Statement of Principles

concerning

ULNAR NEUROPATHY AT THE ELBOW
(Balance of Probabilities)

(No. 66 of 2017)

The Repatriation Medical Authority determines the following Statement of Principles under subsection 196B(3) of the Veterans' Entitlements Act 1986.

Dated                                           3 November 2017

Contents

1 Name

2 Commencement

3 Authority

4 Application

5 Definitions

6 Kind of injury, disease or death to which this Statement of Principles relates

7 Basis for determining the factors

8 Factors that must exist

9 Relationship to service

10 Factors referring to an injury or disease covered by another Statement of Principles

Schedule 1 - Dictionary

1 Definitions

1               Name

This is the Statement of Principles concerning ulnar neuropathy at the elbow (Balance of Probabilities) (No. 66 of 2017).

2               Commencement

              This instrument commences on 4 December 2017.

3               Authority

This instrument is made under subsection 196B(3) of the Veterans' Entitlements Act 1986.

4               Application

This instrument applies to a claim to which section 120B of the VEA or section 339 of the Military Rehabilitation and Compensation Act 2004 applies.

5               Definitions

The terms defined in the Schedule 1 - Dictionary have the meaning given when used in this instrument.

6               Kind of injury, disease or death to which this Statement of Principles relates

(1)          This Statement of Principles is about ulnar neuropathy at the elbow and death from ulnar neuropathy at the elbow.

Meaning of ulnar neuropathy at the elbow

(2)          For the purposes of this Statement of Principles, ulnar neuropathy at the elbow means               an acquired persistent disturbance of function of the ulnar nerve in the region of the elbow, in the presence of:

(a)          altered sensation, pain or weakness in the distribution of the ulnar nerve; and

(b)           electrodiagnostic evidence that confirms impaired ulnar nerve conduction across the elbow.

Note 1: Ulnar nerve dysfunction may be localised to the arcade of Struthers, the medial intermuscular septum of the arm, the retroepicondylar groove of the medial epicondyle, humeroulnar aponeurotic arcade (cubital tunnel), or the outlet from flexor carpi ulnaris muscle (deep flexor pronator aponeurosis).

Note 2: Ulnar neuropathy at the elbow may coexist with carpal tunnel syndrome.

Death from ulnar neuropathy at the elbow

(3)          For the purposes of this Statement of Principles, ulnar neuropathy at the elbow, in relation to a person, includes death from a terminal event or condition that was contributed to by the person's ulnar neuropathy at the elbow.

Note: terminal event is defined in the Schedule 1 – Dictionary.

7               Basis for determining the factors

On the sound medical‑scientific evidence available, the Repatriation Medical Authority is of the view that it is more probable than not that ulnar neuropathy at the elbow and death from ulnar neuropathy at the elbow can be related to relevant service rendered by veterans or members of the Forces under the VEA, or members under the MRCA.

 Note: relevant service is defined in the Schedule 1 – Dictionary.

8               Factors that must exist

At least one of the following factors must exist before it can be said that, on the balance of probabilities, ulnar neuropathy at the elbow or death from ulnar neuropathy at the elbow is connected with the circumstances of a person's relevant service:

(1)          having a fracture of the bones of the affected elbow, including fracture of the medial epicondyle of the humerus, before the clinical onset of ulnar neuropathy at the elbow;

(2)          having trauma to the affected elbow within the one year before the clinical onset of ulnar neuropathy at the elbow;

Note: trauma to the affected elbow is defined in the Schedule 1 - Dictionary.               

(3)          performing repetitive and forceful activities involving flexion and extension of the affected elbow:

(a)          for a cumulative period of at least 90 hours, within a continuous period of three months before the clinical onset of ulnar neuropathy at the elbow; and

(b)          where the repetitive and forceful activities have not ceased more than 30 days before the clinical onset of ulnar neuropathy at the elbow;

Note: Examples of repetitive and forceful activities include lifting, moving or carrying a load greater than ten kilograms, using hand saws or using large, hand-held power machinery, climbing vertical ladders, ammunitioning, using a hand-held piece of equipment such as a jackhammer or shovel, and overhead throwing.

