Decision #90/06 - Type: Workers Compensation
Preamble
This claim essentially deals with the diagnosis of the worker's bilateral hand condition which occurred in December, 2004 as a result of the cold working conditions. The worker takes the position that his bilateral hand condition was frostbite, which has still not resolved. The WCB determined that the worker suffers from pre-existing Raynaud's phenomenon which was aggravated by the cold working conditions until April 14, 2005.An appeal panel hearing was held on May 16, 2006, at the worker's request. The worker appeared and provided evidence to the panel. The employer and its advocate also appeared and provided evidence.
Issue
Whether or not responsibility should be accepted for the worker's bilateral hand condition beyond April 14, 2005.Decision
That responsibility should be accepted for the worker's bilateral hand condition beyond April 14, 2005.Decision: Unanimous
Background
Reasons
Claim HistoryOn January 10, 2005, the worker filed a claim for bilateral hand symptoms that commenced in December 2004 during the course of his employment as a dock worker. His claim was accepted by the Workers Compensation Board (hereafter the "WCB") and wage loss benefits were paid to April 14, 2005 when it was determined that the worker had recovered from what was considered to have been an aggravation of a pre-existing condition, namely Raynaud's phenomenon, due to his exposure to cold in the workplace.
It was felt that the worker's ongoing difficulties and further treatment were solely related to his pre-existing condition and were not the responsibility of the WCB. The worker appealed this decision to Review Office. On January 4, 2006, Review Office found that a causal relationship did not exist between his work environment in December 2004 and his ongoing signs and symptoms and time loss from work beyond April 14, 2005. It is this decision that the worker appeals to the Appeal Commission.
Background
At the time of the workplace accident, the worker was employed as a dock worker in an unheated facility. Part of his duties included receiving shipments and doing paperwork which required him to remove his gloves.
On about December 17, 2004, the worker began experiencing a burning pain, discolouration and tingling in his hands. At the hearing, the worker testified that the discolouration began on top of his hands starting first with the fingers and progressing up to the knuckles. The discolouration went from red, to purple and by December 24, 2004, black.
Then between Christmas and January 5, 2005 the worker remained at home. He applied cream and tensor bandages on his hands to keep them warm.
On January 5, 2005 the worker went to his family physician. By this time the worker's hands were a mild purple in colour. The worker's subjective complaints were noted as a burning pain to all fingertips since December 17, 2004. "Works in cold weather but not improving since he stopped work on December 24, 2004. No blanching." Objective findings included a normal range of motion and Allen's test except for a slight delay. Pre-existing history notes ½ to 1 pack of cigarettes per day for the past 12 years and no history of Raynaud's. The family physician provisionally diagnosed the worker with bilateral finger parasthesia and referred him to a vascular specialist.
The vascular specialist saw the worker on January 24, 2005. He found minor finger tip ulcers and a bilateral positive Allen's test. The diagnosis was "bilateral vasospastic digital occlusive disease affecting both hands with the left more severe than the right, possibly related to chronic exposure to a cold environment at work". He noted that the worker was experiencing discomfort, numbness and pain since 2003, though the worker disputed this at the hearing, testifying that he had begun working for his accident employer in 2003 but only experienced these symptoms in December, 2004. Blood tests taken to rule out collagen vascular disease were normal and the worker was referred to an anesthesiologist at the Pain Clinic for treatment.
In a report dated February 9, 2005, the attending anesthesiologist notes that the worker was referred for Raynaud's disease. His assessment indicates however "cold induced vasospastic disease". The attending anesthesiologist noted pitting of the nails and blanching as well as erythema over the metacarpal phalangeal joints and some degree of bluish discoloration.
On March 16, 2005, a WCB internal medicine consultant reviewed the file information and stated, in part:
In a further report dated April 15, 2005, the attending anesthesiologist described his reassessment of the worker. This time he described his treatment for "persisting Raynaud's phenomenon of both hands that was induced by occupational cold exposure from his workplace". The worker still had significant persistence of the erythema over his metacarpal phalangeal joints as well as some distal blanching and mild paraesthesias. He opined that cold exposure at the work site was the obvious trigger for the worker's vasospastic disease."[The diagnosis] is not clear from the information supplied by the various physicians. I tried to look up in various texts for information regarding vasospastic digital occlusive disease and I could not find any information regarding this diagnosis.
Basically the term means decrease in circulation due to vasospasm. The digital pressures measured in the laboratory were all normal. There was however, no cold sensitivity test done.
Raynaud's phenomena are characterized by sequential development of digital blanching cyanosis and redness of the finger following cold exposure. Such sequence of symptoms is not described either by his family physician or [the vascular specialist]….
Whatever the disease process is, it seems to be related to exposure to cold. However, according to [the vascular specialist], the disease has been present since 2003 and is worse in the cold air.
The presence of the symptoms since 2003 does suggest that the claimant may actually have Raynaud's phenomena with severe recurrence on December 17 on exposure to cold. However, we do not have the typical history of Raynaud's phenomenon according to the medical information. History of cigarette smoking can also make the vascular phenomena more frequent and severe.
The trigger of Raynaud's phenomena is many, including emotional stress. We, however, do not have a definitive history of pre-existing Raynaud's phenomena on file."
The case was again reviewed by the WCB's internal medicine consultant on May 4, 2005. The consultant outlined the following opinions:
- clinically, the diagnosis was Raynaud's phenomenon but confirmatory evidence of a cold sensitivity test was lacking.
- the manifestations of Raynaud's phenomenon are a sequential occurrence of digital blanching followed by cyanosis, redness and pain on warming. The paresthesias noted by both physicians suggest the possibility of carpal tunnel syndrome. (The worker testified that this diagnosis was ruled out by recent testing.)
