Diagnostic Assessment — Right Wrist - Fracture
Example 1 of 1 · fictitious patient
Diagnostic Assessment Right Wrist — Fracture BOP Code: 63 of 2024 (Fracture) RH Code: 62 of 2024 (Fracture)
ADF History
The veteran, date of birth [withheld], served in the Australian Army as an Artilleryman from 30 January 1979 to 15 November 1985
History
The veteran sustained a right wrist fracture during ADF service.
Whilst the specific date and mechanism are not explicitly documented in the available service medical records, under DVA legislation the absence of documentation does not mean the injury did not occur.
The veteran's service involved extensive physically demanding manual handling and rugby league (boxing is reported only by the veteran in 2019 and is not recorded in the service records) — activities with a significant risk of wrist fractures from falls, direct blows, and heavy impacts.
The X-ray of the right elbow and wrist on 4 September 1979 for a right ulnar nerve lesion included the right wrist, though no fracture was identified on that occasion.
The entry of 27 October 1981 records a broken fibreglass (Baycast) cast on the right wrist, applied after the thumb arthrodesis, and its replacement; it is not a record of a wrist fracture.
A right wrist fracture is entirely consistent with the veteran's occupational and sporting exposure during service
Timeline
04 Sep 1979 — X-ray right elbow and right wrist for right ulnar nerve lesion.
No bone or joint injury demonstrated. "No fracture" During service (1979 1986) — The veteran's documented service included rugby league (1979), football (1985), falls on 9 March 1981, December 1981, 26 October 1982 and 1 1 December 1983, and heavy manual handling as an Artilleryman; boxing is self-reported only (2019).
Falls onto an outstretched hand are a common mechanism for wrist fractures.
No wrist injury is recorded
Symptoms
Attributable to a right wrist fracture are not specifically documented in the available records
Imaging
04 Sep 1979 — X-ray right wrist: No fracture demonstrated on this occasion
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Right Wrist Fracture (ICD-10: S62.009A).
Under DVA legislation, the Reasonable Hypothesis standard and the beneficial approach require that the absence of documentation is not treated as evidence that an injury did not occur
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition? During ADF service (1979 1986).
Specific date not documented.
When did the veteran first present to a health / medical provider for this condition? Not specifically documented.
When was the condition confirmed / formally diagnosed? Not specifically dated in available records.
The claim has been accepted for assessment by DVA.
When did the veteran first present to you (or your practice) for this condition? 11 June 2020
3. How was this diagnosis confirmed?
The specific mechanism and diagnosis of the right wrist fracture are not documented in the available service records.
The veteran's service records document a loss of original medical records (PM168) at an artillery regiment, which may account for missing documentation
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 29 April 1999 (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: No contemporaneous diagnosis, imaging or treatment of a right wrist fracture is recorded: the right wrist X-ray of 4 September 1979 showed no bone injury, and the entry of 27 October 1981 records a broken fibreglass cast on the right wrist, applied after the thumb arthrodesis, not a wrist injury.
The SOP definition (an acquired break of bone from a force that would ordinarily break healthy bone) is therefore applied to the claimed in-service fracture by analogy, and imaging of the right wrist for healed fracture would confirm the diagnosis.
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 - A fracture as defined in the SOP results from an applied force that would ordinarily break healthy bone, so a right wrist fracture sustained in service, as claimed, necessarily involved significant physical force applied to or through the wrist at the time of clinical onset.
The event and date are not recorded, and his PM168 medical record could not be located in December 1984.
His service nonetheless included documented falls, onto his back at work on 9 March 1981, in the shower in December 1981 when he injured his right thumb, on a wet deck on 26 October 1982 and onto a floor polisher on 1 1 December 1983, and contact sport; the absence of a record does not show that the injury did not occur.
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 claimed right wrist fracture is a traumatic fracture, and there is no record of, or basis to infer, a stress fracture of the wrist.
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 claimed right wrist fracture is traumatic, and nothing suggests chronic repetitive loading stress of abnormal intensity or direction at the wrist.
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 - There is no record of non-union of a right wrist fracture, and nothing in his history suggests it; no persisting wrist symptoms, imaging or surgery are documented, so this factor does not arise, whatever his smoking.
Factor 9(5): having diabetes mellitus at the time of the fracture non-union — NOT MET - There is no record of non-union of a right wrist fracture, and his diabetes mellitus was diagnosed only in 2015.
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 - If, as claimed, the veteran fractured his right wrist during service, the fracture by definition resulted from a force that would ordinarily break healthy bone, applied to or through the wrist at the time of clinical onset.
The event is not recorded, but his service included documented falls (9 March 1981, December 1981, 26 October 1982 and 1 1 December 1983) and contact sport, and his PM168 medical record could not be located in December 1984; the absence of a record does not show that the injury did not occur.
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 claimed right wrist fracture is traumatic, and there is no record of, or basis to infer, a stress fracture of the wrist.
