Reference Determination Content
Suggested draft · fictitious patient
Left Foot - Fifth Toe Fracture
Evidence
The evidence that I have considered in making this decision includes:
- Formal Claim with supporting statements;
- A Statement of your Service from the Department of Defence;
- Copies of your Service Medical Records.
- A Diagnostic Assessment by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 19 May 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 19 May 2025;
- An emergency department record and X-ray left tibia by the regional hospital, dated 6 August 2004;
- A gastroenterology consultation and duodenal biopsy report by the gastroenterologist, dated 22 June 2009;
- An outpatient health record by the medical officer, Naval base health centre, dated 14 March 2011;
- A DEXA bone densitometry by the radiologist, dated 2 May 2011;
- A pre-deployment medical examination by the medical officer, dated 15 November 2012;
- A ship's sick bay record by the ship's medical officer, dated 10 March 2013;
- A ship's sick bay record and incident report by the ship's medical officer, dated 14 April 2013;
- An X-ray left foot and telehealth orthopaedic opinion by the radiologist and orthopaedic surgeon, dated 27 May 2013;
- A long-leg alignment X-ray by the radiologist, dated 17 June 2013;
- A DEXA bone densitometry by the radiologist, dated 10 October 2013;
- A CT left foot and orthopaedic consultation by the orthopaedic surgeon, dated 21 November 2013;
- An operation report by the orthopaedic surgeon, dated 4 April 2014.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
12 January 1997 and 3 March 2016
Left Foot - Fifth Toe Fracture
You have stated that your condition was caused by:
- having significant physical force applied to or through the affected bone at the time of clinical onset
- for stress fracture only, having significant repetitive loading stress to the affected bone prior to clinical onset
- 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
Diagnosis: Fifth Toe Fracture
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 19 May 2025, and is supported by an X-ray left foot and telehealth orthopaedic opinion by the radiologist and orthopaedic surgeon, dated 27 May 2013.
I am satisfied this is the appropriate diagnosis.
In determining your claim for this condition, I have applied the SOP:
Statement of Principles concerning Fracture (Reasonable Hypothesis) (No. 62 of 2024)
which sets out the factors that can connect the condition with service.
I am satisfied that you have met the following factor:
- having significant physical force applied to or through the affected bone at the time of clinical onset
- for stress fracture only, having significant repetitive loading stress to the affected bone prior to clinical onset
- 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
I have noted your contention as to the cause of this condition. The available evidence indicates, I have noted your contention to the cause of your condition. Your service medical records indicate that you presented to the health facility with immediate severe pain, swelling, bruising and deformity of the left little toe, with inability to bear weight on the outer border of the foot on 14 April 2013.
The diagnosis was confirmed by X-ray on 27 May 2013, which showed a displaced oblique fracture of the proximal phalanx of the left fifth toe with periosteal reaction and sclerosis indicating a pre-existing stress fracture, after a witnessed impact on 14 April 2013 with immediate pain, swelling, bruising and deformity. The fracture resulted from an applied force sufficient to break healthy bone, and the stress component is a stress fracture of the fatigue type, both within the Statement of Principles definition. It was not a pathological fracture through a tumour or other focal lesion.
This has then led to further investigations and the diagnosis of your condition of Fifth Toe Fracture. I have accepted your condition of Fifth Toe Fracture.
Having considered your service records and the available medical evidence, I am satisfied the SOP is met and that this condition is related to your wartime service.
I have therefore accepted that this condition is related to your service with effect from 14 April 2013.
Left Foot - Fifth Toe Fracture (Worsening)
Evidence
The evidence that I have considered in making this decision includes:
- Formal Claim with supporting statements;
- A Statement of your Service from the Department of Defence;
- Copies of your Service Medical Records.