(4)          having a surgical procedure under general anaesthesia, within the one month before the clinical onset of ulnar neuropathy at the elbow;

(5)          having a surgical procedure to the affected elbow, including elbow arthroscopy, within the six months before the clinical onset of ulnar neuropathy at the elbow;

(6)          being hospitalised, or confined to bed in a supine position, for at least two days within the two weeks before the clinical onset of ulnar neuropathy at the elbow;

(7)          daily self-propulsion of a manual wheelchair:

(a)           for a cumulative period of at least 60 hours within a continuous period of three months before the clinical onset of ulnar neuropathy at the elbow; and

(b)           where this activity has not ceased more than 30 days before the clinical onset of ulnar neuropathy at the elbow;

(8)          having paraplegia at the time of the clinical onset of ulnar neuropathy at the elbow;

(9)          using elbow or forearm crutches:

(a)          for a cumulative period of at least 60 hours within a continuous period of three months before the clinical onset of ulnar neuropathy at the elbow; and

(b)          where this activity has not ceased more than 30 days before the clinical onset of ulnar neuropathy at the elbow;

(10)      having an inflammatory or degenerative joint disease from the specified list of specified list of inflammatory and degenerative joint diseases, involving the affected elbow, at the time of the clinical onset of ulnar neuropathy at the elbow;

Note: specified list of inflammatory and degenerative joint diseases is defined in the Schedule 1 - Dictionary.             

(11)      having amyloidosis at the time of the clinical onset of ulnar neuropathy at the elbow;

Note: amyloidosis is defined in the Schedule 1 - Dictionary.             

(12)      having a cerebrovascular accident with hemiplegia, excluding transient ischaemic attack or transient symptoms with infarction, before the clinical onset of ulnar neuropathy at the elbow;

(13)      having an external burn to the affected arm requiring hospitalisation, within the two years before the clinical onset of ulnar neuropathy at the elbow;

(14)      having an infection involving the affected ulnar nerve in the region of the elbow at the time of the clinical onset of ulnar neuropathy at the elbow;

Note: Examples of an infection involving the affected ulnar nerve include Mycobacterium leprae (leprosy) and tuberculosis.

(15)      having a lesion as specified at the elbow that compresses or displaces the affected ulnar nerve at the time of the clinical onset of ulnar neuropathy at the elbow;

Note: lesion as specified is defined in the Schedule 1 - Dictionary.                           

(16)      having acromegaly before the clinical onset of ulnar neuropathy at the elbow;

Note: acromegaly is defined in the Schedule 1 - Dictionary.             

(17)      having a fracture of the bones of the affected elbow, including fracture of the medial epicondyle of the humerus, before the clinical worsening of ulnar neuropathy at the elbow;

(18)      having trauma to the affected elbow within the one year before the clinical worsening of ulnar neuropathy at the elbow;

Note: trauma to the affected elbow is defined in the Schedule 1 - Dictionary.               

(19)      performing repetitive and forceful activities involving flexion and extension of the affected elbow:

(a)          for a cumulative period of at least 90 hours, within a continuous period of three months before the clinical worsening of ulnar neuropathy at the elbow; and

(b)          where the repetitive and forceful activities have not ceased more than 30 days before the clinical worsening of ulnar neuropathy at the elbow;

Note: Examples of repetitive and forceful activities include lifting, moving or carrying a load greater than ten kilograms, using hand saws or using large, hand-held power machinery, climbing vertical ladders, ammunitioning, using a hand-held piece of equipment such as a jackhammer or shovel, and overhead throwing.

(20)      having a surgical procedure under general anaesthesia, within the one month before the clinical worsening of ulnar neuropathy at the elbow;

(21)      having a surgical procedure to the affected elbow, including elbow arthroscopy, within the six months before the clinical worsening of ulnar neuropathy at the elbow;

(22)      being hospitalised, or confined to bed in a supine position, for at least two days within the two weeks before the clinical worsening of ulnar neuropathy at the elbow;

(23)      daily self-propulsion of a manual wheelchair:

(a)           for a cumulative period of at least 60 hours within a continuous period of three months before the clinical worsening of ulnar neuropathy at the elbow; and

(b)           where this activity has not ceased more than 30 days before the clinical worsening of ulnar neuropathy at the elbow;

(24)      having paraplegia at the time of the clinical worsening of ulnar neuropathy at the elbow;

(25)      using elbow or forearm crutches:

(a)          for a cumulative period of at least 60 hours within a continuous period of three months before the clinical worsening of ulnar neuropathy at the elbow; and

(b)          where this activity has not ceased more than 30 days before the clinical worsening of ulnar neuropathy at the elbow;

(26)      having an inflammatory or degenerative joint disease from the specified list of specified list of inflammatory and degenerative joint diseases, involving the affected elbow, at the time of the clinical worsening of ulnar neuropathy at the elbow;

Note: specified list of inflammatory and degenerative joint diseases is defined in the Schedule 1 - Dictionary.             

(27)      having amyloidosis at the time of the clinical worsening of ulnar neuropathy at the elbow;

Note: amyloidosis is defined in the Schedule 1 - Dictionary.             

