Reference Determination Content
Suggested draft · fictitious patient
Right Wrist - Metaphyseal Fracture of Distal Radius
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 February 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 26 February 2025;
- A pre-deployment medical examination by the medical officer, Garrison health centre, dated 4 October 2011;
- A casualty record and X-ray report (left ankle) by Role 2 facility, Afghanistan, dated 2 April 2012;
- A physiotherapy record by the physiotherapist, Afghanistan, dated 14 May 2012;
- A casualty record and X-ray report (right wrist) by Role 2 facility, Afghanistan, dated 21 May 2012;
- A health record by the medical officer, Afghanistan, dated 18 June 2012;
- An orthopaedic consultation and X-ray report by the orthopaedic surgeon, dated 12 November 2012;
- An outpatient health record by the medical officer, Garrison health centre, dated 18 January 2013;
- A DXA report and endocrinology consultation by the endocrinologist, dated 30 January 2013;
- A CT right wrist report by the radiologist, dated 15 February 2013;
- An operation report by the orthopaedic surgeon, dated 7 March 2013;
- A medical discharge documentation by the medical employment classification review board, dated 3 March 2016.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
19 January 2009 and 3 March 2016
Right Wrist - Metaphyseal Fracture of Distal Radius
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: Metaphyseal Fracture of Distal Radius
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 26 February 2025, and is supported by a casualty record and X-ray report (right wrist) by Role 2 facility, Afghanistan, dated 21 May 2012.
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, swelling and deformity of the right distal forearm and wrist after a week of aching over the back of the forearm with crutch walking on 21 May 2012.
The diagnosis was confirmed by X-ray of the right wrist and forearm on 21 May 2012, which showed a transverse fracture through the distal radial metaphysis with dorsal angulation and periosteal new bone along the dorsal cortex, meeting the Statement of Principles definition of fracture as a break in the continuity of a bone. The periosteal reaction and the week of preceding pain with crutch walking identify it as a stress fracture completed by acute trauma.
This has then led to further investigations and the diagnosis of your condition of Metaphyseal Fracture of Distal Radius. I have accepted your condition of Metaphyseal Fracture of Distal Radius.
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 21 May 2012.
Right Wrist - Metaphyseal Fracture of Distal Radius (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 February 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 26 February 2025;
- A pre-deployment medical examination by the medical officer, Garrison health centre, dated 4 October 2011;
- A casualty record and X-ray report (left ankle) by Role 2 facility, Afghanistan, dated 2 April 2012;
- A physiotherapy record by the physiotherapist, Afghanistan, dated 14 May 2012;
- A casualty record and X-ray report (right wrist) by Role 2 facility, Afghanistan, dated 21 May 2012;
- A health record by the medical officer, Afghanistan, dated 18 June 2012;
- An orthopaedic consultation and X-ray report by the orthopaedic surgeon, dated 12 November 2012;
- An outpatient health record by the medical officer, Garrison health centre, dated 18 January 2013;
- A DXA report and endocrinology consultation by the endocrinologist, dated 30 January 2013;
- A CT right wrist report by the radiologist, dated 15 February 2013;
- An operation report by the orthopaedic surgeon, dated 7 March 2013;
- A medical discharge documentation by the medical employment classification review board, dated 3 March 2016.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
19 January 2009 and 3 March 2016
Right Wrist - Metaphyseal Fracture of Distal Radius (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: Metaphyseal Fracture of Distal Radius (Worsening)
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 26 February 2025, and is supported by a casualty record and X-ray report (right wrist) by Role 2 facility, Afghanistan, dated 21 May 2012.
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, swelling and deformity of the right distal forearm and wrist after a week of aching over the back of the forearm with crutch walking on 21 May 2012.
The diagnosis was confirmed by X-ray of the right wrist and forearm on 21 May 2012, which showed a transverse fracture through the distal radial metaphysis with dorsal angulation and periosteal new bone along the dorsal cortex, meeting the Statement of Principles definition of fracture as a break in the continuity of a bone. The periosteal reaction and the week of preceding pain with crutch walking identify it as a stress fracture completed by acute trauma.
After the condition arose, it was worsened during your service. You smoked about 15 cigarettes a day throughout the treatment of the fracture, from 21 May 2012 to the confirmation of non-union on CT on 15 February 2013, as recorded on 21 May 2012, 12 November 2012 and 15 February 2013, including almost six months of peacetime service in Australia after your return. Type 2 diabetes mellitus was diagnosed on 18 January 2013, with a fasting glucose of 8.1 millimoles per litre and an HbA1c of 7.1 per cent, after weight gain of 31 kilograms associated with depot medroxyprogesterone, quetiapine and the inactivity imposed by your ankle and wrist fractures. After your return to Australia on 25 August 2012 your referral to an orthopaedic surgeon was delayed by military waiting lists and you were not reviewed until 12 November 2012, almost six months after the fracture, with no X-ray in the interval.
This has then led to further investigations and the diagnosis of your condition of Metaphyseal Fracture of Distal Radius (Worsening). I have accepted your condition of Metaphyseal Fracture of Distal Radius (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 15 February 2013.
