Reference Determination Content
Suggested draft · fictitious patient
Right Lower Leg - Tibial 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 September 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 2 September 2025;
- An operation report by the orthopaedic surgeon, dated 19 November 2007;
- A CT scanogram report by the radiologist, dated 14 August 2008;
- A pre-deployment health assessment by the medical officer, dated 8 February 2010;
- A deployed health record by the regimental medical officer, Afghanistan, dated 28 June 2010;
- An emergency record and X-ray report by Role 3 hospital, Afghanistan, dated 22 July 2010;
- An operation report by the orthopaedic surgeon, dated 27 July 2010;
- A psychiatric assessment by the consultant psychiatrist, dated 15 September 2010;
- A general practice record and pathology by the medical officer, dated 4 April 2011;
- A DXA bone densitometry report by the radiologist, dated 12 May 2011;
- A specialist consultation and CT report by the orthopaedic surgeon, dated 28 June 2011;
- An operation report by the orthopaedic surgeon, dated 19 September 2011.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
12 February 2005 and 9 September 2016
Right Lower Leg - Tibial 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: Tibial Fracture
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 2 September 2025, and is supported by an emergency record and X-ray report by Role 3 hospital, Afghanistan, dated 22 July 2010.
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 three weeks of aching anterior shin pain with load carriage on 22 July 2010.
The diagnosis was confirmed by X-ray at the role 3 hospital on 22 July 2010, which showed a displaced transverse fracture of the right tibial mid-shaft through a horizontal anterior cortical lucency with periosteal reaction, the appearance of a pre-existing fatigue stress fracture, together with a fibular fracture. This is an acquired break of bone from an applied force that would ordinarily break healthy bone and includes a stress fracture of the fatigue type, meeting the Statement of Principles definition of fracture. The bone was healthy at the time, so it is not a pathological or insufficiency fracture.
This has then led to further investigations and the diagnosis of your condition of Tibial Fracture. I have accepted your condition of Tibial 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 22 July 2010.
Right Lower Leg - Tibial 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 September 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 2 September 2025;
- An operation report by the orthopaedic surgeon, dated 19 November 2007;
- A CT scanogram report by the radiologist, dated 14 August 2008;
- A pre-deployment health assessment by the medical officer, dated 8 February 2010;
- A deployed health record by the regimental medical officer, Afghanistan, dated 28 June 2010;
- An emergency record and X-ray report by Role 3 hospital, Afghanistan, dated 22 July 2010;
- An operation report by the orthopaedic surgeon, dated 27 July 2010;
- A psychiatric assessment by the consultant psychiatrist, dated 15 September 2010;
- A general practice record and pathology by the medical officer, dated 4 April 2011;
- A DXA bone densitometry report by the radiologist, dated 12 May 2011;
- A specialist consultation and CT report by the orthopaedic surgeon, dated 28 June 2011;
- An operation report by the orthopaedic surgeon, dated 19 September 2011.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
12 February 2005 and 9 September 2016
Right Lower Leg - Tibial 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: Tibial Fracture (Worsening)
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 2 September 2025, and is supported by an emergency record and X-ray report by Role 3 hospital, Afghanistan, dated 22 July 2010.
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 three weeks of aching anterior shin pain with load carriage on 22 July 2010.
The diagnosis was confirmed by X-ray at the role 3 hospital on 22 July 2010, which showed a displaced transverse fracture of the right tibial mid-shaft through a horizontal anterior cortical lucency with periosteal reaction, the appearance of a pre-existing fatigue stress fracture, together with a fibular fracture. This is an acquired break of bone from an applied force that would ordinarily break healthy bone and includes a stress fracture of the fatigue type, meeting the Statement of Principles definition of fracture. The bone was healthy at the time, so it is not a pathological or insufficiency fracture.
After the condition arose, it was worsened during your service. You smoked about 25 cigarettes a day throughout treatment of the fracture, from 22 July 2010 to the non-union on 28 June 2011, as recorded on admission on 27 July 2010 and at review on 28 June 2011. Type 2 diabetes mellitus was diagnosed on 4 April 2011, with an HbA1c of 7.6 per cent, caused by weight gain on olanzapine prescribed by Defence-funded psychiatrists for your service-related posttraumatic stress disorder. In February 2011 the orthopaedic surgeon recommended dynamisation of the intramedullary nail for delayed union, but the procedure was delayed four months on the surgical waiting list, and by 28 June 2011 the fracture had progressed to non-union.
This has then led to further investigations and the diagnosis of your condition of Tibial Fracture (Worsening). I have accepted your condition of Tibial 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 28 June 2011.
