Statement of Principles concerning fracture (Balance of Probabilities) (No. 63 of 2024)

The instrument’s central technical concepts are set out in the definitions and in the expansive treatment of “fracture” in s7. Fracture is defined as an acquired break of bone caused by applied force that would ordinarily break healthy bone (s7(2)(a)). The instrument then expressly includes a range of clinical presentations as falling within “fracture,” such as acute vascular shock, acute compartment syndrome or fat embolism resulting from the fractured bone, avulsion, crush, comminuted, burst or blowout fractures, open or closed fractures, fractures contiguous with orthopaedic implants, growth plate fractures, periosteal/muscular/nerve/vascular damage caused directly by displaced bone, stress fractures of the fatigue type, torsion/spiral fractures, and wound infection resulting from bone fragments penetrating skin (s7(2)(b)(i)-(ix)). The text also lists a set of exclusions: pathological fractures, bone stress injuries/bone marrow oedema not amounting to a stress fracture, stress fractures of the insufficiency type, osteonecrosis, periostitis, fractures of teeth or cartilage, fractures of orthopaedic implants (screws, plates, prostheses), and spondylolysis (s7(2)(c)(i)-(ix)). The instrument includes a clinical note clarifying that clinical worsening may include fracture non‑union but not an additional fracture, which would require fresh invocation of the fracture Statement (s7 Note).

“Death from fracture” is conceptually defined to include death caused by a terminal event or terminal condition to which the fracture contributed (s7(3)). The Schedule defines “terminal event” expansively to include causes such as pneumonia, respiratory failure, cardiac arrest, circulatory failure and cessation of brain function (Schedule 1, terminal event). This extends the instrument’s reach beyond immediate fatal trauma to later terminal consequences contributed to by the fracture.

Causation is framed by the statutory evidential standard: the Authority expresses the view that it is “more probable than not” that fracture and death from fracture can be related to relevant service (s8). The instrument operationalises that evidential threshold by specifying factors which, if present and related to relevant service, are sufficient to establish a causal connection on the balance of probabilities (s9). The list is conjunctive only in the sense that at least one factor must exist; it is not framed as a checklist of necessary and jointly sufficient elements. The factors include: significant physical force applied to the affected bone at clinical onset (s9(1)); significant repetitive loading stress for stress fracture (s9(2)); chronic repetitive loading stress due to abnormal force intensity/direction for stress fracture (s9(3)); smoking of at least five cigarettes per day (or equivalent) during treatment prior to fracture non‑union (s9(4)); diabetes mellitus at the time of fracture non‑union (s9(5)); and inability to obtain appropriate clinical management before clinical worsening (s9(6)). Notes attached to those items clarify equivalences (one gram of tobacco equals one cigarette) and that fracture non‑union is considered clinical worsening (Notes to s9(4) and s9(5)).

The relationship of factors to service is explicitly required: any factor relied on must itself be related to the person’s relevant service (s10(1)). The instrument also limits how the “clinical worsening” factors operate in the context of pre‑existing fractures: those clinical worsening aspects only apply to material contribution/aggravation where the fracture was suffered or contracted before or during (but did not arise out of) relevant service (s10(2)). Finally, s11 establishes that where a listed factor refers to an injury or disease governed by a different Statement of Principles, the factors in that other Statement apply per its own terms as in force from time to time, creating a mechanism for cross‑application of other Statements.

The Schedule defines key statutory terms: MRCA, VEA, “relevant service” (eligible war service, defence service, peacetime service as applicable), and “terminal event” (Schedule 1). These definitions are central to determining whether the instrument applies to a given claimant and which service categories may be relied upon.

The instrument directly affects claimants seeking decisions under the Veterans' Entitlements Act 1986 and the Military Rehabilitation and Compensation Act 2004. By its application clause, it applies to claims to which section 120B of the VEA or section 339 of the MRCA applies (s5). Those statutory references identify the class of administrative decisions to which the Statement of Principles will be applied; the instrument itself does not enumerate the administrative decision‑makers but functions as determinative guidance for decision‑making under those provisions.

