Statement of Principles concerning TRAUMATIC BRACHIAL PLEXOPATHY (Reasonable Hypothesis) (No. 1 of 2025) The Repatriation Medical Authority determines the following Statement of Principles under subsection 196B(2) of the Veterans' Entitlements Act 1986. Dated 17 December 2024. Professor Terence Campbell AM Chairperson by and on behalf of The Repatriation Medical Authority 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 traumatic brachial plexopathy (Reasonable Hypothesis) (No. 1 of 2025). 1. Commencement This instrument commences on 28 January 2025. 1. Authority This instrument is made under subsection 196B(2) of the Veterans' Entitlements Act 1986. 1. Application This instrument applies to a claim to which section 120A of the VEA or section 338 of the Military Rehabilitation and Compensation Act 2004 applies. 1. Definitions The terms defined in the Schedule 1 - Dictionary have the meaning given when used in this instrument. 1. Kind of injury, disease or death to which this Statement of Principles relates 1. This Statement of Principles is about traumatic brachial plexopathy and death from traumatic brachial plexopathy. Meaning of traumatic brachial plexopathy 1. For the purposes of this Statement of Principles, traumatic brachial plexopathy: 1. means a physical injury to the brachial plexus; and 2. excludes: 1. Parsonage-Turner syndrome (neuralgic amyotrophy); 2. radiation induced plexus injury; 3. thoracic outlet syndrome; 4. cervical radiculopathy or myelopathy; and 5. upper limb mononeuritis multiplex. Note: There are a separate set of SoPs for thoracic outlet syndrome that may also be applicable. Death from traumatic brachial plexopathy 1. For the purposes of this Statement of Principles, traumatic brachial plexopathy, in relation to a person, includes death from a terminal event or condition that was contributed to by the person's traumatic brachial plexopathy. Note: terminal event is defined in the Schedule 1 – Dictionary. 1. Basis for determining the factors The Repatriation Medical Authority is of the view that there is sound medical‑scientific evidence that indicates that traumatic brachial plexopathy and death from traumatic brachial plexopathy can be related to relevant service rendered by veterans, members of Peacekeeping Forces, or members of the Forces under the VEA, or members under the MRCA. Note: MRCA, relevant service and VEA are defined in the Schedule 1 – Dictionary. 1. Factors that must exist At least one of the following factors must as a minimum exist before it can be said that a reasonable hypothesis has been raised connecting traumatic brachial plexopathy or death from traumatic brachial plexopathy with the circumstances of a person's relevant service: 1. having trauma to the upper chest, shoulder or neck of the affected side within the 1 year before clinical onset or clinical worsening; Note 1: trauma to the upper chest, shoulder or neck is defined in the Schedule 1 – Dictionary. Note 2: Examples of trauma involving traction and or compression to the brachial plexus include blows to the upper chest and shoulder causing injury, injuries from motor vehicle accidents, a fall from height resulting in injury, or sports injuries, Note 3: Examples of types of penetrating injury to the upper chest, shoulder or neck include gunshot wounds or laceration injuries from knives or glass. Note 4: Examples of surgery that may cause trauma to the upper chest, shoulder or neck include surgery for clavicle fracture, brachial plexus nerve block, catheterisation of the subclavian or internal jugular veins, and axillary arteriography. Note 5: Delayed onset of traumatic brachial plexopathy may occur as a result of the response to injury, including the formation of callus around fractures and the development of scar tissue. 1. having malposition of the head, neck, or shoulders in any of the following circumstances within the 24 hours before clinical onset or clinical worsening: 1. surgery under general anaesthesia; 2. prone positioning in an intensive care unit; 3. reduced conscious state; Note 1: Examples of types of surgery that can cause malposition of the head, neck, or shoulders include surgery in the prone position such as oesophagectomy or spinal surgery or surgery involving the Trendelenburg position such as abdominal or pelvic laparoscopy. Note 2: Examples of malposition of the head, neck, or shoulders with reduced conscious state include sleep associated with alcohol or drug induced intoxication ("Friday or Saturday night palsy") or head injury. 1. having a median sternotomy within the 7 days before clinical onset or clinical worsening; Note: Examples where median sternotomy is performed include coronary artery bypass graft, cardiac valve surgery, surgery to the thoracic aorta, thoracic operations (retrosternal goitre, oesophagectomy), neurosurgical procedures where access to thoracic vertebral bodies or discs is required, and in emergency thoracotomy for penetrating trauma. 1. having an electrical injury to the brachial plexus within the 24 hours before clinical onset or clinical worsening; 2. carrying a load of at least 20 kilograms where the bulk of the load is supported by the shoulders, for at least 2 hours within the 24 hours before clinical onset or clinical worsening; Note: Examples of a load include a loaded backpack, body armour, rifle, ammunition, communication systems or sandbags. Where more than one type of load is combined the combined weight must exceed 20kgs. 1. carrying a load of at least 10 kilograms where the bulk of the load is supported by one shoulder, for at least 2 hours within the 24 hours before clinical onset or clinical worsening; Note: Examples of a load include a loaded backpack, body armour, rifle, ammunition, communication systems or sandbags. Where more than one type of load is combined the combined weight must exceed 10kgs. 1. inability to obtain appropriate clinical management for traumatic brachial plexopathy before clinical worsening. 1. 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 clinical worsening aspects of factors set out in section 8 apply only to material contribution to, or aggravation of, traumatic brachial plexopathy where the person's traumatic brachial plexopathy was suffered or contracted before or during (but did not arise out of) the person's relevant service. 2. 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(2) 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: MRCA means the Military Rehabilitation and Compensation Act 2004. relevant service means: (a) operational service under the VEA; (b) peacekeeping service under the VEA; (c) hazardous service under the VEA; (d) British nuclear test defence service under the VEA; (e) warlike service under the MRCA; or (f) non-warlike service under the MRCA. Note: MRCA and VEA are also defined in the Schedule 1 - Dictionary. 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 upper chest, shoulder or neck means traction, compression, penetrating injury or surgery to the affected upper chest, shoulder or neck region. traumatic brachial plexopathy—see subsection 6(2). VEA means the Veterans' Entitlements Act 1986.