Decision #25/00 - Type: Workers Compensation
Preamble
An Appeal Panel hearing was held on February 23, 1999, at the request of the employer. The Appeal Panel discussed this case on several occasions, the last one being February 16, 2000.
Issue
Whether responsibility should be accepted for the worker’s ongoing left wrist difficulties including the surgical procedure performed in November 1997.
Decision
That responsibility should not be accepted for the worker’s ongoing left wrist difficulties including the surgical procedure performed in November 1997.
Background
On August 8, 1974, the claimant was working as a sewer maintenance worker when a co-worker accidentally dropped a heavy chisel onto the claimant’s left wrist, hitting the dorsum of the radial styloid process.
In a medical examination dated August 9, 1974, the treating physician reported that the claimant had a puncture wound with swelling of the synovial sheaths of the abductor pollicus longus. X-rays showed an undisplaced vertical crack at the head of the ulnar and a fracture of the styloid process of the left ulna. The hematoma from the synovial sheath of the tendon was aspirated. A Plaster-of-Paris cast was applied from the knuckles to below the elbow. On September 6, 1974, another physician indicated that the fracture of the left ulna was healing. The claimant returned to work on September 26, 1974.
On December 10, 1997, the claimant wrote to the Workers Compensation Board (WCB) indicating that his wrist had never been the same since the original compensable accident. He stated that over the past four years he was referred to a number of hand specialists and that he underwent surgery to the left wrist on November 28, 1997. Before rendering a decision as to whether the claimant’s current difficulties were related to the compensable accident, primary adjudication at the WCB requested and obtained medical information from the claimant’s attending physician which included reports from various specialists and results of numerous x-ray investigations.
In a letter dated February 9, 1998, the attending physician indicated that the claimant first presented with wrist complaints on March 16, 1992. The claimant had left wrist swelling and pain of approximately two days duration and there was no record of recent trauma. Due to persistent pain the claimant was referred to an orthopaedic specialist on April 22, 1992 who believed the claimant was suffering with a non union fractured left ulnar styloid which was causing pain. The claimant was injected with one c.c. of Depo Medrol. In a follow up appointment on May 15, 1992, no significant improvement was identified and the orthopaedic specialist re-injected the wrist with a further shot of Depo Medrol and this resulted in improvement in the pain and swelling.
The claimant returned for treatment again on February 21, 1994 due to swelling and tenderness about the ulnar styloid. After several treatments ending in June 1994 and inasmuch as the claimant was still experiencing ongoing pain in the left wrist, he was referred to a second orthopaedic specialist on August 11, 1994. The orthopaedic specialist agreed that the pain was secondary to an ununited ulnar styloid fracture. He felt that the claimant was also likely suffering with concurrent injury to the triangular fibrocartilage complex of the distal radial ulnar joint. In addition to anti-inflammatory medication and a splint, it was felt that surgical treatment would be the last treatment resort.
The attending physician stated that the second orthopaedic specialist examined the claimant again in May 1995, and sought a second opinion from a colleague on August 16, 1995. This orthopaedic surgeon felt there was nothing surgically that could be offered to the claimant and that he should continue with a course of conservative care only.
In December 1995, the second orthopaedic specialist disagreed with the orthopedic surgeon’s assessment given that the claimant was suffering chronically with ongoing pain in this wrist and given the fact that all conservative measures had not helped. Arrangements were made for the claimant to be seen at the Hand Clinic on August 12, 1996. The attending hand specialist felt the claimant was suffering with a proven tear of the left triangular fibrocartilage complex and that he also had an extremely unstable end of the ulna. It was felt that most of the symptoms were attributable to the two aforementioned problems and it was decided to proceed with surgical correction of the chronic ongoing wrist problem. On November 28, 1997, the hand specialist proceeded with a surgical attempt at correction of the above problems.
The attending physician stated that when last seen on February 4, 1998, the claimant indicated that the surgery went well although he still had ongoing pain and clicking in his wrist. The physician noted that the claimant was involved in several motor vehicle accidents in the early 1990’s and stated, “while holding on to the steering wheel of his car that he did sustain some jarring injury to the wrist and that this may well have aggravated his underlying problem. The physician felt, however, that the claimant’s main difficulties with his wrist were as a result of his previous compensable injury that occurred at work on August 8, 1974.
Subsequent medical information consisted of the hand specialist’s report dated March 13, 1998, the operative report dated November 27, 1997, a left wrist arthrogram dated March 20, 1995, and a report from a rheumatologist dated June 8, 1998. Following consultation with a WCB medical advisor in July 1998, primary adjudication determined that responsibility would be accepted for the claimant’s left wrist surgery and that it was related to the 1974 compensable injury.
On October 21, 1998, an employer representative appealed the above decision and submitted a report from an independent specialist dated October 9, 1998. The employer contended that there was no basis to have accepted responsibility for the surgical intervention in November 1997 and that the only common denominator was that it involved the same extremity as that injured by the claimant on August 8, 1974.