(28)      having a cerebrovascular accident with hemiplegia, excluding transient ischaemic attack or transient symptoms with infarction, before the clinical worsening of ulnar neuropathy at the elbow;

(29)      having an external burn to the affected arm requiring hospitalisation, within the two years before the clinical worsening of ulnar neuropathy at the elbow;

(30)      having an infection involving the affected ulnar nerve in the region of the elbow at the time of the clinical worsening of ulnar neuropathy at the elbow;

Note: Examples of an infection involving the affected ulnar nerve include Mycobacterium leprae (leprosy) and tuberculosis.

(31)      having a lesion as specified at the elbow that compresses or displaces the affected ulnar nerve at the time of the clinical worsening of ulnar neuropathy at the elbow;

Note: lesion as specified is defined in the Schedule 1 - Dictionary.             

(32)      having acromegaly before the clinical worsening of ulnar neuropathy at the elbow;

Note: acromegaly is defined in the Schedule 1 - Dictionary.             

(33)      inability to obtain appropriate clinical management for ulnar neuropathy at the elbow.

9               Relationship to service

(1)          The existence in a person of any factor referred to in section 8, must be related to the relevant service rendered by the person.

(2)          The factors set out in subsections 8(17) to 8(33) apply only to material contribution to, or aggravation of, ulnar neuropathy at the elbow where the person's ulnar neuropathy at the elbow was suffered or contracted before or during (but did not arise out of) the person's relevant service.

10           Factors referring to an injury or disease covered by another Statement of Principles

In this Statement of Principles:

(1)          if a factor referred to in section 8 applies in relation to a person; and

(2)          that factor refers to an injury or disease in respect of which a Statement of Principles has been determined under subsection 196B(3) of the VEA;

then the factors in that Statement of Principles apply in accordance with the terms of that Statement of Principles as in force from time to time.

Schedule 1 - Dictionary  

Note:               See Section 5

1               Definitions

In this instrument:

                               acromegaly means a chronic disease of adults resulting from hypersecretion of growth hormone after closure of the epiphyses.

                               amyloidosis means the accumulation of insoluble fibrillar proteins in organs or tissues of the body such that vital function is compromised.

                               lesion as specified means:

(a)          benign or malignant neoplasm;

(b)          bony fragment or foreign body;

(c)          calcification;

(d)          cyst;

(e)          ganglion;

(f)           gouty tophus;

(g)          haemorrhage or haematoma;

(h)          lymphoedema;

(i)            scar;

(j)            tuberculoma; or

(k)          another pathological lesion that compresses or displaces the ulnar nerve.

Note: This definition includes thickening, scarring or calcification of the ulnar collateral ligament.

                               MRCA means the Military Rehabilitation and Compensation Act 2004.

                               relevant service means:

(a)          eligible war service (other than operational service) under the VEA;

(b)          defence service (other than hazardous service and British nuclear test defence service) under the VEA; or

(c)          peacetime service under the MRCA.

Note: MRCA and VEA are also defined in the Schedule 1 - Dictionary.             

                               specified list of inflammatory and degenerative joint diseases means:

(a)          amyloid arthropathy;

(b)          gout;

(c)          haemophilic arthropathy;

(d)          neuropathic arthropathy;

(e)          nodular fasciitis;

(f)           osteoarthritis;

(g)          other inflammatory arthritis requiring treatment with a disease modifying agent or a biological agent;

(h)          rheumatoid arthritis;

(i)            sarcoidosis;

(j)            systemic lupus erythematosus; or

(k)          systemic sclerosis.

                               terminal event means the proximate or ultimate cause of death and includes the following:

(a)           pneumonia;

(b)           respiratory failure;

(c)           cardiac arrest;

(d)           circulatory failure; or

(e)           cessation of brain function.

                               trauma to the affected elbow means a discrete event involving the application of significant physical force to or through the affected elbow joint, that causes damage to the joint and the development, within 24 hours of the event occurring, of symptoms and signs of pain and tenderness, and either altered mobility or range of movement of the elbow joint.  These symptoms and signs must last for a period of at least seven days following their onset, save for where medical intervention for the trauma to that joint has occurred and that medical intervention involves one of the following:

(a)           immobilisation of the elbow joint, by splinting or similar external agent;

(b)           injection of corticosteroids or local anaesthetics into that joint; or

(c)           surgery to that joint.

Note: Examples of acute trauma include dislocation of the elbow joint, tearing or stretching of the ulnar collateral ligament, and medial epicondyle apophysitis.

                               ulnar neuropathy at the elbow—see subsection 6(2).

                               VEA means the Veterans' Entitlements Act 1986.