Reference Determination Content
Suggested draft · fictitious patient
Left Hip - ASIS Avulsion 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 17 June 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 17 June 2025;
- A hospital admission and operation report by the orthopaedic surgeon, dated 26 March 2009;
- An annual fitness assessment and remedial program record by the physical training instructor, dated 14 October 2013;
- A pre-deployment medical examination by the medical officer, dated 6 January 2014;
- A ship's sick bay record by the medical sailor, Middle East, dated 22 April 2014;
- A ship's sick bay record by the ship's medical officer, Middle East, dated 17 June 2014;
- An X-ray report by the coalition medical facility, dated 19 June 2014;
- A specialist consultation and CT report by the orthopaedic surgeon and radiologist, dated 2 October 2014;
- An operation report (open reduction and internal fixation) by the orthopaedic surgeon, dated 14 October 2014;
- An outpatient health record and pathology by the medical officer, dated 10 March 2015;
- A DXA report and vitamin D result by the radiologist and pathologist, dated 15 April 2015;
- A CT pelvis report by the radiologist, dated 22 April 2015;
- An operation report (revision fixation and bone grafting) by the orthopaedic surgeon, dated 18 June 2015.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
7 July 2004 and 14 May 2021
Left Hip - ASIS Avulsion 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
- 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
- having osteoporosis at the time of the fracture non-union
- 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
- having a Body Mass Index (BMI) of 40 or greater at the time of the fracture non-union
Diagnosis: ASIS Avulsion Fracture
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 17 June 2025, and is supported by an X-ray report by the coalition medical facility, dated 19 June 2014.
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
- 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
- having osteoporosis at the time of the fracture non-union
- 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
- having a Body Mass Index (BMI) of 40 or greater at the time of the fracture non-union
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 two months of aching left anterior hip pain with running on 17 June 2014.
The diagnosis was confirmed by radiographs on 19 June 2014, which showed a displaced avulsion fracture of the left anterior superior iliac spine with the fragment 15 mm from its bed and sclerotic margins indicating a pre-existing fatigue-type stress fracture. This meets the Statement of Principles definition of fracture, which includes avulsion fracture and stress fracture of the fatigue type, and the injury was caused by an applied force. The clinical findings were consistent: sudden pain and a pop during a forceful hip movement, inability to bear weight, a palpable step, bruising and pain on resisted hip flexion.
This has then led to further investigations and the diagnosis of your condition of ASIS Avulsion Fracture. I have accepted your condition of ASIS Avulsion 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 17 June 2014.
Left Hip - ASIS Avulsion 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 17 June 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 17 June 2025;
- A hospital admission and operation report by the orthopaedic surgeon, dated 26 March 2009;
- An annual fitness assessment and remedial program record by the physical training instructor, dated 14 October 2013;
- A pre-deployment medical examination by the medical officer, dated 6 January 2014;
- A ship's sick bay record by the medical sailor, Middle East, dated 22 April 2014;
- A ship's sick bay record by the ship's medical officer, Middle East, dated 17 June 2014;
- An X-ray report by the coalition medical facility, dated 19 June 2014;
- A specialist consultation and CT report by the orthopaedic surgeon and radiologist, dated 2 October 2014;
- An operation report (open reduction and internal fixation) by the orthopaedic surgeon, dated 14 October 2014;
- An outpatient health record and pathology by the medical officer, dated 10 March 2015;
- A DXA report and vitamin D result by the radiologist and pathologist, dated 15 April 2015;
- A CT pelvis report by the radiologist, dated 22 April 2015;
- An operation report (revision fixation and bone grafting) by the orthopaedic surgeon, dated 18 June 2015.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
7 July 2004 and 14 May 2021
Left Hip - ASIS Avulsion 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: ASIS Avulsion Fracture (Worsening)
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 17 June 2025, and is supported by an X-ray report by the coalition medical facility, dated 19 June 2014.
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 two months of aching left anterior hip pain with running on 17 June 2014.
The diagnosis was confirmed by radiographs on 19 June 2014, which showed a displaced avulsion fracture of the left anterior superior iliac spine with the fragment 15 mm from its bed and sclerotic margins indicating a pre-existing fatigue-type stress fracture. This meets the Statement of Principles definition of fracture, which includes avulsion fracture and stress fracture of the fatigue type, and the injury was caused by an applied force. The clinical findings were consistent: sudden pain and a pop during a forceful hip movement, inability to bear weight, a palpable step, bruising and pain on resisted hip flexion.
After the condition arose, it was worsened during your service. You smoked 15 to 20 cigarettes a day throughout your treatment, from the fracture on 17 June 2014 through the fixation of 14 October 2014 to the non-union confirmed on 22 April 2015. Type 2 diabetes mellitus was diagnosed on 10 March 2015 with an HbA1c of 8.1 per cent, after weight gain from 112 kg to 124 kg during prolonged immobility on crutches following the service fracture. After the fracture was diagnosed on 19 June 2014 no orthopaedic surgeon was available, and you were returned to your ship, which sailed for nine weeks.
This has then led to further investigations and the diagnosis of your condition of ASIS Avulsion Fracture (Worsening). I have accepted your condition of ASIS Avulsion 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 22 April 2015.