At the primary level, affected persons are veterans and members of the Forces whose fractures or deaths from fracture are alleged to be connected with “relevant service” as defined in the Schedule (Schedule 1, relevant service). The Schedule defines “relevant service” to include eligible war service (other than operational service) under the VEA, defence service (other than hazardous service and British nuclear test defence service) under the VEA, and peacetime service under the MRCA. Therefore claimants whose service falls into those categories are the intended subjects.

Medical practitioners and reporting clinicians are also affected in practice: the instrument specifies clinical categories, timing markers (for example, the moment of clinical onset and the timing of fracture non‑union), and clinical entities that need to be recorded and evidenced if a claimant is to meet a factor in s9. For stress fractures, the instrument requires evidence of significant repetitive loading stress prior to clinical onset or chronic repetitive loading stress due to abnormal force direction or intensity (s9(2)-(3)), which calls for specific clinical and occupational detail from treating clinicians.

Decision‑makers within the departments administering the VEA and MRCA are materially affected because the instrument alters the evidentiary landscape they must apply when deciding causation for fracture claims (s8-s11). The Authority’s expressed view that fracture may be related to relevant service on the balance of probabilities (s8) and the list of qualifying factors (s9) set the parameters for administrative determinations.

Third parties who may be involved in claims processes , for example, insurers, rehabilitation providers, and legal advisers , will be affected indirectly because the instrument changes what evidence is necessary and potentially sufficient to establish service connection for fracture and death from fracture claims. The cross‑reference mechanism in s11 means that matters touching on other Statements of Principles will pull in the substantive standards of those instruments, so organisations and advisers dealing with multi‑factor claims need to map which Statements apply.

Finally, the instrument affects the administrative agencies’ resource and evidentiary burdens: claimants and agencies will need to gather and evaluate evidence that aligns with the listed factors, including potentially granular smoking histories, records of diabetes status at particular clinical milestones, and documentation that clinical management was unavailable prior to worsening (s9(4)-(6)). These evidentiary demands change the information flows between claimants, clinicians and decision‑makers, and therefore affect the behaviour of those actors.

The instrument itself does not create new criminal or civil duties; rather it creates statutory evidentiary criteria that must be met for an administrative finding of causal connection between fracture (or death from fracture) and relevant service when deciding claims under the VEA or MRCA. The primary “duties” are therefore procedural and evidential: claimants and their advisers must present evidence that at least one factor in s9 exists and is related to the person’s relevant service, and decision‑makers must test that evidence against the balance of probabilities standard and the content of these Principles (s8-s10).

Key duties and obligations implied by the instrument, and who bears them, include:

• Claimant duty to adduce evidence mapped to s9: To secure a positive finding, claimants will need to prove at least one of the factors in s9 on the balance of probabilities and show the factor is related to relevant service (s9; s10(1)). Where a factor refers to another injury or disease governed by a different Statement, claimants must adduce evidence satisfying that other Statement’s factors as they read from time to time (s11).

• Clinical documentation duty: Treating clinicians are not legally obliged by this instrument to produce particular documents, but evidence from clinicians will be decisive. The instrument makes clear that temporal markers (time of clinical onset; time of non‑union), quantification of repetitive loading stress, smoking quantity and timing, diabetes status at the time of non‑union, and evidence of inability to obtain appropriate clinical management are all relevant (s9(1)-(6)). The Schedule’s note that one gram of tobacco equals one cigarette converts clinical reports of tobacco consumption into a numerical threshold relevant to s9(4).

• Decision‑maker duty to apply the Principles: Administrative decision‑makers handling claims under s120B VEA or s339 MRCA must apply these Principles as the Authority’s statement of the medical‑scientific view relevant to causation (s3, s5, s8). They must consider whether, on the balance of probabilities, the listed factors exist and are connected to relevant service.

Rights created or affected by the instrument are administrative rights to claim and to have causation assessed under a specified evidentiary standard. Those include:

• Right to have causation assessed against these criteria: For applicable claims, a claimant has the right to have the fracture causation question decided in accordance with the Statement’s factors, and to rely on the Authority’s formulation that fracture can be related to relevant service on the balance of probabilities (s8, s9).

