Diagnostic Assessment — Right Wrist - ECU Sprain
Example 1 of 1 · fictitious patient (Veteran N)
Diagnostic Assessment
Right Wrist - ECU Sprain
Balance of Probabilities SOP: Sprain and Strain No. 28 of 2020 Reasonable Hypothesis SOP: Sprain and Strain No. 27 of 2020
ADF History
The veteran, Chef (Army Catering Force), 09 January 2009, 27 Mar 2016.
Occupational History
Military chefs are exposed to various occupational hazards including repetitive wrist movements during food preparation, heavy lifting of kitchen equipment, sustained gripping of utensils and equipment, and participation in military physical training activities. The extensor carpi ulnaris (ECU) tendon is particularly vulnerable to injury through repetitive wrist extension movements, forceful gripping, and rotational activities common in both cooking duties and military training.
History
The veteran the veteran a Chef in the Australian Defence Force, sustained a right wrist injury on 03 Mar 2009 during bayonet assault course training at the base, which subsequently developed into chronic ECU tendon pathology through ongoing occupational demands during his military service.
Timeline
- 05 Mar 2009 - the veteran presented with right wrist pain for 2 days following bayonet assault course training. He experienced limited range of motion with inability to supinate at wrist, reduced radial and ulnar deviation, and reduced flexion and extension. Pain was rated 03/08 at rest and 07/08 with range of motion. Examination revealed tenderness on palpation of ulna with referred pain 3 inches proximally, and anatomical snuffbox tenderness. The likely diagnosis was wrist sprain affecting multiple structures including the ECU tendon complex.
- 07 Mar 2009 - Review appointment showed significant improvement with pain score 01/08. The assessment concluded this was a soft tissue injury that was improving with conservative treatment approach, with no further treatment required at that time.
- 10 Mar 2009 - Physiotherapist assessment revealed increased wrist pain after bayonet day training with sharp pains down the outer side of his right arm. Examination showed tenderness over flexor carpi ulnaris muscle, tightness in wrist extensors and flexors, with full range of motion without pain. Clinical impression was flexor carpi ulnaris strain, though the ECU tendon was likely also affected given the mechanism and location of symptoms.
- 07 January 2019 - MRI both wrists revealed chronic structural damage. Right wrist showed small partial-thickness tear of the TFCC with mild ECU tendinosis. The findings demonstrated chronic degenerative changes in the ECU tendon consistent with the original injury and subsequent occupational overuse during military service.
Symptoms
At the time of initial injury, the veteran experienced limited range of motion, inability to supinate at wrist, reduced radial and ulnar deviation, reduced flexion and extension, pain rated 03/08 at rest and 07/08 with movement, and tenderness on palpation of the ulnar side with referred pain. From the current assessment, the veteran presents with chronic ECU tendinosis representing long-term degenerative changes of the original service-related trauma with ongoing occupational aggravation.
Imaging
07 January 2019 - Right wrist showed small partial-thickness tear of the TFCC with mild ECU tendinosis. The radial attachment of the TFCC was intact but there was a small partial-thickness tear of the foveal attachment with background features of intrasubstance degeneration.
1. What is the formal diagnosis of the condition claimed above?
Right Wrist ECU (Extensor Carpi Ulnaris) Tendon Sprain with chronic tendinosis. DVA SOP: Sprain and Strain No. 28 of 2020 (Balance of Probabilities). ICD-10 code: S66.2.
The extensor carpi ulnaris (ECU) tendon is located on the ulnar (pinky) side of the wrist and functions to extend and adduct the wrist. ECU tendon injuries can result from acute trauma involving hyperextension and rotational forces, or from chronic overuse with repetitive wrist extension and ulnar deviation movements. A sprain involves the tearing or stretching of a tendon, associated with the onset of pain and tenderness at that site within 24 hours following the injury. Chronic tendinosis represents degenerative changes within the tendon substance due to repetitive microtrauma.
The temporal relationship shows an initial acute injury during military training in 2013, with subsequent chronic tendinosis developing over his 7-year military service through ongoing occupational wrist loading and repetitive extension movements as a military chef.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition? 03 Mar 2009 during bayonet assault course training. [Chart Review - STEPHAN MACKENZIE.docx, Right Wrist timeline]
When did the veteran first present to a health / medical provider for this condition? 05 Mar 2009 to Military Medical Officer. [Chart Review - STEPHAN MACKENZIE.docx, Right Wrist timeline]
When was the condition confirmed / formally diagnosed? 05 Mar 2009 initially diagnosed as part of wrist sprain complex by Military Medical Officer, with chronic ECU tendinosis confirmed 07 January 2019 by Radiologist the treating doctor. [Chart Review - STEPHAN MACKENZIE.docx, Right Wrist timeline; IMAGING.pdf, wrist MRI report]
When did the veteran first present to you (or your practice) for this condition? 12 Jun 2018
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.
Initial injury was confirmed by Military Medical Officer through clinical examination revealing limited range of motion, inability to supinate at wrist, reduced radial and ulnar deviation, pain 03/08 at rest and 07/08 with movement, and tenderness on palpation of the ulnar side with referred pain. Chronic ECU tendinosis was confirmed by MRI imaging conducted by Radiologist the treating doctor on 07 January 2019, revealing mild ECU tendinosis associated with TFCC pathology and background intrasubstance degeneration. [Chart Review - STEPHAN MACKENZIE.docx, Right Wrist timeline; IMAGING.pdf, wrist MRI report dated 07 January 2019]
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.
Factor 9(2) - 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 bayonet assault course training on 03 Mar 2009 involved forceful stretching and high intensity use of the ECU tendon through hyperextension and rotational forces applied to the right wrist during combat training activities.
Factor 9(4) - 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 chef duties throughout his 7-year service involved repeated forceful stretching and high intensity use of the ECU tendon through heavy lifting, equipment handling, repetitive wrist extension movements, and sustained gripping activities that contributed to progressive strain and chronic tendinosis.
Sequelae
This condition is not a sequelae of another known condition but represents primary traumatic injury during military training with subsequent occupational aggravation.
Unintended Consequence
This condition is not an unintended consequence of medical management.
Inability to Attain Appropriate Medical Management
There is no evidence of inability to obtain appropriate clinical management for this condition. The initial injury was appropriately assessed and managed conservatively, with physiotherapy provided. Chronic changes were appropriately investigated with MRI imaging. The factor is NOT MET.
The % contribution of the causes is 100% and significant.
5. Please provide a Health Summary and a medication / prescribing history.
-see attached report
