The Appeal CommissionThe Workers Compensation Act of Manitoba

Preamble

An Appeal Panel hearing was held on May 1, 2001, at the request of the claimant and the employer. The Panel discussed this appeal on May 1, 2001.

Issue

Employer's Issue: Whether or not the claim for right sided carpal tunnel syndrome is acceptable on an acute basis.

Claimant's Issue: Whether or not the claimant's persisting carpal tunnel syndrome symptoms are related to the two remote incidents occurring in September, 1998; and

Whether or not responsibility should be accepted for the decompression surgery.

Decision

Employer's Issue: That the claim for right sided carpal tunnel syndrome is acceptable on an acute and chronic basis.

Claimant's Issue: That the claimant's persisting carpal tunnel syndrome symptoms are related to the two remote incidents occurring in September, 1998; and

That responsibility should be accepted for the decompression surgery.

Background

While performing the duties of a pipelayer on September 21, 1998, the claimant injured his right wrist while tightening a repair clamp with an 18 inch rachet when the rachet slipped, causing him to push his wrist and hand into a wall.

On October 23, 1998, the claimant advised a Workers Compensation Board (WCB) adjudicator that he continued working after the September 21st incident and that his wrist seemed to get better. On September 26, 1998, however, he injured the same wrist again while using a shovel at work.

Initial medical information revealed that the claimant had been diagnosed with a right wrist sprain. On September 29, 2000, the attending physician referred the claimant for physiotherapy treatments directed towards the flexor tendons of the right wrist. Following nerve conduction studies (NCS) on December 16, 1998, the diagnosis was changed to mild to moderate right carpal tunnel syndrome (CTS).

In late January 1999, a WCB medical advisor reviewed the case at the request of primary adjudication. The medical advisor commented that the mechanics of the two injuries described by the claimant were consistent with the diagnosis of CTS based on trauma to the flexor retinaculum of the carpal tunnel. On February 22, 1999, the claimant was advised by primary adjudication that his compensable restrictions would be to avoid repetitive use of his right wrist. As his employer was accommodating him with modified duties, he would not be entitled to WCB wage loss benefits.

On June 14, 1999, a hand specialist noted that 4 months were spent on conservative management with a dorsal ulnar night splint, but there had been no improvement in the claimant's symptoms. The specialist noted a strongly positive Phalen's test and a strongly positive Tinel's sign at the proximal part of the carpal tunnel. It was felt that the claimant would benefit from surgical release. Financial responsibility for the surgical procedure was accepted by the WCB on July 20, 1999.

On June 29, 1999, an employer representative wrote to the Review Office appealing the decision to accept the claim. Based on a review of medical literature regarding CTS and a previous Review Office decision, the employer argued that there was no relationship between a specific incident such as those described by the claimant and the development of CTS.

A WCB orthopaedic specialist reviewed the case on August 3, 1999 at the request of Review Office. The orthopaedic specialist was asked to provide his opinion with respect to the employer's position that one could not get CTS through trauma as described by the claimant. In response, the orthopaedic specialist stated the following:

"If the work place incidents gave rise to any swelling (edema and/or hematoma) within the carpal tunnel due to local soft tissue trauma then an acute carpal tunnel syndrome might ensue. However I would expect the symptoms to resolve as the swelling resolved. It is also not clear whether the trauma of the 2 incidents was sufficient to cause this to occur."

On August 6, 1999, Review Office determined that the claim for right sided CTS was acceptable on an acute basis only and that no responsibility could be accepted for the proposed surgical procedure. Review Office was of the view that when the claimant sustained the two separate traumas to his right wrist in September of 1998, this caused the swelling to develop. The swelling compromised the median nerve such that the claimant developed CTS symptoms. When the swelling resolved, the signs and symptoms of the CTS should also have resolved. Review Office could not accept that these symptoms were still present in June of 1999, some 10 months after the original accident.

With respect to the proposed surgical procedure, Review Office did not dispute the fact that the claimant may have right sided CTS, but did not believe it was reasonable to attribute this to the two remote incidents described as having occurred in September of 1998.

On February 6, 2001, the claimant's union representative appealed Review Office's decision and an oral hearing was requested. The union representative submitted a January 24, 2001 report from a hand specialist for the Panel's consideration.

The employer's representative appealed the initial acceptance of the claim on March 16, 2001 and on May 1, 2001, an oral hearing was convened.

Reasons

Section 4(1) of The Workers Compensation Act (the Act) provides for the payment of compensation benefits to a worker where he or she sustains personal injury by accident arising out of and in the course of employment.

“Where, in any industry within the scope of this Part, personal injury by accident arising out of and in the course of the employment is caused to a worker, compensation as provided by this part shall be paid by the board out of the accident fund, subject to the following subsections.”

In accordance with this section, the Panel must, initially, be satisfied that there has been an accident within the meaning of Section 1(1) of the Act. That is, “a chance event occasioned by a physical or natural cause; and includes

(a) A wilful and intentional act that is not the act of the worker,

(b) any

(i) event arising out of, and in the course of, employment, or

(ii) thing that is done and the doing of which arises ut of, and in the course of, employment, and

(c) an occupational disease and as a result of which a worker is injured.”