• Right to invoke cross‑referenced Statements: Where a factor in s9 refers to another injury or disease that is itself the subject of a separate Statement, the claimant has the right to have the decision‑maker apply the factors in that other Statement in accordance with its terms as in force (s11).

The instrument also creates limits on what may be treated as clinical worsening and what falls outside the Statement’s scope. For example, clinical worsening can include fracture non‑union but not an additional fracture (s7 Note); pathological fractures and fractures of implants are excluded entirely (s7(2)(c)). Those exclusions operate as restrictions on entitlements via causation findings: if a claimant’s injury is an excluded condition, the fracture Statement cannot be used to establish service connection for that excluded condition.

Finally, s10(2) establishes an important constraint: the clinical worsening aspects of s9 apply only to material contribution/aggravation where the fracture was suffered or contracted before or during (but did not arise out of) relevant service. That restricts the circumstances in which non‑union, smoking during treatment, diabetes at non‑union, or inability to obtain management can be counted as service‑related worsening.

The instrument contains no penalty provisions, does not create criminal offences, and does not itself specify civil remedies or mechanisms of enforcement. It is a Statement of Principles made under subsection 196B(3) of the VEA (s3) and intended for use within the administrative decision framework of the VEA and MRCA (s5). The instrument’s effect is evidentiary and procedural: it tells decision‑makers what the Repatriation Medical Authority regards, on available medical‑scientific evidence, as capable of establishing a connection between fracture (and death from fracture) and relevant service on the balance of probabilities (s8-s9). Enforcement therefore occurs through administrative application of these Principles to individual claims handled under the referenced statutory provisions.

Because there are no enforcement sanctions in the text, the main practical “enforcement” effect is that decision‑makers will accept or reject causation submissions based on whether evidence aligns with the listed factors. That acceptance or rejection will determine entitlement outcomes under the VEA or MRCA. The instrument does not itself set the consequences of a favourable or unfavourable finding; those consequences are governed by the enabling Acts and their regulations, which are not reproduced in this instrument. The Statement’s use in decision‑making is thus instrumental to entitlement determinations conducted under the VEA or MRCA.

Administrative compliance is therefore evidence‑driven and rests on:

• The claimant producing medical and factual evidence addressing one or more s9 factors and showing connection to relevant service (s9, s10(1)).

• Decision‑makers applying the balance of probabilities standard as framed in s8 and determining whether the Authority’s factors are satisfied.

• Where s11 applies, decision‑makers applying the other Statement of Principles in force to the extent necessary.

The instrument’s lack of penalty provisions reduces the risk of direct legal sanctions for non‑compliance with the Statement itself, but non‑alignment with its factors will typically result in adverse administrative outcomes for claims. The practical enforcement mechanism is therefore the administrative determinations made under the VEA and MRCA, rather than statutory penalties within the Statement. The instrument also repeals the previous Statement (s4), so the transition of applicable administrative standards is enforced by application of this instrument from its commencement date (s2-s4).

The Statement is explicitly tied to the VEA and MRCA by its authority and application clauses. It is made under subsection 196B(3) of the Veterans' Entitlements Act 1986 (s3). It applies to claims to which section 120B of the VEA or section 339 of the MRCA applies (s5). Those cross‑references embed the Statement within the statutory decision framework of the VEA and MRCA: the Statement provides the Repatriation Medical Authority’s medical‑scientific position which decision‑makers under those Acts must take into account when assessing causation for fracture claims.

The Schedule defines “relevant service” for the purposes of the instrument (Schedule 1). That definition ties the application of the Statement to the particular categories of service recognised under the VEA and MRCA: eligible war service (other than operational service), defence service (other than hazardous service and British nuclear test defence service) and peacetime service under the MRCA (Schedule 1, relevant service). The legal effect is that the Statement’s factors are only directly applicable within the statutory contexts where those service definitions are operative.

Section 11 creates a specific cross‑instrument interaction mechanism: if a s9 factor refers to an injury or disease covered by another Statement of Principles made under subsection 196B(3) of the VEA, then the factors in that other Statement apply in accordance with that Statement as in force from time to time (s11). That is a legal bridge. Practically, it means that where a fracture causation factor is tied to, say, an infection or a metabolic disease that has its own Statement, decision‑makers must apply the other Statement’s factors to determine whether the reference condition is established. The instrument thereby imports, rather than duplicates, relevant standards from other Statements and ensures consistent treatment across Statements.

