Diagnostic Assessment — Right Wrist - De Quervain Tendinopathy
Example 1 of 1 · fictitious patient (Veteran AY)
Diagnostic Assessment
Right Wrist - De Quervain Tendinopathy
BOP Code: 42 of 2019 (De Quervain Tendinopathy)
RH Code: 41 of 2019 (De Quervain Tendinopathy)
ADF History
Veteran AY, date of birth 23 April 1984, Australian Army, Cook (later Corporal and kitchen supervisor), enlisted 07 February 2003, medically discharged 19 July 2019. Operational service: Afghanistan, 14 September 2010 to 30 March 2011 (warlike); Iraq, 10 May 2016 to 15 November 2016 (warlike). Right-hand dominant.
Occupational History
Army cooks prepare meals for large numbers of personnel in garrison kitchens and in field and deployed kitchens. The work involves prolonged knife work, chopping and slicing hundreds of kilograms of produce, whisking and stirring large pots with long paddles, lifting and carrying 10 to 25 kilogram pots, trays, ration boxes and gas cylinders, scrubbing equipment, and unloading pallets of supplies. Shifts in field and deployed kitchens commonly run 12 hours or more, seven days a week.
These tasks combine repeated forceful gripping with ulnar deviation of the wrist and thumb flexion, the classic mechanism for overload of the first extensor compartment. Cooks also sustain knife lacerations, burns and blows to the hands and wrists, and on operations they work in base areas exposed to rocket and mortar attack, with limited access to physiotherapy and hand therapy.
History
Veteran AY, a right-handed cook in the Australian Army, developed right de Quervain tendinopathy on 08 August 2011 after months of heavy repetitive kitchen work on warlike service in Afghanistan and in garrison, two right wrist injuries, fluoroquinolone antibiotics, and growth hormone and aromatase inhibitor treatment for post-traumatic hypopituitarism. The condition worsened after his 2016 deployment to Iraq, where he injured the wrist again and could not obtain treatment, and he required surgical release in 2017.
Timeline
- 03 Mar 2010 — An endocrinologist confirmed post-traumatic hypopituitarism following a moderate traumatic brain injury sustained in a vehicle rollover on a peacetime exercise on 18 June 2009. An insulin tolerance test showed severe growth hormone deficiency and he had hypogonadotrophic hypogonadism. Somatropin 0.4 mg daily by subcutaneous injection was commenced on 22 March 2010 and testosterone undecanoate on 06 April 2010. Anastrozole 1 mg twice weekly was added on 02 August 2010 for a raised oestradiol and tender gynaecomastia on testosterone. "GH deficiency, somatropin commenced"
- 12 Jan 2011 — On warlike service in Afghanistan, during a rocket attack on the base, the veteran dived for cover in the kitchen and a loaded steel tray rack fell onto his right wrist. He attended the role 2 facility with swelling and bruising over the radial side of the wrist. X-ray showed no fracture. He was strapped and returned to duty the next day. He was working 12-hour shifts, seven days a week, in the main kitchen feeding about 900 personnel. "heavy blow right wrist, no fracture"
- 20 Feb 2011 — The deployed medical officer treated acute traveller's diarrhoea with ciprofloxacin 500 mg twice daily for three days. The veteran's somatropin, testosterone and anastrozole continued throughout the deployment, with refrigerated storage arranged through the medical facility. "ciprofloxacin for gastroenteritis"
- 20 Jun 2011 — Back in Australia in a garrison kitchen, he sustained a 2 cm laceration over the radial side of the right wrist from a boning knife while breaking down carcasses. The wound was sutured at the health centre and he returned to duties after three days. He had been treated with norfloxacin 400 mg twice daily for seven days for a urinary tract infection on 10 May 2011. "laceration radial wrist, sutured"
- 15 Aug 2011 — He presented with a week of pain over the radial styloid of the right wrist, worse when gripping knives, lifting pots and wringing cloths, which began on 08 August 2011. There was swelling and tenderness over the first extensor compartment and Finkelstein's test was strongly positive. His post-deployment medical review on 04 April 2011 had recorded no wrist symptoms. Ultrasound on 19 August 2011 confirmed de Quervain tenosynovitis. "Finkelstein positive, radial wrist pain"
- 14 Sep 2011 — A sports physician performed an ultrasound-guided corticosteroid injection into the first extensor compartment and prescribed a thumb spica splint and hand therapy. Symptoms improved substantially by December 2011. Through 2012 to 2015 he had intermittent mild pain on heavy kitchen work, managed with the splint, with a QuickDASH score of 25. "steroid injection, spica splint"
- 03 Oct 2016 — On warlike service in Iraq his right wrist was crushed between a pallet and a truck tailgate while unloading ration supplies. Pain and swelling over the radial wrist flared severely. No physiotherapist or splint was available at the base and an ultrasound-guided injection could not be arranged, so he continued 12-hour kitchen shifts. On 25 October 2016 he was treated with ciprofloxacin 500 mg twice daily for five days for gastroenteritis. "crush injury, no physio available"
- 20 Mar 2017 — After returning to garrison he had struck the wrist on a stainless steel bench when he slipped on a wet kitchen floor on 14 February 2017, and on 06 February 2017 he had been treated with moxifloxacin 400 mg daily for seven days for pneumonia. He now had constant pain, crepitus and weakness of grip. Ultrasound showed marked thickening of the extensor retinaculum and tendons with an intratendinous split. The QuickDASH score was 68, up from 25. Surgical release was performed on 12 June 2017. "QuickDASH 68, retinaculum thickened"
Symptoms
At onset the veteran had pain and swelling over the radial side of the right wrist and the base of the thumb, worse with gripping knives, lifting and pouring from heavy pots, whisking and wringing cloths, with weakness of pinch grip and occasional catching of the thumb. The pain eased with rest and the splint but returned with each block of heavy kitchen work.