As the background notes indicate, the claimant was tightening a water main repair clamp when the ratchet he was using slipped causing a full force right wrist push into the excavation wall. Approximately a week later, the right wrist appeared to be recovering. However, he injured it once again while using a shovel. Following this second injury, the claimant began to experience “intermittent numbness of the median innervated fingers of the right hand, at night and pain in the right wrist during the day.” In addition, this tingling was also recorded in the attending physician’s first report of injury dated October 13^th, 1998 (“numbness in right hand 3^rd & 4^th digits”).

It should be noted that on the physiotherapy referral form of September 30^th, 1998 the problem area was identified as the flexor tendons right wrist. Nerve conduction studies were carried out on December 16^th, 1998. These tests revealed: “a mild to moderate right carpal tunnel syndrome, likely from the trauma and the swelling of the injury.” A conservative course of treatment was initially recommended.

A WCB medical advisor was asked to provide comment as to whether the mechanics of the claimant’s two injuries were consistent with a diagnosis of carpal tunnel syndrome. In a memorandum of January 28^th, 1999, he responded by saying: “Yes on basis of trauma to flexor retinaculum of carpal tunnel. This is traumatic and should be expected to recover without surgery. However it may continue to require modified work for a period of time.”

The evidence confirms that the claimant continued to experience positive clinical findings of a right carpal tunnel syndrome. The hand surgeon reported to the WCB on June 14^th, 1999:

“We have spent 4 months now trying conservative management with a dorsal ulnar night splint, but I am afraid there has been no improvement in his symptoms whatsoever. He persists with a strongly positive Phalen’s test, but is present almost immediately and a strongly positive Tinel’s sign at the proximal part of the carpal tunnel. I feel that he would benefit from a surgical release under local anesthesia…”.

The employer appealed the WCB’s decision to authorize the right carpal decompression surgery. Review Office concluded not to permit the surgery largely on the basis of an opinion expressed by a WCB medical advisor dated August 3^rd, 1999.

“If the work place incidents gave rise to any swelling (edema & or hematoma) within the carpal tunnel due to local soft tissue trauma then an acute carpal tunnel syndrome might ensue. However I would expect the symptoms to resolve as the swelling resolved. It is also not clear whether the trauma of the 2 incidents was sufficient to cause this to ocur (sic).”

In arriving at our decisions with respect to the issues under appeal, we attached a considerable amount of weight to the opinion expressed by the hand surgeon and the analogy outlined in his letter of January 24^th, 2001 to the claimant’s union representative.

“The view from both the employer and the Workers Compensation Board is that an acute carpal tunnel syndrome does not proceed to a chronic stage. It is a well documented fact that the most common cause of carpal tunnel syndrome in the world is in fact pregnancy because of the increased fluid that these patients have in their body particularly during the 3^rd trimester. It is also very well known that as soon as the pregnancy is over, the situation reverses itself and the carpal tunnel syndrome settles down spontaneously. However, it is also known that a certain proportion of these patients do not always settle down following pregnancy and will continue to go into a chronic state of compression that then requires surgical release.

I feel that this is a suitable comparison with Mr. [the claimant’s] situation. It is known that after any swelling of the hand, the resolution of the swelling takes place because of fluid reabsorption, leaving residual fibrin behind that can cause scarring and compression.” Also of significance were the findings at the time of surgery (Retinaculum fully divided – very tight in distal ½).

The employer’s representative submitted an article entitled Carpal Tunnel Syndrome by Roy G. Kulick, MD, which we considered to be supportive, in part, of the opinion expressed by the surgeon.

“The carpal tunnel has, as its roof, the transverse carpal ligament. This tough, unyielding band serves to contain the tendons of flexor pollicis longus, flexor digitorum superficialis, and flexor digitorum profundus, as well as the median nerve.

Any factor that takes up space in the carpal canal, thereby causing pressure on the median nerve, can cause the symptoms of carpal tunnel syndrome.”

Finally, we took into account the evidence of the claimant at the hearing. He stated that the decompression surgery immediately and permanently relieved the pain and pressure in his right wrist.

We find that the claimant did sustain two accidents arising out of and in the course of his employment, which resulted in his right-sided carpal tunnel syndrome. Therefore, we further find the claim to be acceptable both on an acute and chronic basis. In light of the foregoing decision, it naturally follows that responsibility for the decompression surgery should be accepted by the WCB. The claimant’s persisting carpal tunnel syndrome symptoms were most definitely related to the two remote incidents occurring in September 1998.

Panel Members

R. W. MacNeil, Presiding Officer
A. Finkel, Commissioner
C. Monk, Commissioner

Recording Secretary, B. Miller

R. W. MacNeil - Presiding Officer
(on behalf of the panel)

Signed at Winnipeg this 30th day of May, 2001