The Statement’s definitional choices and exclusions have interaction effects with other statutory and clinical categories. For example, the Statement excludes pathological fractures and fractures of orthopaedic implants (s7(2)(c)(i), (viii)). If a claimant’s injury is one of those excluded conditions, another legal route (potentially under a different Statement or statutory category) would be required to establish service connection. The instrument does not extinguish other legal avenues; it simply does not cover excluded conditions.

The instrument also interacts with clinical practice standards because it treats fracture non‑union as “clinical worsening” for the purposes of the Statement (s7 Note; s9(4)-(5)). That categorisation affects how pre‑existing fractures are handled: the clinical worsening aspects of s9 are limited to cases where the fracture was suffered or contracted before or during (but did not arise out of) relevant service (s10(2)). This constrains the interplay between pre‑existing conditions and service‑related aggravation within the statutory decision framework.

The instrument does not specify appeals, review routes or procedural remedies; those are set out in the enabling Acts and regulations, which are not contained in this Statement. Consequently, while the Statement alters the evidentiary content for causation findings, it does so inside the procedural architecture of the VEA and MRCA rather than supplanting it. Decision‑makers must therefore apply this Statement in conjunction with the procedural and substantive provisions of the VEA and MRCA that govern entitlement, adjudication, and any administrative or judicial review mechanisms.

Finally, the repealer clause (s4) removes the prior fracture Statement (No. 95 of 2015) from the corpus of operative Statements, so the new text governs future determinations from commencement (s2-s4). That transition will affect cases and decisions made on or after the commencement date; the Statement itself does not specify transitional arrangements for matters decided before commencement.

The instrument contains a concise amendment history confined to its own instatement and the repeal of the earlier Statement of Principles for fracture. Section 4 expressly repeals the Statement of Principles concerning fracture No. 95 of 2015 (Federal Register of Legislation No. F2015L01343) that had been made under subsection 196B(3) of the VEA. The new Statement is dated 20 August 2024 and commences on 24 September 2024 (s2). The instrument is made under the statutory authority conferred by subsection 196B(3) of the Veterans' Entitlements Act 1986 (s3). Other than the repeal of the 2015 Statement, no further amendments or prior iterations are noted within the text.

Because the instrument is a Statement of Principles made under the VEA procedure, it is an instrument that can be replaced at the Authority’s direction; the immediate repeal indicates a conscious update to the medical‑scientific criteria governing fracture. The text contains no retrospective amendment provision or transitional schedule addressing how decisions made under the repealed 2015 Statement are to be treated after commencement; it simply states the repeal and the commencement date (s2-s4). Therefore, from the document itself, the amendment history is a single‑step replacement of the preceding Statement.

The Schedule and the rest of the instrument include definitional changes and content that may differ from the prior Statement, but the text of the prior Statement is not reproduced or compared. The Statement’s repeal clause is absolute in form: it declares the 2015 instrument repealed. The new Statement’s force from 24 September 2024 means that any administrative decisions to be made after that date under the cited sections of the VEA and MRCA will be governed by this instrument rather than the 2015 Statement (s2-s5).

No other amendment history (such as prior minor corrections, consultation addenda, or staggered implementation) is recorded in the instrument. For a complete legislative history beyond the instrument text, one would need to consult the Federal Register entry or departmental records, but those sources fall outside the instrument’s own text. Within this instrument, the amendment history is limited to the repeal of the 2015 Statement and the issuance of the new Statement with the stated commencement date (s2-s4).

The Statement of Principles document provided does not record any litigation history, judicial decisions, or tribunal determinations that have interpreted or tested its provisions. The text contains no cases, no citations to judicial authority, nor any discussion of prior litigation. Consequently, within the bounds of this instrument, there is no explicit litigation history to report.

