstrates progression from acute wrist strain in December 1994 to chronic sprain with TFCC tear, representing the natural evolution of the initial service-related injury with development of degenerative changes over more than two decades.

2. For each diagnosis identified, please also provide the following dates:

When did the veteran first experience symptoms attributable to this condition?

19 November 1991 - morning of presentation, following work on vehicle 1.5 days prior [CHART REVIEW .docx, multiple references; MRI - Left Elbow & Shoulder, Right Wrist, Cervical & Thoracic Spine - John the veteran - 19.03.25.pdf, p.2].

When did the veteran first present to a health / medical provider for this condition?

19 November 1991 to military medical officer in an overseas deployment [CHART REVIEW .docx, multiple timeline references].

When was the condition confirmed / formally diagnosed?

19 November 1991 for acute strain by military medical officer; 16 January 2016 for chronic sprain and TFCC tear via MRI imaging conducted by the treating doctor, reported to Dr Thomas Perkins [MRI - Left Elbow & Shoulder, Right Wrist, Cervical & Thoracic Spine - John the veteran - 19.03.25.pdf, p.2; CHART REVIEW .docx].

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

15 Jun 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 initial diagnosis of right wrist strain was made clinically on 19 November 1991 by a military medical officer based on the history of trauma from working on a service vehicle and examination findings of pain on movement without swelling or significant functional limitation [CHART REVIEW .docx]. The chronic conditions were diagnosed via MRI imaging on 16 January 2016, which demonstrated high signal intensity at the ulnar styloid attachment of the TFCC with cystic changes suggesting an old degenerative partial thickness tear, along with minor osteoarthritic changes of the distal radioulnar joint [MRI - Left Elbow & Shoulder, Right Wrist, Cervical & Thoracic Spine - John the veteran - 19.03.25.pdf, p.2]. Dr Thomas Perkins correlated these imaging findings with the patient's ongoing symptoms of wrist pain, restricted range of motion, and functional limitation, establishing the chronic consequences of the original service-related injury.

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.

Note: This condition has an onset date of 19 November 1991, which is before 31 Apr 1995 and did not occur on warlike deployment, therefore it comes under DRCA legislation. However, analysis against SOP factors is provided below.

Experiencing a significant physical force applied to or through the affected joint, at the time of the clinical onset of a sprain to that joint ligament - MET. The veteran sustained his right wrist injury while working on a service vehicle, which involved manual tasks and tool use that applied significant physical force to the wrist joint, directly causing the initial sprain.

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 - MET. The mechanism of injury involved forceful use of the wrist during vehicle maintenance work, which caused stretching and tearing of the TFCC and associated structures.

Experiencing a significant physical force applied to or through the affected joint, at the time of the clinical worsening of a sprain to that joint ligament - MET. Continued military duties following the initial injury, including ongoing vehicle maintenance and equipment handling, exposed the injured wrist to repeated significant physical forces that contributed to the worsening and chronicity of the condition.

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 - MET. Ongoing military duties required continued forceful use of the injured wrist, preventing optimal healing and contributing to the development of chronic pathology.

Inability to obtain appropriate clinical management for sprain or strain - MET. There was a period of more than 20 years between the initial injury and formal diagnosis of the chronic consequences via MRI imaging, which constitutes an inability to obtain appropriate medical management for the underlying TFCC pathology, satisfying this factor as per Brew v Repatriation Commission precedent.

Sequelae

The chronic sprain and TFCC tear are not sequelae of another known condition but represent the direct progression of the acute wrist strain sustained during service.

Unintended Consequence

This condition is not an unintended consequence of medical management, as it resulted from the initial traumatic injury during service duties rather than from any medical treatment or procedure.

Inability to Attain Appropriate Medical Management

The inability to attain appropriate medical management factor is MET. There was a period of more than 20 years between the initial presentation in December 1994 and the formal diagnosis of chronic TFCC pathology via MRI in February 2019. This lengthy delay in obtaining definitive investigation and diagnosis of the underlying chronic pathology constitutes an inability to attain appropriate medical management. As established in Brew v Repatriation Commission (10 July 1990), the "inability" encompasses both objective and subjective barriers to obtaining treatment, including systemic failures to provide timely and appropriate investigation of chronic symptoms. This delay in diagnosis resulted in a permanent worsening of the condition, as the TFCC tear progressed from acute injury to chronic degenerative pathology without appropriate early intervention that might have prevented or minimized the long-term consequences.

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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