After the worsening in 2016 and 2017 the pain became constant, with crepitus, marked weakness of grip and pain at night. Since the surgical release in 2017 he has residual aching on heavy use, reduced grip strength and numbness over the dorsum of the thumb from irritation of the superficial radial nerve. He can no longer use a chef's knife for extended periods, lift heavy pots one-handed or carry shopping bags in his right hand.
Imaging
- 12 Jan 2011 — X-ray right wrist: "No fracture or dislocation. Soft tissue swelling over the radial aspect of the wrist."
- 19 Aug 2011 — Ultrasound right wrist: "Thickening of the abductor pollicis longus and extensor pollicis brevis tendons in the first extensor compartment with a tendon sheath effusion and hyperaemia on Doppler, consistent with de Quervain tenosynovitis."
- 20 Mar 2017 — Ultrasound right wrist: "Marked thickening of the extensor retinaculum over the first compartment to 2.4 mm (previously 1.1 mm), tendon thickening with a longitudinal intratendinous split of the abductor pollicis longus, and an intracompartmental septum."
- 05 Apr 2017 — MRI right wrist: "Chronic stenosing tenosynovitis of the first extensor compartment with tendinosis and partial longitudinal tear of the abductor pollicis longus. No carpal instability."
Onset Date
The most likely date of onset of this condition is 08 Aug 2011.
At that date the veteran was serving full time as a cook in a garrison kitchen in Australia, four months after returning from warlike service in Afghanistan, and working 40-hour weeks of heavy food preparation. He was taking somatropin, testosterone and anastrozole for post-traumatic hypopituitarism. On 08 August 2011 he noticed pain over the radial side of his right wrist while breaking down produce, and it persisted.
This date is appropriate because his post-deployment medical review of 04 April 2011 recorded no wrist symptoms after the January contusion had settled, and he first presented with the characteristic findings on 15 August 2011, one week after the pain began. It falls within uninterrupted full-time service.
For the repetitive and forceful activity factor, the six months before onset run from 08 Feb 2011 to 08 Aug 2011. From 08 February to 30 March 2011 he worked 12-hour kitchen shifts seven days a week on warlike service in Afghanistan, about 600 hours, and from 26 April to 08 August 2011 he worked about 40 hours a week in a garrison kitchen, a further 600 hours, each well over the 500 hours required. For the acute trauma, growth hormone and aromatase inhibitor factors, the one year before onset runs from 08 Aug 2010 to 08 Aug 2011; it contains the heavy blow of 12 January 2011, the laceration of 20 June 2011, and continuous somatropin and anastrozole. For the fluoroquinolone factor, the six months before onset contain the ciprofloxacin course of 20 February 2011 and the norfloxacin course of 10 May 2011.
For the worsening factors, the documented worsening is 20 Mar 2017. The six months before the worsening run from 20 Sep 2016 to 20 Mar 2017, comprising about 680 hours of kitchen work on warlike service in Iraq to 15 November 2016 and about 600 hours in garrison from late November 2016, and containing the ciprofloxacin course of 25 October 2016 and the moxifloxacin course of 06 February 2017. The one year before the worsening runs from 20 Mar 2016 to 20 Mar 2017 and contains the crush injury of 03 October 2016, the heavy blow of 14 February 2017 and continuous somatropin and anastrozole.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is De Quervain Tendinopathy of the right wrist (ICD-10-AM M65.4), under the Statements of Principles concerning de Quervain tendinopathy, Balance of Probabilities No. 42 of 2019 and Reasonable Hypothesis No. 41 of 2019.