Despite that absence, the instrument sets out a number of legal and evidential flashpoints that are likely to generate contestation in claims adjudication and potentially in judicial review or merits appeals under the VEA and MRCA frameworks. Those contested issues are embedded in particular textual features of the Statement and are matters of inference rather than recorded litigation. They include, for example:

• Interpretation of undefined terms: The Statement uses phrases such as “significant physical force” (s9(1)), “significant repetitive loading stress” (s9(2)), and “significant chronic repetitive loading stress” due to “abnormal force intensity or direction” (s9(3)) without articulating precise quantification. Disputes could arise about the threshold of “significance” and what objective evidence satisfies it.

• Timing and causation issues: The Statement requires that any factor relied upon must be “related to the relevant service rendered by the person” (s10(1)). The meaning of “related to” in particular fact patterns may invite legal argument about temporal and causal nexus, especially for fractures that occurred close to, during, or shortly after service.

• Clinical worsening scope: The instrument treats fracture non‑union as “clinical worsening” (s7 Note) and identifies smoking during treatment and diabetes at the time of non‑union as separate factors relevant to non‑union (s9(4)-(5)). Questions may arise about the evidentiary standards for establishing non‑union and the temporal specification of “during treatment prior to fracture non‑union” for smoking, which could become a subject of dispute.

• Cross‑application of other Statements: Section 11 requires application of other Statements of Principles where a s9 factor refers to another injury or disease. Litigation could focus on the correct methodology for integrating multiple Statements, especially where statutory versions of those other Statements have changed “as in force from time to time” (s11), and whether the decision‑maker applied the relevant version.

• Exclusions and overlap: The Statement excludes pathological fractures and other specific conditions (s7(2)(c)). Contestation may arise where a claimant’s injury straddles the boundary between included and excluded conditions, for example a stress fracture that is argued to have insufficiency elements, or fractures involving implants where there is linked bone injury.

Because no actual litigation is recorded in the instrument itself, those potential disputes are descriptive of where litigation would likely focus rather than a summary of extant cases. Any authoritative litigation history would need to be drawn from tribunal or court records interpreting the VEA/MRCA and Repatriation Medical Authority Statements, but such sources are not contained in the text supplied. The Statement therefore provides the menu of doctrinal issues that decision‑makers, claimants and advisers will need to anticipate and document, but it does not provide a record of how courts or tribunals have addressed any of those issues.

The instrument contains a number of technical points, definitional choices and evidentiary thresholds that can catch claimants, clinicians and decision‑makers if not carefully attended to. These “gotchas” flow directly from the instrument’s wording and are important for practitioners and advisers to note when preparing or assessing a fracture claim.

1. At least one factor is mandatory: The instrument does not allow a finding of causation absent at least one of the s9 factors. That shifts the evidential focus: general assertions that a fracture occurred in service without evidence meeting s9’s enumerated factors will not satisfy the Statement’s standard (s9).

2. Undefined thresholds for “significant”: Terms such as “significant physical force” (s9(1)), “significant repetitive loading stress” (s9(2)), and “significant chronic repetitive loading stress” (s9(3)) are not quantitatively defined. Practical consequence: claimants must provide precise clinical and activity evidence to demonstrate that the force or loading reaches the required level; vague or generic descriptions of training or activity may be insufficient. The instrument’s examples (military training, weight training, athletics or running for s9(2)) are illustrative but not prescriptive (s9(2) Note).

3. Stress fracture subcategories: The Statement distinguishes fatigue‑type stress fractures (included) from insufficiency‑type stress fractures (excluded) (s7(2)(b)(vii); s7(2)(c)(iii)). Correctly diagnosing and documenting the type of stress fracture is essential because the included/excluded distinction determines whether the Statement applies.

4. Exclusions are absolute for this Statement: Pathological fractures and fractures of orthopaedic implants and prostheses are explicitly excluded (s7(2)(c)(i), (viii)). If the claimant’s injury is one of these exclusions, the fracture Statement cannot be used to support service connection for those specific entities; other legal routes would need to be explored.

5. Clinical worsening limited to non‑union, not additional fracture: The Note to s7 clarifies that clinical worsening can include fracture non‑union but not an additional fracture. If a claimant experiences a new fracture, that is treated as a fresh event requiring invocation of the fracture Statement anew, rather than being captured as worsening of a previous fracture (s7 Note).

