Decision #127/03 - Type: Workers Compensation
Preamble
An Appeal Panel hearing was held on June 11, 2003, at the request of a union representative, acting on behalf of the claimant. The Panel discussed this appeal on June 11, 2003 and again on September 29, 2003.Issue
Whether or not the claimant is entitled to wage loss benefits from September 9, 2002 onward.Decision
That the claimant is entitled to wage loss benefits from September 9, 2002 onward.Decision: Unanimous
Background
In July 2002, the claimant contacted the call center at the Workers Compensation Board (WCB) to report left ring finger difficulties that she attributed to her work activities as a labourer. The claimant described her injury to the call center as follows:"My finger locks Repetitive use of the wizard knife cutting the bellies. I hold the knife in my left hand and repetitively cutting (sic). The wizard knife is a round knife with a handle and it vibrates. My finger started locking up on me and I usually could get it to unlock but it won't anymore."On August 19, 2002, a WCB adjudicator contacted the claimant to gather additional information concerning her work history and job duties that led to her left ring finger difficulties. The claimant was also asked questions pertaining to the medical treatment that she had received and details regarding how and when she reported her left ring finger difficulties to her employer.
In a report dated July 15, 2002, the attending physician confirmed that the claimant had triggering of the left ring finger and that the finger became locked in flexion. The physician requested the WCB's permission to release the finger surgically.
Upon review of the case on August 21, 2002, a WCB medical advisor commented that the claimant's left ring finger difficulties were consistent with her work activities. He further stated, "If claim is accepted surgery will be authorized." On August 22, 2002, the WCB adjudicator accepted the claim and on August 26, 2002, the WCB accepted financial responsibility for all costs associated with the surgical procedure.
On August 21, 2002, surgery was performed to the claimant's left ring finger. On September 3, 2002, the claimant returned to modified duties avoiding the use of her left hand.
In a memo to file dated September 13, 2002, a WCB adjudicator reported that she met with the claimant in her home on September 12, 2002. The adjudicator documented that the claimant was now off work and was unable to open her 3rd, 4th or 5th fingers. Furthermore, the claimant described problems she was experiencing with the left side of her body and the adjudicator noted a purple discoloration on the claimant's left hand and forearm.
On October 15, 2002, primary adjudication asked a WCB medical advisor to review the case and to comment on whether or not the claimant's symptoms in her face and feet were related to the compensable surgery. The medical advisor responded that the symptoms in her face and feet were not related to the compensable injury. The medical advisor also made the following statement, "I don't think she had a true trigger finger for which surgery was required."
Subsequent medical information revealed that a neurologist assessed the claimant on October 21, 2002 and he reported no objective neurological deficits.
On October 28, 2002, a plastic surgeon outlined his clinical examination findings stating, in part, that the claimant's fingers were tightly flexed into her palm and there was positive movement of the fingers but this was met with resistance. The surgeon indicated that the claimant likely had a complex regional pain disorder involving the left upper extremity or perhaps a fictitious disorder. Further treatment included aggressive physiotherapy with serial splinting or casting, an appointment with the Pain Clinic for guanethidine blocks and a bone scan to help rule out reflex sympathetic dystrophy (RSD). The surgeon also advised the claimant to stay off work and to attend physiotherapy until her hand became normal.
On November 4, 2002, the claimant underwent a three phase bone scan. The impression of the test results were recorded as follows: "There is no evidence for acute RSD. The findings are more compatible with chronic disuse of the left arm. This pattern can also be seen in the chronic atrophic form of RSD and this requires clinical correlation."
In a submission dated November 21, 2002, an advocate for the employer appealed the acceptance of the claim and any responsibility for ongoing acceptance. The advocate relied on the opinions expressed by the WCB medical advisor on October 15, 2002 and the neurologist dated October 21, 2002 as evidence to refute the claim.
In a memo dated December 9, 2002, a WCB adjudicator documented her discussion of the case with a WCB medical advisor. The medical advisor did not feel that the claimant's current symptoms were related to the compensable injury or the surgery. He said there was no organic explanation for a clenched hand and other symptoms. The normal recovery period for trigger finger release was approximately 10 days.
On December 11, 2002, primary adjudication advised the claimant of the medical advisor's comments as noted above. Primary adjudication determined that the claimant had recovered from the effects of her compensable injury and that she was not entitled to any wage loss benefits beyond October 11, 2002.
On January 31, 2003, Review Office determined that the claim was acceptable based on the opinion of a WCB orthopaedic consultant.
Review Office also determined that the claimant was not entitled to wage loss benefits from September 9, 2002 onward. Review Office stated that the existing medical documentation clearly established that the claimant's complaints of facial numbness, throbbing of the left arm and the inability to extend her left 3rd, 4th and 5th fingers could not be attributed to her employment. There had been no objective basis identified for these complaints and two specialists have suggested these symptoms were either due to a severe functional overlay or are fictitious. In concluding that these symptoms were not compensable, it was felt that the claimant should not have been entitled to wage loss benefits from September 9, 2002 onward.
