Diagnostic Assessment — Right Wrist - TFCC Sprain
Example 1 of 2 · fictitious patient (Veteran C)
Diagnostic Assessment
Right Wrist - TFCC Sprain
Balance of Probabilities: Sprain and Strain No. 28 of 2020 Reasonable Hypothesis: Sprain and Strain No. 29 of 2020
ADF History
The veteran, Date of Birth: [withheld] Communications and Information Systems Controller (CISCON), enlistment date 28 July 1986, discharge date 22 Mar 2003.
Occupational History
As a Communications and Information Systems Controller in the Royal Australian Air Force, the veteran was exposed to repetitive manual handling of communication equipment, prolonged computer use with repetitive hand and wrist movements, physical training activities including obstacle courses and combat training, deployment conditions requiring equipment setup and maintenance, and ergonomic stressors from field operations. The role involved significant risk of falls during training exercises, manual handling of heavy technical equipment, repetitive wrist-intensive tasks during equipment operation and maintenance, and exposure to environments that increased the likelihood of traumatic injuries during both training and operational activities.
History
The veteran a Communications and Information Systems Controller in the RAAF, sustained a TFCC sprain to his right wrist following a fall where he used his hand to break his fall during service-related activities. The injury occurred during his military service and resulted in ongoing pain and limited range of motion affecting his functional capacity.
Timeline
- 19 January 2016 - the veteran underwent comprehensive MRI imaging of the right wrist which revealed a focal full-thickness central tear/perforation of the triangular fibrocartilage disc immediately adjacent to the radial insertion, with associated fraying of the foveal and styloidal attachments of the TFCC noted. He reported experiencing ongoing wrist pain and significantly limited range of motion following a fall where he used his hand to break the fall during service-related activities. The MRI also demonstrated a small effusion within the distal radioulnar joint, indicating active inflammation and joint irritation. The patient described persistent and debilitating pain occurring 7 days per week for 14 hours daily, with severe functional limitations in gripping and manual tasks that significantly impacted his ability to perform activities of daily living. His current management regime included physiotherapy sessions, exercise physiology consultations, and regular use of anti-inflammatory medications including Panadol and ibuprofen gel, however symptoms were reported as persisting and continuing to affect his daily activities including basic tasks such as lifting, pushing, and performing routine household functions.
Symptoms
At the time of the initial injury, the veteran experienced immediate and severe wrist pain accompanied by markedly reduced range of motion following the traumatic fall on his outstretched hand. The acute symptoms included sharp, localized pain to the ulnar aspect of the wrist joint with significant difficulty in gripping objects and severely restricted wrist movement in all planes of motion, particularly affecting his ability to perform rotational movements of the forearm.
Currently, the veteran continues to experience chronic and debilitating right wrist pain occurring consistently 7 days per week for 14 hours daily, representing a substantial burden of ongoing symptoms. He reports significant functional limitations in gripping and manual tasks, with persistent pain and markedly limited range of motion that severely impacts his quality of life. The symptoms significantly impair his activities of daily living including lifting objects, pushing movements, and performing basic household tasks such as opening jars, carrying shopping, and routine manual activities. Despite ongoing conservative management including physiotherapy, exercise physiology interventions, and regular anti-inflammatory medications, he continues to experience persistent symptoms that limit his functional capacity and occupational activities.
Imaging
- 19 January 2016 - MRI right wrist: Focal full-thickness central tear/perforation of the triangular fibrocartilage disc immediately adjacent to the radial insertion. Fraying of the foveal and styloidal attachments of the TFCC noted. Small effusion noted within the distal radioulnar joint.