6. Smoking and tobacco equivalence: Smoking is a factor only when the person smoked at least five cigarettes per day (or equivalent) during treatment prior to fracture non‑union (s9(4)). The Schedule equates one gram of tobacco with one cigarette for conversion purposes, a potentially non‑intuitive metric that clinicians and advisers must apply when converting tobacco consumption records (s9(4) Note 1; Schedule 1).

7. Diabetes and timing: Diabetes mellitus is only a relevant factor if present at the time of fracture non‑union (s9(5)). Consequently, documentation must show diabetes status at the specific clinical milestone of non‑union, not merely a historical diagnosis.

8. “Inability to obtain appropriate clinical management” is a factor: s9(6) accepts inability to obtain appropriate clinical management prior to clinical worsening as a factor. That turns attention to systemic and access‑to‑care evidence: it requires demonstration that appropriate management was unavailable rather than that management was suboptimal. Evidence may include records of referral wait times, documentation of service access failures, or contemporaneous clinical notes.

9. Relationship to relevant service required: Any factor must be related to the person’s relevant service (s10(1)). A factor that existed but cannot be linked to relevant service will not suffice. For pre‑existing fractures, the clinical worsening aspects of s9 apply only where the fracture was suffered before/during (but did not arise out of) relevant service (s10(2)). Practically, this creates an important temporal and causal linkage requirement on claimants with pre‑existing conditions.

10. Cross‑referenced Statements: Where a factor refers to an injury or disease covered by another Statement, that other Statement’s factors apply as in force (s11). Practically, this can complicate claims because the applicable version of the other Statement may change “from time to time,” and claimants must ensure they meet the currently operative criteria.

11. Death from fracture includes later terminal events: A death that is the proximate or ultimate result of a terminal event contributed to by the fracture can fall within the Statement (s7(3); Schedule 1, terminal event lists). That expands possible claims but requires strong causal evidence linking the fracture to the later terminal pathway.

12. Repeal and timing: The instrument repeals the 2015 Statement (s4) and commences 24 September 2024 (s2). Practitioners must check which Statement applies to a given claim depending on its timing relative to commencement.

13. No procedural or appeal guidance in the Statement: The Statement provides medical‑scientific criteria but does not set out appeal routes or procedural timing. Practitioners must turn to the VEA and MRCA for procedural and review mechanisms.

In short, the major compliance pitfalls are evidentiary: failing to demonstrate one of the s9 factors, failing to link that factor to relevant service, or relying on an excluded clinical presentation. The lack of precise numerical thresholds for “significant” stresses the need for well‑documented clinical and activity history rather than reliance on general statements.

For claimants, clinicians and advisers, compliance with the Statement means aligning medical and factual evidence to the exact contours of the Statement’s definitions, factors and timing requirements. Below are concrete steps and evidentiary checklists grounded in the instrument’s text.

Claimant and adviser checklist

1. Establish applicable service type: Confirm the claimant’s service falls within “relevant service” as defined in the Schedule (eligible war service other than operational service; defence service other than hazardous service and British nuclear test defence service under the VEA; or peacetime service under the MRCA). The Statement only applies if the claim is a matter under s120B VEA or s339 MRCA (s5; Schedule 1).

2. Map factual evidence to s9 factors: At least one factor in s9 must be proven and shown to be related to relevant service (s9; s10(1)). For each s9 factor likely to apply, assemble targeted evidence:

   • s9(1) “significant physical force”: contemporaneous incident reports, military activity logs, clinical notes documenting force at time of clinical onset, imaging showing force‑related fracture patterns.
   • s9(2) or s9(3) stress fractures: training rosters, duty records, exercise regimens, physician notes diagnosing stress fracture of the fatigue type, expert statements connecting repetitive loading to the bone affected; if relying on changed force intensity/direction, document objective biomechanical contributors (for example, leg length discrepancy or joint malalignment) with clinical assessment.
   • s9(4) smoking during treatment prior to non‑union: precise smoking history showing at least five cigarettes per day (or weight equivalent in grams per Schedule note) during the period of fracture treatment up to non‑union; contemporaneous medical notes or statements from treating clinicians.
   • s9(5) diabetes mellitus at time of non‑union: medical records showing diabetes diagnosis and glycaemic control status contemporaneous with the non‑union date.
   • s9(6) inability to obtain appropriate clinical management: records of referrals, waiting lists, correspondence showing lack of access to appropriate care, and clinical notes linking lack of management to worsening.