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; nothing suggests chronic repetitive loading stress of abnormal intensity or direction at the right wrist.
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 - There is no record of non-union of a right wrist fracture, and nothing in his history suggests it, so this factor does not arise, whatever his smoking.
Factor 9(5): having diabetes mellitus at the time of the fracture non-union — NOT MET - There is no record of non-union of a right wrist fracture, and his diabetes mellitus was diagnosed only in 2015.
Factor 9(6): having osteoporosis at the time of the fracture non-union — NOT MET - There is no record of non-union of a right wrist fracture, and osteoporosis has never been diagnosed.
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 - There is no record of non-union of a right wrist fracture, and no serum 25(OH)D level has been recorded.
Factor 9(8): having a Body Mass Index (BMI) of 40 or greater at the time of the fracture non-union — NOT MET - There is no record of non-union of a right wrist fracture; his BMI was below 40 throughout his service (35.7 at discharge) and reached 40 or more only after it.
Other Plausible Links to Service Independently of the SOP, if the right wrist fracture was sustained during the veteran's service, as claimed, the question under the DRCA is whether it arose out of, or in the course of, his employment as a member.
His documented service involved falls and impacts of the kind that fracture the wrist, including a fall at work onto his back on 9 March 1981, a slip on a wet deck on duty aboard an artillery regiment on 26 October 1982 and a fall onto a floor polisher while polishing the deck on duty on 1 1 December 1983, as well as rugby in 1979 and football training in 1985; the specific event is not recorded.
The absence of a contemporaneous record is not evidence that the injury did not occur.
His PM168 medical record could not be located at an artillery regiment in December 1984 and a duplicate had to be requested, much of his care in an artillery regiment was given by civilian practitioners, and his service included survey ships at sea and remote locations such as Cooktown; an in- service fracture treated in those circumstances may not appear in the surviving records.
Conclusion The date and mechanism of the veteran's right wrist fracture are not recorded, and the surviving records show no wrist injury.
If, as claimed, it was sustained during his service (30 January 1979 15 November 1985), it resulted from significant force applied through the wrist in one of the falls, sporting injuries or other physical events of that service, which meets the significant-force factor by analogy and makes it an injury arising out of, or in the course of, his service.
The absence of any recorded assessment or treatment also meets the clinical management factor, consistent with the documented barriers to care and the loss of his medical record in 1985.
The % contribution of the causes is 100% and significant.
Worsening Factors In the alternative, if the veteran's right wrist fracture is found not to have arisen out of his service, the following factor addresses whether events after its clinical onset, on an undocumented date during his service (30 January 1979 15 November 1985), aggravated it or contributed to it in a material degree.
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 — MET - No in-service presentation, imaging or treatment for a right wrist fracture is recorded; if it occurred during service, as claimed, it was never assessed or treated, which points to barriers to care rather than absence of injury, and an untreated fracture is liable to malunion and later degenerative change.
His service included survey ships and remote locations such as Cooktown (1981), his PM168 medical record could not be located in December 1984, and a command signal of March 1982 suspected him of malingering, a sanction-type pressure.
Under Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), inability is assessed objectively and subjectively and includes psychological or emotional incapacity and the threat of sanctions that make seeking treatment unrealistic.
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 — MET - No in-service assessment or treatment of a right wrist fracture is recorded, which, if the fracture occurred during service as claimed, indicates barriers to care: service on survey ships and in remote locations such as Cooktown (1981), the loss of his PM168 medical record in December 1984 and the March 1982 command signal suspecting malingering.
Under Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), inability is assessed objectively and subjectively and includes psychological or emotional incapacity and the threat of sanctions that make seeking treatment unrealistic
Sequelae
No specific sequelae documented
Unintended Consequence
This condition is not an unintended consequence of medical management
Inability to Attain Appropriate Medical Management
MET.
No in-service assessment or treatment of a right wrist fracture is recorded, which, if the fracture occurred during service as claimed, indicates barriers to care: service on survey ships and in remote locations such as Cooktown (1981), the loss of his PM168 medical record in December 1984, and the command signal of March 1982 suspecting malingering.
Under Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), inability is assessed objectively and subjectively and includes psychological or emotional incapacity and the threat of sanctions that make seeking treatment unrealistic
Date of Clinical Onset
Right wrist 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.
The date of the injury is not recorded in the available service records.
The only in-service record concerning the right wrist is the X-ray of the right elbow and wrist on 4 September 1979, which showed no bone or joint injury [CHART REVIEW document].
The clinical onset of the fracture is the date of the injury itself, during ADF service; neither the date of any later imaging nor the date of the claim can be substituted for it.
Date of clinical onset: the date of injury during ADF service (30 January 1979 15 November 1985); the specific date is not documented.
This date falls within the veteran's ADF service (30 January 1979 15 November 1985).
In-service events and exposures before this date relate to clinical onset, and those after it to clinical worsening
