Reference Determination Content
Suggested draft · fictitious patient
Right Ribs - 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 26 August 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 26 August 2025;
- An outpatient health record by the medical officer, Garrison health centre, dated 18 September 2008;
- A pre-deployment medical examination by the medical officer, dated 20 November 2008;
- A trauma admission and CT chest report by Role 3 hospital, Afghanistan, dated 4 June 2009;
- A discharge summary and outpatient record by the medical officer, Afghanistan, dated 22 June 2009;
- An outpatient health record and X-ray report by Role 2 facility, Afghanistan, dated 15 December 2009;
- A CT chest report by the radiologist, dated 22 February 2010;
- A DEXA report and endocrinology consultation by the endocrinologist, dated 1 March 2010;
- An operation report by the thoracic surgeon, dated 10 August 2010.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
13 January 1986 and 9 June 2011
Right Ribs - 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: Fracture
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 26 August 2025, and is supported by a trauma admission and CT chest report by Role 3 hospital, Afghanistan, dated 4 June 2009.
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 severe right chest wall pain worse on breathing, coughing and movement, with crepitus over the lower right ribs and pain at the base of the right neck on 4 June 2009.
The diagnosis was confirmed by CT of the chest on 4 June 2009, which showed a displaced fracture of the right first rib through a fatigue-type stress fracture with sclerotic margins and periosteal new bone, and acute fractures of the right sixth, seventh and eighth ribs. This meets the Statement of Principles definition of fracture, which includes stress fracture of the fatigue type.
This has then led to further investigations and the diagnosis of your condition of Fracture. I have accepted your condition of 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 4 June 2009.
Right Ribs - 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 26 August 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 26 August 2025;
- An outpatient health record by the medical officer, Garrison health centre, dated 18 September 2008;
- A pre-deployment medical examination by the medical officer, dated 20 November 2008;
- A trauma admission and CT chest report by Role 3 hospital, Afghanistan, dated 4 June 2009;
- A discharge summary and outpatient record by the medical officer, Afghanistan, dated 22 June 2009;
- An outpatient health record and X-ray report by Role 2 facility, Afghanistan, dated 15 December 2009;
- A CT chest report by the radiologist, dated 22 February 2010;
- A DEXA report and endocrinology consultation by the endocrinologist, dated 1 March 2010;
- An operation report by the thoracic surgeon, dated 10 August 2010.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
13 January 1986 and 9 June 2011
Right Ribs - 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
- 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
- inability to obtain appropriate clinical management for fracture before clinical worsening
Diagnosis: Fracture (Worsening)
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 26 August 2025, and is supported by a trauma admission and CT chest report by Role 3 hospital, Afghanistan, dated 4 June 2009.
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:
- 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
- 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 severe right chest wall pain worse on breathing, coughing and movement, with crepitus over the lower right ribs and pain at the base of the right neck on 4 June 2009.
The diagnosis was confirmed by CT of the chest on 4 June 2009, which showed a displaced fracture of the right first rib through a fatigue-type stress fracture with sclerotic margins and periosteal new bone, and acute fractures of the right sixth, seventh and eighth ribs. This meets the Statement of Principles definition of fracture, which includes stress fracture of the fatigue type.
After the condition arose, it was worsened during your service. You smoked about 20 cigarettes a day while on warlike service in Afghanistan throughout the treatment of the fractures, from 4 June 2009 to the non-union on 15 December 2009. Poorly controlled type 2 diabetes, with an HbA1c of 8.9 per cent on 15 December 2009, was present at the non-union on warlike service in Afghanistan. DEXA on 1 March 2010 showed osteoporosis, with a lumbar spine T-score of minus 2.8, due to hypogonadism and coeliac disease. Serum 25-hydroxyvitamin D was 31 nmol/L on 22 February 2010, below 50 nmol/L, after a year of working in covered headquarters and vehicles in Afghanistan with coeliac malabsorption. You weighed 128 kg at a height of 1.78 m on 15 December 2009, a BMI of 40.4, at the non-union on warlike service in Afghanistan. On warlike service in Afghanistan you could not obtain the advised follow-up imaging, physiotherapy or rest from load carriage after your fractures, and you resumed carrying the radio in July 2009.
This has then led to further investigations and the diagnosis of your condition of Fracture (Worsening). I have accepted your condition of 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 wartime service.
I have therefore accepted that the worsening of this condition is related to your service with effect from 15 December 2009.