3. Document timing and clinical milestones: The Statement turns on clinical onset and, for non‑union, on the timing of non‑union. Ensure records identify date of clinical onset, dates of interventions, and the date non‑union was diagnosed or established (s7 Note; s9(4)-(5)).

4. Address exclusions explicitly: If the claimant’s presentation might fall within an exclusion in s7(2)(c) (pathological fractures, implant fractures, insufficiency stress fractures, etc.), obtain diagnostic documentation to rebut an exclusion or to show the presentation is within the included categories (s7(2)(b)-(c)).

5. Link factors to service: For any asserted factor, provide evidence that the factor was caused by or materially related to the person’s relevant service (s10(1)). That may include linking a training regime to significant repetitive loading, or linking inability to obtain treatment to service‑related relocation or other service events.

Clinician and expert checklist

1. Provide objective clinical descriptions: Describe the fracture type (avulsion, comminuted, growth plate, torsion/spiral, fatigue stress fracture) and exclude excluded entities where appropriate (pathological fracture, insufficiency stress fracture, implant fracture) (s7(2)(b)-(c)).

2. Quantify exposures where possible: For smoking, quantify consumption in cigarettes or equivalent grams of tobacco (Schedule note equates one gram to one cigarette) and specify the timeframe relative to treatment and non‑union (s9(4); Schedule 1). For repetitive loading, describe frequency, duration and intensity of loading activities and the onset pattern.

3. State clinical causation opinions on the balance of probabilities: Where appropriate, provide an expert opinion that a listed factor is present and that it is related to relevant service on the balance of probabilities, grounding the opinion in clinical findings and objective records (s8-s9).

4. Record access‑to‑care limitations: If clinical worsening is alleged due to inability to obtain appropriate management (s9(6)), clinicians should document attempts to refer, wait times, treatment refusals, or resource limitations contemporaneously.

Decision‑maker checklist

1. Apply the “balance of probabilities” standard as framed in s8: assess whether, on the balance of probabilities, fracture and death from fracture can be related to relevant service and whether at least one s9 factor exists and is related to service (s8-s10).

2. Verify factor applicability and timing: Confirm that the factor relied upon is relevant to the clinical circumstances, that the timing (clinical onset, non‑union date) is correctly identified, and that the factor is related to relevant service per s10(1). For pre‑existing fractures, ensure clinical worsening aspects are only applied where the fracture was suffered before/during (but did not arise out of) relevant service (s10(2)).

3. Use cross‑Statement application when necessary: If a factor refers to an injury or disease governed by another Statement, apply that Statement’s factors “as in force from time to time” (s11). Record which version of the other Statement was applied and why.

4. Address exclusions and ambiguous categories explicitly: Determine whether the presentation falls within the exclusions of s7(2)(c) or the inclusions of s7(2)(b), and document reasoning.

Practical evidence standards and documentation

• Prefer contemporaneous records: Incident reports, training logs, medical imaging, surgical notes, microbiology records for wound infection, and diabetes management records will be decisive.

• Witness and chain‑of‑custody evidence: For inability to obtain management, maintain correspondence, referral slips, and dated logs that show attempts to access care.

• Expert reports should engage the Statement’s language: Experts should address s9 factors one by one, explaining how the clinical picture meets the specific textual criteria and whether each factor is related to relevant service on the balance of probabilities.

• For death claims: Provide medical cause‑of‑death documentation and an opinion linking the terminal event (as defined in the Schedule) to the antecedent fracture (s7(3); Schedule 1).

Record‑keeping and timing

• Note the commencement and repeal dates: For claims straddling the implementation date, confirm which Statement applies (s2-s4).

• When relying on other Statements via s11, document the relevant Statement version and how its factors were met.

By structuring evidence to the Statement’s specific factors and their temporal requirements, and by ensuring clinicians provide quantifiable and temporally specific reports, claimants and advisers can align submissions with the Statement’s criteria and reduce the risk that an adjudicator will find no factor present or not related to relevant service.