1. What is the formal diagnosis of the condition claimed above?
Right Wrist TFCC Sprain - DVA SOP: Sprain and Strain No. 28 of 2020 (Balance of Probabilities), ICD-10: S63.519
The Triangular Fibrocartilage Complex (TFCC) is a critical anatomical structure located on the ulnar (pinky finger) side of the wrist, situated between the distal ulna bone and the proximal carpal bones. The TFCC is composed of several interconnected components including the triangular fibrocartilage disc (also known as the articular disc), the dorsal and volar radioulnar ligaments, the ulnocarpal ligaments (specifically the ulnolunate and ulnotriquetral ligaments), the meniscal homologue, and the extensor carpi ulnaris tendon sheath. This complex structure serves multiple critical biomechanical functions including acting as a primary shock absorber for forces transmitted through the ulnar side of the wrist, providing essential stability to the distal radioulnar joint during forearm rotation (pronation and supination), and facilitating smooth load transfer between the forearm and the hand during weight-bearing activities. A TFCC sprain represents an injury involving tearing, stretching, or disruption of the ligamentous and fibrocartilaginous components of this complex, most commonly occurring as a result of falls on an outstretched hand with the wrist positioned in extension and ulnar deviation, rotational injuries during sports or occupational activities, or repetitive loading activities that place excessive stress on the ulnar wrist structures. The severity of TFCC injuries can range from partial thickness tears affecting only specific components of the complex to complete perforations extending through the full thickness of the triangular fibrocartilage disc, and may be associated with concurrent inflammation, joint effusion, and secondary instability of the distal radioulnar joint.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition? The veteran first experienced symptoms of right wrist pain and limited range of motion following a fall where he used his hand to break the fall. The exact date of symptom onset is not specified in the documentation but occurred prior to the MRI diagnosis in 2022. [IMAGING.pdf, Page 1; PTQ.pdf, Page 1]
When did the veteran first present to a health / medical provider for this condition? The first documented presentation for the right wrist TFCC sprain was on 19 January 2016 when he underwent comprehensive MRI imaging. The specific healthcare provider who ordered the MRI is not identified in the documentation. [IMAGING.pdf, Pages 3, 5]
When was the condition confirmed / formally diagnosed? The TFCC sprain was confirmed and formally diagnosed on 19 January 2016 via MRI imaging performed by the treating doctor, which demonstrated a focal full-thickness central tear/perforation of the triangular fibrocartilage disc immediately adjacent to the radial insertion. [IMAGING.pdf, Pages 3, 5]
When did the veteran first present to you (or your practice) for this condition? 01 August 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 diagnosis was definitively confirmed through comprehensive MRI imaging performed on 19 January 2016. The key clinical symptoms included ongoing right wrist pain and significantly limited range of motion following a traumatic fall where the patient used his hand to break the fall. The investigation results demonstrated clear pathological findings including a focal full-thickness central tear/perforation of the triangular fibrocartilage disc immediately adjacent to the radial insertion, with associated fraying of the foveal and styloidal attachments of the TFCC, and a small effusion within the distal radioulnar joint indicating active inflammation. The patient reported persistent and debilitating pain occurring 7 days per week for 14 hours daily, with severe functional limitations in gripping and manual tasks that significantly impacted his ability to perform routine activities of daily living. The clinical presentation was consistent with a significant TFCC injury, and the MRI findings provided definitive imaging confirmation of the structural damage to the triangular fibrocartilage complex. [IMAGING.pdf, Pages 3, 5; PTQ.pdf, Page 1]
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.
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 the TFCC sprain from a traumatic fall where he used his hand to break the fall, which constitutes significant physical force applied through the wrist joint at the time of clinical onset. The mechanism of injury involving a fall on an outstretched hand with the wrist in extension is a well-recognized cause of TFCC injuries, where the sudden impact and loading forces transmitted through the wrist joint exceed the structural capacity of the triangular fibrocartilage complex, resulting in tearing and disruption of the ligamentous components.
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 - NOT MET
- While the TFCC injury involved ligamentous structures rather than muscle or tendon strain, the traumatic mechanism did involve forceful stretching of the wrist ligaments. However, this factor specifically relates to muscle or tendon strain rather than ligamentous sprain, and therefore does not directly apply to this TFCC ligament injury.
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 - NOT MET
- There is no documented evidence of a specific incident involving significant physical force that caused clinical worsening of the existing TFCC sprain. The ongoing symptoms appear to represent the natural progression and chronic effects of the original traumatic injury rather than a separate worsening event.
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 - NOT MET
- This factor relates to clinical worsening of muscle or tendon strain, which is not applicable to this case of ligamentous TFCC sprain. Additionally, there is no documented evidence of a specific incident causing clinical worsening of the condition.
inability to obtain appropriate clinical management for sprain or strain - NOT MET
- There is no evidence of inability to obtain appropriate clinical management for the TFCC sprain. The condition was diagnosed via comprehensive MRI imaging and is being managed with appropriate conservative treatment including physiotherapy, exercise physiology consultations, and anti-inflammatory medications. The patient has access to and is receiving suitable clinical care for his condition.
Sequelae
The TFCC sprain is not a sequelae of another known condition but appears to be a primary injury resulting directly from the traumatic fall mechanism. The condition represents the immediate consequence of the acute trauma rather than a secondary complication or progression from a pre-existing musculoskeletal disorder.
Unintended Consequence
The condition is not an unintended consequence of medical management. There are no procedures, medications, or medical interventions documented as causing or contributing to this TFCC sprain. The injury resulted from a traumatic accident rather than any form of medical treatment or intervention.
Inability to Attain Appropriate Medical Management
The condition does not demonstrate inability to attain appropriate medical management. The TFCC sprain was diagnosed via comprehensive MRI imaging providing definitive structural assessment, and is being managed with appropriate conservative treatment modalities including physiotherapy for functional restoration, exercise physiology for strength and conditioning, and anti-inflammatory medications for pain and inflammation control. The Full Federal Court in Brew v Repatriation Commission (19 July 1990) enlarges on the meaning of "inability" as the lack of the ability to get treatment in both an objective and subjective sense, encompassing not only the normal lack of power, capacity, ability or means, but also recognizing that the "condition of being unable" can encompass various circumstances including psychological or emotional incapacity that could prevent seeking treatment, or threats of sanctions that would realistically prevent a veteran from seeking required treatment. In this case, appropriate clinical management was provided following diagnosis, with ongoing access to multidisciplinary conservative care. There is no evidence of barriers to healthcare access, delays in diagnosis, or inadequate treatment provision that would satisfy the criteria for inability to attain appropriate medical management. 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