On February 24, 2003, the treating plastic surgeon reported that the claimant was followed up for management of her RSD in the left upper extremity. He reported that the claimant continued to have significant swelling and contracture of the digits and that the Pain Clinic was going to attempt to anesthetize her and open up the contracture.
On March 25, 2003, a union representative disagreed with Review Office's decision to deny the claimant's wage loss benefits from September 9, 2002 onward and an oral hearing was requested.
Following the hearing and discussion of the case, further information was requested and received from a physician at the Pain Clinic. This information was forwarded to the interested parties for comment. On September 29, 2003, the Panel met to render its final decision with respect to the issue under appeal.
Reasons
This case involves a worker who suffered an injury to her left hand in a workplace accident in July, 2002. Her claim for compensation was accepted and benefits paid accordingly. Benefits were terminated in September 2002, as it was determined that her ongoing problems with her hand did not result from her compensable injury. Review Office upheld this decision upon reconsideration. She then appealed to the Appeal Commission.For her appeal to be successful, the Appeal Panel would have to determine that she continued to incur a loss of earning capacity beyond September 9, 2002, as a result of her compensable injury. We did make such a determination.
In coming to our decision, we conducted a thorough review of the claim file, as well as holding a hearing at which we heard testimony from the claimant and argument from the claimant's union representative and a representative of the employer.
The claimant worked in a hog-killing plant. One of her principal duties was to cut hog bellies with a "wizard" knife. As noted in the Background section, this led to the development of "trigger" finger, which was accepted as a compensable injury, and for which she had surgery. In the aftermath of the surgery, she developed other problems with her hand, some of which radiated up her arm. It was these other problems that were not accepted as compensable by the case manager and Review Office.
In order to come to a decision, the Panel had to determine whether or not these other problems were related to the original injury. We considered the following evidence:
- On September 9, 2002, the case manager authorized a continuation of full wage loss benefits.
- On September 12, 2002, her attending physician referred her to a specialist, querying the neurovascular integrity of her left hand. This specialist wrote, on October 21, that he could find no neurological deficits.
- On October 28, a specialist in hand, wrist and reconstructive medicine reported that "she likely has a complex regional pain disorder involving the left upper extremity or perhaps a fictitious disorder." He referred her for a bone scan "to help rule out a reflex sympathetic dystrophy" (RSD).
- The bone scan report, dated November 4, 2002, noted: "There is no evidence for acute RSD. … This pattern can also be seen in the chronic atrophic form of RSD and this requires clinical correlation."
- In late November, the hand specialist referred her to the Pain Clinic for assessment and treatment.
- In January 2003, the orthopaedic consultant to Review Office wrote in a memo that: "The initial reported clinical symptoms and subsequent findings at surgery are consistent with a trigger finger or stenosing tenosynovitis of the left ring finger. The clinical course and subsequent signs and symptoms following surgery are not consistent with a trigger finger.
- Subsequent to our hearing, the treating physician at the Pain Clinic reported to the Panel that he began to see the claimant in December 2002 and that he continues to treat her for "very severe reflex sympathetic dystrophy".
The paper further notes:
"There are no diagnostic tests to confirm the diagnosis of RSD. The diagnosis can only be made by thoughtful and careful analysis of the history and clinical picture, together with radiologic and laboratory data, by an experienced clinician who has examined the patient and has followed his/her progress. Some commonly used diagnostic tests include radionuclide three phase bone scan, electro-physiologic tests, and the response or lack thereof to sympathetic blockade."
In respect of diagnosis, the paper goes on to note that:
"RSD is unilateral, affecting one limb only. It is a complex pain syndrome in a limb following an initiating noxious event. Its occurrence or severity is not necessarily related to the severity of the initial injury…. Essential to the diagnosis is that the pain be disproportionate to the initiating cause in severity, duration and distribution, and that there are or have been some vascular … changes. Abnormality on a three phase bone scan tends to support the diagnosis, but a normal three phase bone scan does not rule out the diagnosis. There may be temporary relief of pain following sympathetic nerve blockade, but a response by no means confirms the diagnosis. Lack of pain relief following sympathetic nerve blockade does not rule out the diagnosis."The paper also notes that RSD must be distinguished from a number of other possible diagnoses or causes.
The report of the Pain Clinic physician on his diagnosis and management of the claimant for RSD is consistent with the scenario set out in the discussion paper.
Both - the physician's report and the discussion paper - would explain the comment of the Review Office consultant who noted that her ongoing problems were not consistent with "trigger" finger.
Our consideration of the foregoing evidence leads us to conclude that - on a balance of probabilities - the diagnosis of reflex sympathetic dystrophy is correct. We further conclude that her RSD is a sequela of the compensable injury. Thus, it is compensable.
Accordingly, the appeal is allowed. The claimant is entitled to wage loss from September 9, 2002 onward.
Footnotes
1 Dr. J.F.R. Fleming, Reflex SympatheticDystrophy, April 2000.
Panel Members
T. Sargeant, Presiding OfficerA. Finkel, Commissioner
M. Day, Commissioner
Recording Secretary, B. Mill
T. Sargeant - Presiding Officer
(on behalf of the panel)
Signed at Winnipeg this 12th day of November, 2003