Reference Determination Content
Suggested draft · fictitious patient
Right Ankle - Talus 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 2 July 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 2 July 2025;
- A training accident report and operation report by the orthopaedic surgeon, dated 18 August 2011;
- An orthopaedic review and long-leg radiographs by the orthopaedic surgeon, dated 5 June 2012;
- A role 2 consultation by the medical officer, Afghanistan, dated 2 March 2013;
- A role 3 hospital trauma record and CT report by the afghanistan, dated 14 April 2013;
- An operation report by the orthopaedic surgeon, dated 18 April 2013;
- A specialist consultation and bronchoscopy report by the respiratory physician, dated 28 May 2013;
- An outpatient health record (pathology and bone densitometry) by the medical officer, dated 15 November 2013;
- A pathology report by the medical officer, dated 16 January 2014;
- A CT right ankle and orthopaedic review by the orthopaedic surgeon, dated 20 January 2014;
- An operation report by the orthopaedic surgeon, dated 12 March 2014;
- A CT right ankle by the radiologist, dated 14 October 2014.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
5 February 2007 and 11 March 2016
Right Ankle - Talus 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: Talus Fracture
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 2 July 2025, and is supported by a role 3 hospital trauma record and CT report by the afghanistan, dated 14 April 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 sudden severe pain in the right ankle and hindfoot with immediate inability to bear weight, swelling and bruising, preceded by six weeks of load-related aching over the front of the ankle on 14 April 2013.
The diagnosis was confirmed by CT of the right ankle on 14 April 2013, which showed a displaced talar neck fracture with subtalar subluxation (Hawkins type II) and sclerotic margins of a pre-existing fatigue stress fracture at the fracture site. This is an acquired break of bone from a force that ordinarily breaks a healthy bone, and a stress fracture of the fatigue type, both within the Statement of Principles definition. It is not a pathological fracture, an insufficiency fracture, a bone stress injury without fracture or osteonecrosis: the bone was normal before the 2013 deployment and the osteoporosis developed only after the fracture.
This has then led to further investigations and the diagnosis of your condition of Talus Fracture. I have accepted your condition of Talus 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.
Right Ankle - Talus 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 2 July 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 2 July 2025;
- A training accident report and operation report by the orthopaedic surgeon, dated 18 August 2011;
- An orthopaedic review and long-leg radiographs by the orthopaedic surgeon, dated 5 June 2012;
- A role 2 consultation by the medical officer, Afghanistan, dated 2 March 2013;
- A role 3 hospital trauma record and CT report by the afghanistan, dated 14 April 2013;
- An operation report by the orthopaedic surgeon, dated 18 April 2013;
- A specialist consultation and bronchoscopy report by the respiratory physician, dated 28 May 2013;
- An outpatient health record (pathology and bone densitometry) by the medical officer, dated 15 November 2013;
- A pathology report by the medical officer, dated 16 January 2014;
- A CT right ankle and orthopaedic review by the orthopaedic surgeon, dated 20 January 2014;
- An operation report by the orthopaedic surgeon, dated 12 March 2014;
- A CT right ankle by the radiologist, dated 14 October 2014.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
5 February 2007 and 11 March 2016
Right Ankle - Talus 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: Talus Fracture (Worsening)
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 2 July 2025, and is supported by a role 3 hospital trauma record and CT report by the afghanistan, dated 14 April 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 sudden severe pain in the right ankle and hindfoot with immediate inability to bear weight, swelling and bruising, preceded by six weeks of load-related aching over the front of the ankle on 14 April 2013.
The diagnosis was confirmed by CT of the right ankle on 14 April 2013, which showed a displaced talar neck fracture with subtalar subluxation (Hawkins type II) and sclerotic margins of a pre-existing fatigue stress fracture at the fracture site. This is an acquired break of bone from a force that ordinarily breaks a healthy bone, and a stress fracture of the fatigue type, both within the Statement of Principles definition. It is not a pathological fracture, an insufficiency fracture, a bone stress injury without fracture or osteonecrosis: the bone was normal before the 2013 deployment and the osteoporosis developed only after the fracture.
After the condition arose, it was worsened during your service. You smoked 10 cigarettes a day before deployment, increasing to 20 a day in Afghanistan. High-dose prednisolone for chronic eosinophilic pneumonia from 28 May 2013 caused glucocorticoid-induced diabetes mellitus, diagnosed on 15 November 2013 with an HbA1c of 7.6 per cent and a fasting glucose of 9.1 mmol/L, and treated with metformin. After your return from Afghanistan you sought help through your regimental medical officer, but follow-up imaging was cancelled twice because of posting and unit relocation, so the delayed union was not identified until CT on 20 January 2014, nine months after fixation.
This has then led to further investigations and the diagnosis of your condition of Talus Fracture (Worsening). I have accepted your condition of Talus 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 20 January 2014.
