The Appeal CommissionThe Workers Compensation Act of Manitoba

Preamble

An Appeal Panel hearing was held on January 21, 2004, at the employer's request. The Panel discussed this appeal on the same day.

Issue

Whether or not the claim is acceptable.

Decision

That the claim is acceptable.

Decision: Unanimous

Background

On August 28, 1997, the claimant filed a claim with the Workers Compensation Board (WCB) for left wrist difficulties that she experienced in April 1997 when she lifted a heavy object at work and damaged the tendons in her left wrist. The claimant also reported instant pain in her left wrist as a result of lifting a jug of milk on August 27, 1997. The diagnosis rendered by the attending physician on August 28, 1997 was tendonitis of the left wrist and physiotherapy was prescribed as a form of treatment.

On June 30, 1998, the claimant submitted another claim with the WCB with respect to a scaphoid lunate ligament tear due to the repetitive nature of her work activities on March 24, 1998. The employer's report of injury dated June 30, 1998/July 7, 1998, noted that the claimant informed her store manager of an injury to her left wrist and possibly her elbow back in March 1998 but did not specify that it was a work related injury.

In a sworn statement dated August 10, 1998, the claimant stated that she worked as a cashier for about 11 years. In mid March 1998, she began to notice tingling and numbness in her fingers with shooting pains up her left arm. She also found a lump on her wrist which looked like a ganglion cyst. The claimant said there was nothing unusual about work around the time that her symptoms began. The claimant stopped working on June 25, 1998.

In a letter which was faxed to the WCB on July 23, 1998, the employer's representative outlined several concerns with respect to the claim. Specifically, the employer noted that the claimant worked an average of 14.375 hours per week in 1997 and 16 hours per week in 1998.

The employer believed that there was not enough of a large volume of hours worked per week to result in the claimant's type of condition. The employer was also of the opinion that the injury as described, i.e. "torn ligament and tendons", should not occur gradually over time especially since the claimant's working hours were short.

In a Doctor's First Report dated July 13, 1998, the attending physician noted that the claimant was assessed on March 24, 1998. The claimant had recurrent pain in her left wrist and carpal tunnel evaluation had been negative. X-rays suggested a scaphoid lunate ligament tear. The claimant was scheduled to undergo an arthrogram in August 1998 and the physician felt the claimant was unable to work because of the repetitive nature of her work duties.

In a referral letter to the Hand Clinic dated May 4, 1998, the attending physician confirmed that the claimant was seen on March 24, 1998 with a lump on her left wrist. He also noted that the claimant injured her left wrist in June of last year when she twisted it by picking up two boxes at work. The physician could not see a direct correlation between that injury and what the claimant was now experiencing.

A report from the Hand Clinic dated June 15, 1998, stated, in part, "Lateral films of the wrist show that there is dorsal deviation of the carpal lunate and all these findings together raise the possibility of a scaphoid lunate ligament tear." Accordingly, a wrist arthrogram was being arranged. (The arthrogram was subsequently cancelled due to the claimant's pregnancy.)

Following review of all the medical documentation on file, a WCB medical advisor stated on August 18, 1998 that the most likely diagnosis was a tear of the scaphoid lunate ligament. He further stated, "…Usually, a scaphoid lunate ligament tear is caused by a significant wrist strain, i.e. traumatic rupture from one time event. It is possible, although much less likely, that this could be caused by repetitive supination/pronation carrying weight, e.g. loading heavy groceries into bags."

In a decision dated September 10, 1998, Claims Services determined that the claim was not acceptable as it could not substantiate that the worker suffered a personal injury due to an accident arising out of and in the course of her employment. This decision was reached based on the following factors:

• the claimant had no left wrist difficulties prior to March 1998.
  
  
• the claimant had previous injuries to her wrist in 1997, however, none resulted in significant injury;
  
  
• in March 1998, the claimant noted a gradual onset of left wrist pain but was unsure as to what caused her difficulties. She did not relate these to any work related injury.
  
  
• the opinion expressed by the WCB medical advisor that a scaphoid lunate ligament tear would normally be caused by a traumatic rupture from a specific event. The claimant, however, had not sustained any specific accident or incident at work in 1998 and she was a part-time worker, averaging only approximately 16 hours per week.

On September 23, 1998, the claimant's union representative appealed the decision rendered by Claims Services dated September 10, 1998. The union representative outlined his position that on a balance of probabilities, the claimant's wrist problems were the result of her work activities as cashier. The case was sent to Review Office for consideration.

In a decision dated October 23, 1998, Review Office felt there was sufficient information to support a conclusion that the claimant's job activities more likely than not contributed to the cause of her left wrist injury.

Review Office was satisfied that the employment situation and the job activities of the cashier position probably resulted in some increased risk for this type of injury (scaphoid lunate ligament tear) and that the claimant's onset of symptoms in March 1998 probably developed in the course of her employment and that there had been no particular evidence of a more probable cause outside of employment.

In correspondence dated July 17, 2002, the employer's representative asked Review Office to reconsider its 1998 decision to accept the claim based on the comments expressed by a WCB orthopaedic consultant under a right wrist claim when it was concluded that a TFCC (triangular fibrocartilagenous complex) tear was not related to the claimant's employment as a cashier.

In a memorandum dated December 6, 2002, a WCB orthopaedic consultant expressed his view that a TFCC tear required significant trauma and that repetitive movement will not tear a TFCC. He suggested that no significant trauma had been reported.

