Diagnostic Assessment — Right Wrist - Strain
Example 1 of 1 · fictitious patient (Veteran N)
Diagnostic Assessment
Right Wrist - Strain
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. These activities involve forceful stretching and high intensity use of wrist muscles and tendons through lifting, carrying, gripping, and sustained wrist positioning during cooking operations and combat training.
History
The veteran the veteran a Chef in the Australian Defence Force, sustained a right wrist strain on 03 Mar 2009 during bayonet assault course training at the base, which was subsequently aggravated by 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 with consideration for medical officer referral for possible x-ray.
- 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. This demonstrated the strain injury to the muscle and tendon structures of the wrist from the original trauma and subsequent aggravation during ongoing military training activities.
- 07 January 2019 - MRI both wrists revealed chronic structural damage consistent with the original strain injury. The findings showed evidence of long-standing soft tissue changes and degenerative processes that developed following the initial traumatic strain during military service.
Symptoms
At the time of initial injury, the veteran experienced limited range of motion with 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, tenderness on palpation of ulna with referred pain, anatomical snuffbox tenderness, and subsequent development of flexor carpi ulnaris muscle strain. From the current assessment, the veteran presents with chronic structural changes representing long-term sequelae of the original service-related wrist strain.
Imaging
07 January 2019 - Chronic structural damage consistent with long-standing soft tissue changes and degenerative processes following the original wrist strain injury sustained during military service.
1. What is the formal diagnosis of the condition claimed above?
Right Wrist Strain involving multiple soft tissue structures including muscles, tendons, and ligaments. DVA SOP: Sprain and Strain No. 28 of 2020 (Balance of Probabilities). ICD-10 code: S63.9.
Wrist strain is an injury involving the tearing or stretching of muscles or tendons around the wrist joint, associated with the onset of pain and tenderness at that site within 24 hours following the injury. Strain injuries can affect multiple structures including the flexor and extensor muscle groups, particularly the flexor carpi ulnaris as documented in this case. The condition results from forceful stretching or high intensity use of muscles or tendons, leading to microscopic or macroscopic tears in the tissue fibers.
The temporal relationship shows an initial acute strain injury during military training in 2013, with subsequent chronic changes developing over his 7-year military service through ongoing occupational wrist loading and repetitive 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 wrist sprain/strain by Military Medical Officer, with specific flexor carpi ulnaris strain confirmed 10 Mar 2009 by Physiotherapist. [Chart Review - STEPHAN MACKENZIE.docx, Right Wrist timeline]
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 diagnosis 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, tenderness on palpation of ulna with referred pain, and anatomical snuffbox tenderness. Specific muscle strain was confirmed by Physiotherapist assessment on 10 Mar 2009, revealing tenderness over flexor carpi ulnaris muscle, tightness in wrist extensors and flexors, with clinical impression of flexor carpi ulnaris strain. [Chart Review - STEPHAN MACKENZIE.docx, Right Wrist timeline]
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 wrist muscles and tendons through hyperextension, rotational forces, and combat training activities that caused immediate onset of strain injury.
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 wrist muscles through heavy lifting, equipment handling, repetitive gripping, and sustained wrist positioning during food preparation activities that contributed to progressive worsening of the initial strain.
Sequelae
This condition is not a sequelae of another known condition but represents primary traumatic strain 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 for specific muscle strain identification and treatment. 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