- A Diagnostic Assessment by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 19 May 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 19 May 2025;
- An emergency department record and X-ray left tibia by the regional hospital, dated 6 August 2004;
- A gastroenterology consultation and duodenal biopsy report by the gastroenterologist, dated 22 June 2009;
- An outpatient health record by the medical officer, Naval base health centre, dated 14 March 2011;
- A DEXA bone densitometry by the radiologist, dated 2 May 2011;
- A pre-deployment medical examination by the medical officer, dated 15 November 2012;
- A ship's sick bay record by the ship's medical officer, dated 10 March 2013;
- A ship's sick bay record and incident report by the ship's medical officer, dated 14 April 2013;
- An X-ray left foot and telehealth orthopaedic opinion by the radiologist and orthopaedic surgeon, dated 27 May 2013;
- A long-leg alignment X-ray by the radiologist, dated 17 June 2013;
- A DEXA bone densitometry by the radiologist, dated 10 October 2013;
- A CT left foot and orthopaedic consultation by the orthopaedic surgeon, dated 21 November 2013;
- An operation report by the orthopaedic surgeon, dated 4 April 2014.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
12 January 1997 and 3 March 2016
Left Foot - Fifth Toe Fracture (Worsening)
You have stated that the worsening of your condition was caused by:
- smoking at least 5 cigarettes per day, or the equivalent thereof in other tobacco products, during treatment for fracture prior to fracture non-union
- having diabetes mellitus at the time of the fracture non-union
- inability to obtain appropriate clinical management for fracture before clinical worsening
Diagnosis: Fifth Toe Fracture (Worsening)
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 19 May 2025, and is supported by an X-ray left foot and telehealth orthopaedic opinion by the radiologist and orthopaedic surgeon, dated 27 May 2013.
I am satisfied this is the appropriate diagnosis.
In determining your claim for this condition, I have applied the SOP:
Statement of Principles concerning Fracture (Balance of Probabilities) (No. 63 of 2024)
which sets out the factors that can connect the condition with service.
I am satisfied that you have met the following factor:
- smoking at least 5 cigarettes per day, or the equivalent thereof in other tobacco products, during treatment for fracture prior to fracture non-union
- having diabetes mellitus at the time of the fracture non-union
- inability to obtain appropriate clinical management for fracture before clinical worsening
I have noted your contention as to the cause of this condition. The available evidence indicates, I have noted your contention to the cause of your condition. Your service medical records indicate that you presented to the health facility with immediate severe pain, swelling, bruising and deformity of the left little toe, with inability to bear weight on the outer border of the foot on 14 April 2013.
The diagnosis was confirmed by X-ray on 27 May 2013, which showed a displaced oblique fracture of the proximal phalanx of the left fifth toe with periosteal reaction and sclerosis indicating a pre-existing stress fracture, after a witnessed impact on 14 April 2013 with immediate pain, swelling, bruising and deformity. The fracture resulted from an applied force sufficient to break healthy bone, and the stress component is a stress fracture of the fatigue type, both within the Statement of Principles definition. It was not a pathological fracture through a tumour or other focal lesion.
After the condition arose, it was worsened during your service. You smoked 20 cigarettes a day throughout treatment of the fracture, from 14 April 2013 to the confirmation of non-union on 21 November 2013, as recorded at the port visit of 27 May 2013 and by the orthopaedic surgeon. Type 2 diabetes mellitus was diagnosed on 14 March 2011 during peacetime service and treated with metformin. After the injury on 14 April 2013 no X-ray was available for six weeks, the fracture was buddy-taped only, and the recommended stiff-soled boot and restricted weight bearing could not be provided at sea, so you kept climbing ladders in safety boots.
This has then led to further investigations and the diagnosis of your condition of Fifth Toe Fracture (Worsening). I have accepted your condition of Fifth Toe Fracture (Worsening).
Having considered your service records and the available medical evidence, I am satisfied the SOP is met and that the worsening of this condition is related to your peacetime service.
I have therefore accepted that the worsening of this condition is related to your service with effect from 21 November 2013.