- Raynaud's phenomenon occurs more frequently in females and symptoms are worse in cigarette smokers. An attack can be precipitated by exposure to cold.
- Raynaud's phenomenon was a pre-existing condition.
- exposure to a cold environment may precipitate an attack but would be temporary until warmed up.
The worker's attending anesthesiologist wrote to the WCB on February 28, 2006 to clarify and support his opinion that the worker's bilateral hand condition was due to exposure to the cold and more particularly, frostbite:
"I had the pleasure of reassessing this gentleman today for the cold hypersensitivity, vasospasm and numbness of his fingers secondary to frostbite from occupational cold exposure in December of 2004."The WCB internal medicine consultant did not agree with a diagnosis of frostbite as there was no specific incident of it. In a March 22, 2006 memorandum to file he writes:
"I have done extensive literature search on the subject of frostbite. Superficial frostbite can lead to pallor, edema, blistering and discoloration and the deeper frostbite can lead to hemorrhagic blisters, paraesthesia, followed later by hyperesthesia, ulceration and gangrene…The examination by [the vascular specialist] does not indicate that there was any tissue damage and the pressure studies of the finger indicated normal blood flow to all the fingers. Unfortunately, skin sensitivity tests were not done…Please refer to my memo of March 16, 2005, where I concluded that the claimant may be suffering from Raynaud's Phenomena with an episode on December 17 due to exposure to cold."Worker's Position
The worker disputes that he has Raynaud's disease or Raynaud's phenomenon. He says that he suffered from severe frostbite and still has not yet recovered.
Employer's position
The employer takes the position that the medical evidence shows that the worker suffered a temporary aggravation of Raynaud's phenomenon. It also takes the position that the worker failed to mitigate and is therefore not entitled to further benefits.
Analysis
To accept the worker's appeal, this panel must find that the worker's continuing symptoms past April 14, 2005 are related to his compensable injury. This finding essentially means that the panel must reject the diagnosis of Raynaud's phenomenon as a pre-existing condition or, as a sequelae to a pre-existing condition, and accept a diagnosis of frostbite.
In reviewing and weighing the evidence the panel finds on a balance of probabilities that the worker did suffer frostbite as a result of his workplace duties from December 17 to 24, 2004.
The panel notes that the diagnosis of Raynaud's phenomenon based on a pre-existing underlying condition appears to have come about as a result of a lack of an initial clear cut diagnosis of the worker's symptoms, complete testing, and some misinformation.
At the hearing, the parties referred to the Mayo Clinic's definition of Raynaud's disease which it sub-divides into primary and secondary Raynaud's (secondary is also referred to as Raynaud's phenomenon). Raynaud's phenomenon is caused by an underlying condition which includes carpal tunnel syndrome, smoking as well as by injuries such as frostbite. Raynaud's disease occurs without an underlying condition. As explained by the WCB internal medicine consultant, Raynaud's is characterized by a short duration episode, after which the skin tissue returns to a normal colour. It also typically follows a sequence of symptoms - blanching and redness.
The worker's symptoms do not match this presentation. The worker's evidence is that on December 17, 2004 he experienced pain and redness in his hands, which did not abate. His continued exposure to cold worsened his symptoms. His hands turned red, then purple, then black. They later ulcerated and then the nails pitted. There was no initial blanching as recorded by the worker's family physician. This was the first time the worker experienced these symptoms that were not short-lived and did not improve outside of a cold environment.
At the hearing, the worker testified that the only relief he has had is with injections which started in about May, 2005. The beneficial effect only lasts one to two months. He also testified that his hands still hurt and he continues to work them with exercise.
On the basis of this evidence, we find on a balance of probabilities, that the worker suffered frostbite on December 17, 2004, the effects from which, the worker had not recovered as of April 14, 2005. As the worker stated at the hearing, on April 14, 2005, he had not yet begun to receive adequate treatment for his hands.
The employer argues that notwithstanding the worker's continued symptoms, he was still able to work modified duties. As the employer had offered modified duties to the worker in May and June, 2005 which the worker did not accept, the worker should not be entitled to further benefits.
Section 22 of The Workers Compensation Act (hereafter the "Act") states that a worker must take all reasonable steps to reduce or eliminate any loss of earnings resulting from an injury, failing which the WCB may reduce or suspend compensation payable to the worker.
In the case before us, the employer says that it has multiple modified duties that the worker could have done. While a specific job was not offered to the worker it would have been able to place the worker in one of these positions. Further, these modified duties would have taken place during the summer months when the worker was not exposed to the cold.
The worker says that he was not ready to return to employment in the summer of 2005 as his treatment was just beginning. However, he also says that he would have loved a dispatch job, though he is not sure how he would have fared at some of the duties given his reduced bilateral hand function. The worker was also worried about a reduced wage for the modified duties. That said, the worker testified that he has applied for several other jobs.
The application of section 22 of the Act is a discretionary provision. In the circumstances of the present case, the panel is not prepared to invoke it. The worker has been undergoing treatment for his hands and is still quite symptomatic. Though he has tried to find alternate employment, there is no evidence as to the type of modified duties he would have been capable of performing.
Given the foregoing, we find that responsibility should be accepted for the worker's bilateral hand condition and full wage loss and medical benefits paid beyond April 14, 2005.
Accordingly, the worker's appeal is allowed.
Panel Members
L. Martin, Presiding OfficerA. Finkel, Commissioner
C. Monk, Commissioner
Recording Secretary, B. Miller
L. Martin - Presiding Officer
(on behalf of the panel)
Signed at Winnipeg this 5th day of July, 2006