De Quervain tendinopathy is entrapment of the abductor pollicis longus and extensor pollicis brevis tendons as they pass through the first extensor compartment at the radial styloid, caused by thickening of the tendons and the overlying retinaculum. It produces pain, swelling and tenderness at the radial side of the wrist that is worsened by gripping and by movement of the thumb and wrist, and a positive Finkelstein test. It is strongly associated with repetitive and forceful hand use, and also with local trauma and certain medications, including fluoroquinolone antibiotics, growth hormone and aromatase inhibitors.
The diagnosis followed repetitive and forceful kitchen work on warlike service in Afghanistan and in garrison, a heavy blow and a laceration to the right wrist, fluoroquinolone antibiotics and continuous growth hormone and aromatase inhibitor therapy. It began on 08 August 2011, was confirmed on ultrasound on 19 August 2011 and worsened in 2016 to 2017, requiring surgical release.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
08 August 2011.
When did the veteran first present to a health / medical provider for this condition?
15 August 2011.
When was the condition confirmed / formally diagnosed?
19 August 2011.
When did the veteran first present to you (or your practice) for this condition?
24 February 2025.
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was made clinically on 15 August 2011 and confirmed by ultrasound on 19 August 2011. The veteran had localised pain and tenderness over the first extensor compartment at the radial styloid, swelling, pain exacerbated by movement of the thumb and wrist and a strongly positive Finkelstein test. Ultrasound showed thickening of the abductor pollicis longus and extensor pollicis brevis tendons with a sheath effusion and Doppler hyperaemia. This meets the Statement of Principles definition of entrapment of the tendons in the first extensor compartment producing localised pain and tenderness exacerbated by thumb or wrist movement.
The diagnosis was supported by the response to an ultrasound-guided corticosteroid injection on 14 September 2011. The worsening was confirmed on ultrasound on 20 March 2017, showing retinacular thickening increased from 1.1 to 2.4 mm with an intratendinous split, on MRI on 05 April 2017, and at surgical release on 12 June 2017, when a thickened retinaculum and a separate compartment for the extensor pollicis brevis were found. The QuickDASH score rose from 25 to 68.
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 08 August 2011, 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 his garrison kitchen work, the knife laceration and the medications prescribed in Australia. The Reasonable Hypothesis instrument applies to the veteran's warlike service in Afghanistan from September 2010 to March 2011, before onset, and in Iraq from May to November 2016, before the worsening.
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 De Quervain Tendinopathy, No. 42 of 2019
Causative factors
Factor 8(1): performing repetitive activities or forceful activities using the affected hand or wrist, for a cumulative period of at least 500 hours within the six months before the clinical onset of de Quervain tendinopathy; — MET
- From 26 April to 08 August 2011 the veteran worked about 40 hours a week in a garrison kitchen, chopping and slicing produce with his right hand well over 50 times an hour, stirring large pots with a paddle and lifting 15 to 25 kilogram pots and trays many times an hour. This amounted to about 600 hours of repetitive and forceful activity with the right hand and wrist within the six months before onset, which run from 08 February to 08 August 2011.
Factor 8(2): having acute trauma involving the affected wrist or tendon, within the one year before the clinical onset of de Quervain tendinopathy; — MET
- On 20 June 2011, in a garrison kitchen, he sustained a 2 cm laceration over the radial side of the right wrist from a boning knife, directly over the first extensor compartment, which was sutured at the health centre. This was seven weeks before onset, within the one year from 08 August 2010 to 08 August 2011.
Factor 8(3): being treated with or using growth hormone within the one year before the clinical onset of de Quervain tendinopathy; — MET
- The veteran was treated with somatropin 0.4 mg daily from 22 March 2010 for growth hormone deficiency caused by post-traumatic hypopituitarism, which followed a moderate traumatic brain injury in a vehicle rollover on a peacetime exercise on 18 June 2009. He took it continuously throughout the one year before onset.
Factor 8(4): being treated with a fluoroquinolone antibiotic within the six months before the clinical onset of de Quervain tendinopathy; — MET
- On 10 May 2011 the garrison medical officer treated a urinary tract infection with norfloxacin 400 mg twice daily for seven days, three months before onset and within the six months from 08 February to 08 August 2011.
