Reference Determination Content
Suggested draft · fictitious patient
Right Thumb - 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 22 May 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 22 May 2025;
- An outpatient health record by the medical officer, frigate, dated 14 May 2011;
- A hand therapy assessment by the hand therapist, dated 30 August 2011;
- A bone densitometry report by the radiologist, dated 12 March 2012;
- A ship's medical record by the medical officer, dated 20 January 2014;
- A ship's medical record by the medical officer, dated 11 February 2014;
- An X-ray right thumb report by the radiologist, coalition medical facility, dated 2 March 2014;
- A CT right thumb report by the radiologist, dated 3 March 2014;
- A specialist consultation by the hand surgeon, dated 4 March 2014;
- An operation report by the hand surgeon, dated 9 April 2014;
- A pathology report by the hba1c and 25-hydroxyvitamin d, dated 20 August 2014;
- A bone densitometry report by the radiologist, dated 21 August 2014;
- A CT right thumb report and specialist review by the hand surgeon, dated 25 August 2014;
- An operation report by the hand surgeon, dated 16 October 2014.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
14 January 1980 and 19 September 2016
Right Thumb - 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 22 May 2025, and is supported by an X-ray right thumb report by the radiologist, coalition medical facility, dated 2 March 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
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 pain, swelling and deformity at the base of the right thumb, inability to pinch or grip, and pain on any thumb movement on 11 February 2014.
The diagnosis was made clinically by the ship's medical officer on 11 February 2014 and confirmed on X-ray on 2 March 2014, which showed an intra-articular fracture of the base of the right first metacarpal with radial and proximal subluxation of the metacarpal shaft. CT on 3 March 2014 confirmed a 3 mm articular step. This meets the Statement of Principles definition of fracture, an acquired break of bone from an applied force that ordinarily would cause bone breakage in a healthy bone. The periosteal new bone at the metacarpal base on CT indicates that a stress reaction from repetitive loading preceded the acute break.
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 11 February 2014.
Right Thumb - 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 22 May 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 22 May 2025;
- An outpatient health record by the medical officer, frigate, dated 14 May 2011;
- A hand therapy assessment by the hand therapist, dated 30 August 2011;
- A bone densitometry report by the radiologist, dated 12 March 2012;
- A ship's medical record by the medical officer, dated 20 January 2014;
- A ship's medical record by the medical officer, dated 11 February 2014;
- An X-ray right thumb report by the radiologist, coalition medical facility, dated 2 March 2014;
- A CT right thumb report by the radiologist, dated 3 March 2014;
- A specialist consultation by the hand surgeon, dated 4 March 2014;
- An operation report by the hand surgeon, dated 9 April 2014;
- A pathology report by the hba1c and 25-hydroxyvitamin d, dated 20 August 2014;
- A bone densitometry report by the radiologist, dated 21 August 2014;
- A CT right thumb report and specialist review by the hand surgeon, dated 25 August 2014;
- An operation report by the hand surgeon, dated 16 October 2014.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
14 January 1980 and 19 September 2016
Right Thumb - 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: Fracture (Worsening)
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 22 May 2025, and is supported by an X-ray right thumb report by the radiologist, coalition medical facility, dated 2 March 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 severe pain, swelling and deformity at the base of the right thumb, inability to pinch or grip, and pain on any thumb movement on 11 February 2014.
The diagnosis was made clinically by the ship's medical officer on 11 February 2014 and confirmed on X-ray on 2 March 2014, which showed an intra-articular fracture of the base of the right first metacarpal with radial and proximal subluxation of the metacarpal shaft. CT on 3 March 2014 confirmed a 3 mm articular step. This meets the Statement of Principles definition of fracture, an acquired break of bone from an applied force that ordinarily would cause bone breakage in a healthy bone. The periosteal new bone at the metacarpal base on CT indicates that a stress reaction from repetitive loading preceded the acute break.
After the condition arose, it was worsened during your service. You smoked about 15 cigarettes a day throughout the treatment of the fracture, from 11 February 2014 to the diagnosis of non-union on CT on 25 August 2014, as recorded by the hand surgeon on 4 March 2014 and 25 August 2014. You had type 2 diabetes mellitus, diagnosed on 17 June 2009 with an HbA1c of 8.4 per cent and treated with metformin and gliclazide. On board the frigate there was no X-ray facility.
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 peacetime service.
I have therefore accepted that the worsening of this condition is related to your service with effect from 25 August 2014.
