Reference Determination Content
Suggested draft · fictitious patient
Right Hand Fifth Metacarpal - Undisplaced 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 3 April 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 3 April 2025;
- An outpatient health record and X-ray report by the medical officer, dated 16 June 2004;
- A pre-deployment medical examination by the medical officer, dated 28 March 2005;
- A treatment record by the medical officer, Iraq, dated 3 July 2005;
- A treatment record by the medic, Iraq, dated 29 July 2005;
- A field hospital record and X-ray report by the medical officer, Iraq, dated 19 August 2005;
- An outpatient health record and pathology by the medical officer, Garrison health centre, dated 6 February 2006;
- A DXA report and endocrinology consultation by the endocrinologist, dated 8 March 2006;
- A CT right hand report by the radiologist, dated 20 March 2006;
- An operation report by the hand surgeon, dated 12 April 2006;
- An X-ray right hand report by the radiologist, dated 18 September 2006.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
12 February 2002 and 21 September 2010
Right Hand Fifth Metacarpal - Undisplaced 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: Undisplaced Fracture
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 3 April 2025, and is supported by a field hospital record and X-ray report by the medical officer, Iraq, dated 19 August 2005.
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 pain, swelling and bruising over the ulnar side of the right hand and the fifth knuckle, with loss of the knuckle prominence, pain on gripping and on making a fist on 19 August 2005.
The diagnosis was made on 19 August 2005 on the history of a clenched-fist impact, the clinical findings of swelling and tenderness over the fifth metacarpal neck, and X-rays showing an undisplaced fracture of the neck of the fifth metacarpal with periosteal new bone along the shaft. This meets the Statement of Principles definition of fracture, a break in the continuity of a bone.
This has then led to further investigations and the diagnosis of your condition of Undisplaced Fracture. I have accepted your condition of Undisplaced 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 19 August 2005.
Right Hand Fifth Metacarpal - Undisplaced 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 3 April 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 3 April 2025;
- An outpatient health record and X-ray report by the medical officer, dated 16 June 2004;
- A pre-deployment medical examination by the medical officer, dated 28 March 2005;
- A treatment record by the medical officer, Iraq, dated 3 July 2005;
- A treatment record by the medic, Iraq, dated 29 July 2005;
- A field hospital record and X-ray report by the medical officer, Iraq, dated 19 August 2005;
- An outpatient health record and pathology by the medical officer, Garrison health centre, dated 6 February 2006;
- A DXA report and endocrinology consultation by the endocrinologist, dated 8 March 2006;
- A CT right hand report by the radiologist, dated 20 March 2006;
- An operation report by the hand surgeon, dated 12 April 2006;
- An X-ray right hand report by the radiologist, dated 18 September 2006.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
12 February 2002 and 21 September 2010
Right Hand Fifth Metacarpal - Undisplaced 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: Undisplaced Fracture (Worsening)
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 3 April 2025, and is supported by a field hospital record and X-ray report by the medical officer, Iraq, dated 19 August 2005.
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 pain, swelling and bruising over the ulnar side of the right hand and the fifth knuckle, with loss of the knuckle prominence, pain on gripping and on making a fist on 19 August 2005.
The diagnosis was made on 19 August 2005 on the history of a clenched-fist impact, the clinical findings of swelling and tenderness over the fifth metacarpal neck, and X-rays showing an undisplaced fracture of the neck of the fifth metacarpal with periosteal new bone along the shaft. This meets the Statement of Principles definition of fracture, a break in the continuity of a bone.
After the condition arose, it was worsened during your service. You smoked about 20 cigarettes a day throughout the treatment of the fracture, from 19 August 2005 to the confirmation of non-union on 20 March 2006, as recorded on 3 July 2005, 6 February 2006 and 20 March 2006, including the four months of peacetime service in Australia after your return. Type 2 diabetes mellitus was diagnosed on 6 February 2006, with a fasting glucose of 8.4 millimoles per litre and an HbA1c of 7.2 per cent, after weight gain of 25 kilograms during the inactivity imposed by your knee injury and opioid treatment. After your return to Australia on 30 November 2005 you reported continuing knuckle pain, but the referral to a hand surgeon and the follow-up imaging were delayed by military waiting lists until March 2006, and the fracture remained unsplinted and unimaged for almost four months.
This has then led to further investigations and the diagnosis of your condition of Undisplaced Fracture (Worsening). I have accepted your condition of Undisplaced 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 March 2006.