Factor 8(5): being treated with an aromatase inhibitor within the one year before the clinical onset of de Quervain tendinopathy; — MET
- His endocrinologist prescribed anastrozole 1 mg twice weekly from 02 August 2010 for raised oestradiol and gynaecomastia on testosterone replacement for his service-related hypopituitarism. It continued throughout the one year before onset.
Worsening factors
Factor 8(6): performing repetitive activities or forceful activities using the affected hand or wrist, for a cumulative period of at least 500 hours within the six months before the clinical worsening of de Quervain tendinopathy; — MET
- After returning to garrison in November 2016, he worked about 45 hours a week as kitchen supervisor and cook, with heavy knife work and lifting, from late November 2016 to the worsening documented on 20 March 2017, about 600 hours within the six months before the worsening, which run from 20 September 2016 to 20 March 2017.
Factor 8(7): having acute trauma involving the affected wrist or tendon, within the one year before the clinical worsening of de Quervain tendinopathy; — MET
- On 14 February 2017 he slipped on a wet garrison kitchen floor and struck the radial side of his right wrist heavily on the edge of a stainless steel bench, five weeks before the worsening.
Factor 8(8): being treated with or using growth hormone within the one year before the clinical worsening of de Quervain tendinopathy; — MET
- Somatropin continued daily throughout the one year before the worsening, from 20 March 2016 to 20 March 2017.
Factor 8(9): being treated with a fluoroquinolone antibiotic within the six months before the clinical worsening of de Quervain tendinopathy; — MET
- On 06 February 2017 he was treated with moxifloxacin 400 mg daily for seven days for community-acquired pneumonia, six weeks before the worsening.
Factor 8(10): being treated with an aromatase inhibitor within the one year before the clinical worsening of de Quervain tendinopathy; — MET
- Anastrozole 1 mg twice weekly continued throughout the one year before the worsening.
Factor 8(11): inability to obtain appropriate clinical management for de Quervain tendinopathy. — MET
- From the flare on 03 October 2016 to his return on 15 November 2016 the veteran could not obtain a splint, physiotherapy or an ultrasound-guided injection on deployment, and he continued 12-hour kitchen shifts. On return the first specialist appointment was not available until March 2017. The condition progressed to chronic stenosing tenosynovitis with an intratendinous split requiring surgical release. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.
Reasonable Hypothesis — Statement of Principles concerning De Quervain Tendinopathy, No. 41 of 2019
Causative factors
Factor 8(1): performing repetitive activities or forceful activities using the affected hand or wrist, for a cumulative period of at least 500 hours within the six months before the clinical onset of de Quervain tendinopathy; — MET
- On warlike service in Afghanistan the veteran worked 12-hour shifts seven days a week in a kitchen feeding about 900 personnel, with continuous knife work, stirring with paddles and lifting of pots, trays and ration boxes. From 08 February to 30 March 2011, within the six months before onset, this amounted to about 600 hours of repetitive and forceful activity using the right hand and wrist.
Factor 8(2): having acute trauma involving the affected wrist or tendon, within the one year before the clinical onset of de Quervain tendinopathy; — MET
- On 12 January 2011, during a rocket attack on warlike service in Afghanistan, a loaded steel tray rack fell onto his right wrist as he dived for cover, causing swelling and bruising over the radial side of the wrist. This heavy blow was seven months before onset, within the one year before 08 August 2011.
Factor 8(3): being treated with or using growth hormone within the one year before the clinical onset of de Quervain tendinopathy; — MET
- The veteran used somatropin daily throughout his warlike deployment to Afghanistan from September 2010 to March 2011, with refrigerated storage arranged by the deployed medical facility, and continued it to onset.
Factor 8(4): being treated with a fluoroquinolone antibiotic within the six months before the clinical onset of de Quervain tendinopathy; — MET
- On 20 February 2011, on warlike service in Afghanistan, the deployed medical officer treated traveller's diarrhoea with ciprofloxacin 500 mg twice daily for three days, within the six months before onset.
Factor 8(5): being treated with an aromatase inhibitor within the one year before the clinical onset of de Quervain tendinopathy; — MET
- Anastrozole 1 mg twice weekly was taken throughout his warlike deployment to Afghanistan and continued to onset, within the one year before 08 August 2011.
Worsening factors
Factor 8(6): performing repetitive activities or forceful activities using the affected hand or wrist, for a cumulative period of at least 500 hours within the six months before the clinical worsening of de Quervain tendinopathy; — MET
- On warlike service in Iraq from 20 September to 15 November 2016 he worked 12-hour kitchen shifts seven days a week, about 680 hours of repetitive and forceful right hand and wrist activity within the six months before the worsening.