Prior to considering the employer's appeal, the Review Office sought the advice of a WCB medical advisor on June 26, 2003. The advisor was advised of the fact that there was a similar claim for compensation involving the right wrist and was asked to consider the information contained on both claims.

In his report to file dated September 10, 2003, the medical advisor explained that TFCC injuries are generally classified as either traumatic or degenerative. Traumatic TFCC lesions most often result from a fall on an outstretched hand or from loaded twisting of the wrist. Radial sided tears of the TFCC, as was determined at a January 8, 2002 arthroscopy are generally felt to result from direct injury to the wrist.

Based upon his review of the file, the medical advisor came to the conclusion that it was more likely than not that the claimant's workplace duties caused or influenced the symptomatic expression of the radial TFCC tear noted at arthroscopy.

In his view, the radial tear of the TFCC would not likely have resulted from repetitive activity including repetitive lifting. Rather, the injury would more likely have been the consequence of an acute definable traumatic incident such as a fall on an outstretched hand or an aggressive twisting force through the wrist.

In terms of a likely identifiable mechanism to account for the injury, reference was made to the claimant's statement that she first injured her left wrist in April 1997 by lifting a heavy object and she re-injured her wrist in August when she lifted a jug. In his view, it was conceivable that the incidents acutely traumatized the TFCC. In this scenario, the usual workplace activities could have aggravated a pre-existing although asymptomatic condition leading to symptoms and the claimant's presentation in March 1998.

In a decision dated September 19, 2003, Review Office confirmed that the claim was acceptable. Review Office relied upon the opinion expressed by the WCB medical advisor that the location of the TFCC tear points to a specific injury rather than a degenerative tear as previously thought by the WCB orthopaedic consultant. With respect to the diagnosed ganglions, Review Office considered the WCB's policy 44.10.20.20, Ganglia. In the opinion of Review Office, the claimant's employment as a grocery cashier involved prolonged, highly repetitive movement of the wrist against resistance and accordingly, the ganglions were compensable. On September 26, 2003, the employer's representative appealed Review Office's decision and an oral hearing was arranged.

An oral hearing was held on January 21, 2004. In his submission, the employer's representative argued that:

• A TFCC tear to the wrist joint requires a significant trauma to have occurred;
  
  
• There is no evidence of any trauma occurring to the claimant between March and June 1998.
  
  
• The evidence of bilateral central defects in the TFCC suggests this is a normal anatomical variant and does not represent a tear.

Reasons

The central issue in this appeal is whether, on a balance of probabilities, a causal relationship can be found between the claimant's job duties in the workplace and an injury to her wrist.

Upon reviewing the totality of the evidence including the record of the oral hearing, the medical and WCB reports and the submissions of the representatives of the claimant and the employer, the panel finds, on a balance of probabilities, that there is a causal relationship between the claimant's injury to her left wrist (a TFCC tear) and the workplace.

Our analysis begins with a diagnosis of the left wrist injury and an exploration of its causes keeping in mind the location of the injury on the wrist.

The injury in question related to the left TFCC. In considering whether the injury was causally related to the workplace, the medical evidence suggests that the key issue is whether there was a direct injury or trauma to the wrist which occurred during the course of work. As both the orthopaedic consultant and the medical advisor observed, a tear to the TFCC must be linked to a direct injury. It would not result from repetitive use in the workplace.

The injury was a radial side tear of the TFCC. The location of the injury is important because as the September 2003 report of the medical advisor suggests, radial-sided tears of the TFCC are generally felt to result from direct injury to the wrist.

The panel notes that the orthopaedic consultant was of the view that no significant trauma had been reported. In contrast, the WCB medical advisor traced the claimant's circumstances in March of 1998 to injuries to her left wrist in April and August of 1997. One of these incidents at work led to the claimant twisting her left wrist while picking up two boxes. The second unreported incident occurred when the claimant lifted a jug of milk.

Based upon its complete review of the file, the Panel does not accept the view that there was no significant workplace trauma. In the panel's view, based upon a balance of probabilities, the left wrist accidents occurring in April and August 1997 were traumatic events and were causally related to the compensable injury/aggravation in March 1998.

In making these findings, the panel notes the opinion of the medical advisor that the radial tear of the TFCC would likely have been the consequence of an acute definable traumatic incident such as a fall on an outstretched hand or an aggressive twisting force through the wrist. In our view, the nature of the workplace accidents occurring in April and August of 1997 are consistent with an acute definable traumatic incident such as an aggressive twisting force through the wrist.

In terms of the ganglion, the Panel makes reference to Board Policy # 44.10.20.20 and notes that the Board will accept a claim where it is probable that a condition was caused or aggravated by an accident arising out of and in the course of employment.

The panel notes that the nature of the claimant's employment involved prolonged, highly repetitive movement of the wrist against resistance. In the panel's view, on a balance of probabilities, the ganglions were caused or aggravated by the prolonged, highly repetitive movement of the area affected, which were a necessary component of the claimant's job duties.

For these reasons, the panel finds that the claim is acceptable. The employer's appeal is denied.

Panel Members

B. Williams, Presiding Officer
A. Finkel, Commissioner
M. Day, Commissioner

Recording Secretary, B. Miller

B. Williams - Presiding Officer
(on behalf of the panel)

Signed at Winnipeg this 17th day of March, 2004