Factor 8(7): having acute trauma involving the affected wrist or tendon, within the one year before the clinical worsening of de Quervain tendinopathy; — MET
- On 03 October 2016, on warlike service in Iraq, his right wrist was crushed between a pallet and a truck tailgate while he unloaded ration supplies, causing a severe flare of pain and swelling over the first extensor compartment, within the one year before the worsening.
Factor 8(8): being treated with or using growth hormone within the one year before the clinical worsening of de Quervain tendinopathy; — MET
- Somatropin was used daily throughout his warlike deployment to Iraq in 2016 and continued to the worsening.
Factor 8(9): being treated with a fluoroquinolone antibiotic within the six months before the clinical worsening of de Quervain tendinopathy; — MET
- On 25 October 2016, on warlike service in Iraq, he was treated with ciprofloxacin 500 mg twice daily for five days for gastroenteritis, within the six months before the worsening.
Factor 8(10): being treated with an aromatase inhibitor within the one year before the clinical worsening of de Quervain tendinopathy; — MET
- Anastrozole was taken throughout his warlike deployment to Iraq in 2016 and continued to the worsening.
Factor 8(11): inability to obtain appropriate clinical management for de Quervain tendinopathy. — MET
- On warlike service in Iraq after the crush injury of 03 October 2016 no physiotherapist, thumb spica splint or ultrasound-guided injection was available, and operational demands kept him on 12-hour kitchen shifts for six more weeks. The condition progressed and required surgical release in June 2017.
The % contribution of the causes is 100% and significant.
Sequelae
The de Quervain tendinopathy is a sequela of the veteran's service-related post-traumatic hypopituitarism, through the growth hormone and aromatase inhibitor treatment it required, and of the right wrist injuries sustained in service. In turn, the surgical release has left superficial radial nerve irritation with numbness over the dorsum of the thumb, and reduced grip strength.
Unintended Consequence
Met. Somatropin and anastrozole, prescribed and paid for by the Commonwealth for his service-related hypopituitarism, and the fluoroquinolone antibiotics prescribed by Defence medical officers, contributed to the onset and worsening of the condition. The superficial radial nerve irritation after the Defence-funded surgical release is also an unintended consequence of treatment (section 6A of the DRCA and the equivalent provisions of the MRCA).
Inability to Attain Appropriate Medical Management
MET. After the crush injury of 03 October 2016 on warlike service in Iraq, the veteran's established de Quervain tendinopathy flared severely, but no physiotherapist, splint or image-guided injection was available and he remained on 12-hour kitchen shifts until 15 November 2016. After his return a specialist appointment was not available until March 2017. The condition progressed from intermittent mild symptoms with a QuickDASH score of 25 to chronic stenosing tenosynovitis with an intratendinous split, a QuickDASH score of 68 and surgical release on 12 June 2017. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), operational constraints that prevent the provision of recognised 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 Jun 2009, Trauma admission and CT brain, Regional hospital
- 03 Mar 2010, Endocrinology consultation and insulin tolerance test, Endocrinologist
- 02 Aug 2010, Endocrinology review, Endocrinologist
- 12 Jan 2011, Role 2 attendance and X-ray right wrist, Medical Officer, Afghanistan
- 20 Feb 2011, Deployed health record, Medical Officer, Afghanistan
- 04 Apr 2011, Post-deployment medical review, Medical Officer, Garrison health centre
- 10 May 2011, Outpatient health record, Medical Officer, Garrison health centre
- 20 Jun 2011, Outpatient health record, Nursing Officer, Garrison health centre
- 15 Aug 2011, Outpatient health record, Medical Officer, Garrison health centre
- 19 Aug 2011, Ultrasound right wrist, Radiologist
- 14 Sep 2011, Sports medicine consultation and injection report, Sports physician
- 03 Oct 2016, Deployed health record, Medical Officer, Iraq
- 06 Feb 2017, Outpatient health record, Medical Officer, Garrison health centre
- 20 Mar 2017, Ultrasound right wrist and specialist consultation, Hand surgeon
- 05 Apr 2017, MRI right wrist, Radiologist
- 12 Jun 2017, Operation report, Hand surgeon
- Statement of Principles concerning De Quervain Tendinopathy (Balance of Probabilities) No. 42 of 2019, Repatriation Medical Authority
- Statement of Principles concerning De Quervain Tendinopathy (Reasonable Hypothesis) No. 41 of 2019, Repatriation Medical Authority