Following consultation with a WCB orthopaedic consultant on November 3, 1998, Review Office determined that responsibility was properly accepted for the worker’s ongoing left wrist difficulties, including the surgical procedure performed in November 1997. In its decision dated November 13, 1998, Review Office agreed with the orthopaedic consultant that the destruction of the extensor carpi ulnaris tendon was likely precipitated by the cortisone injections into this area. Repeated x-rays reported that the fractured ulnar styloid healed by means of fibrous union which had been aggravated through minor trauma throughout the years. The surgery that was performed on the left wrist was performed essentially because of ongoing pain in the region of the ulnar styloid process, because of the fibrous union and not because of a speculative tear of the triangular fibro cartilage complex. On November 17, 1998, the employer’s representative appealed Review Office’s decision and asked for an oral hearing.
On February 23, 1999, the Appeal Panel requested additional information from the Manitoba Public Insurance Corporation and a copy of an “intake report” from a local hospital regarding an examination in late 1991. This information was later received and was forwarded to the interested parties for comment.
The case was again considered by the Appeal Panel on May 12, 1999. At this time the Panel requested that the Appeal Commission’s medical advisor arrange for an independent hand specialist to review the case and then attend the Appeal Commission to answer any questions that the Panel may have. An independent hand specialist was asked to review the case in August 1999, however, in November 1999, the hand specialist advised that due to time constraints he would not be able to review the case as requested. Arrangements were then made for a second independent hand specialist to review the case. On January 14, 2000, the Panel met with the independent hand specialist and a copy of the transcript was forwarded to the interested parties for comment.
On February 16, 2000, the Panel met to render its final decision.
Reasons
As outlined in the background notes, the claimant sustained an injury to his left wrist on August 8th, 1974. The claimant described the accident on the worker’s claim form as follows: “I was working down under ground about 16 feet knocking a hole in a pipe for a connection when this chissel (sic) or drill weighing from 3 to 5 lbs. accidently fell down stricking (sic) my wrist on the thumb side. Left wrist. Fractured bone on thumb side & cracked bone on opposite side.” An x-ray of the left wrist was taken that day and the radiologist reported: “The ulnar styloid appears separate but this does not have the appearance of recent bone injury.”
A treating orthopaedic specialist examined the claimant and reported to the attending physician “he has got a puncture wound with a swelling of the synovial sheaths of the abductor pollicis longus. X-ray showed a vertical crack undisplaced of the head of the ulnar and a fracture of the styloid process of the left ulnar. The hematoma from the synovial sheath of the tendon was aspirated. A back slab of Plaster-of-Paris was applied from the knuckles to below the elbow.” The diagnosis furnished to the WCB by the attending physician was a fracture of the head of the left ulna. The worker remained in a cast for about five weeks and was able to resume his employment activities by September 26th, 1974.
Twenty-three years later, the claimant contacted the WCB on December 10th, 1997, to advise that he had been experiencing problems with his wrist. “For the past 5 years especially, my ability to function normally with the use of my left hand has been very limited.” He further advised that his wrist had been operated on approximately a month earlier. The WCB then requested complete medical histories from both the claimant’s attending physician and wrist surgeon. The attending physician forwarded photocopies of the claimant’s entire file together with a covering letter outlining the claimant’s wrist complaints.
The claimant first presented to his current physician on March 16th, 1992 with complaints of left wrist swelling and pain of approximately two days duration. X-rays were taken of the left wrist, which revealed evidence of an old ulnar styloid fracture as well as a mild soft tissue prominence overlying the ulnar styloid. But no other significant abnormality was identified. Repeat x-rays were again taken two weeks later. The radiologist’s report stated the following: “Comparison is made with a recent examination dated March 16, 1991 (sic). Again noted was the remote non-displaced fracture of the ulnar styloid. No new abnormality is seen, specifically, there is no callus formation. The soft tissues are prominent, however, this may be normal for this patient.”
Because of the claimant’s persistent pain, the attending physician arranged for an orthopaedic assessment in April 1992. The orthopaedic specialist considered that the claimant’s source of pain resulted from the “non union fractured left ulnar styloid.” He administered a couple of injections of depo medrol, which improved the claimant’s left wrist pain and swelling.
The claimant next presented with chronic wrist pain to his treating physician in February 1994. He advised that the previous injections in 1992 had provided some temporary relief for his wrist. However, he continued to complain of ongoing pain, which he attributed to a motor vehicle accident. A referral was then made to a second orthopaedic specialist on August 11th, 1994. The specialist agreed that the claimant’s pain was secondary to an ununited ulnar styloid fracture. In addition, he believed that the claimant was also likely suffering from a concurrent injury to the triangular fibrocartilage complex of the distal radial ulnar joint. However, an arthrogram conducted on March 20th, 1995 ruled out the possibility of a triangular fibrocartilage complex tear. The radiologist reported as follows:
“No abnormalities of the triangular fibrocartilage complex are identified. There is a prominent ulnar styloid recess however no tear is seen. Contrast is seen in the mid carpal space and this is felt to occur through a tear in the lunotriquetral ligament. This finding is of questionable clinical significance given the clinical history.”
The second orthopaedic specialist once again examined the claimant in May of 1995 because of persistent left wrist difficulties. An injection of depo medrol was administered, which resulted in minimal improvement. In light of this outcome, the specialist decided to have the claimant reexamined by yet a third orthopaedic surgeon on August 16th, 1995. This latter physician determined that surgery was not an option and that conservative care should be continued.
The second orthopaedic specialist disagreed with this assessment and subsequently made arrangements for a surgeon at a local hospital hand clinic to examine the claimant on August 12th, 1996. The surgeon recorded: “On examination however he also has an extremely unstable end of ulna and I feel that most of his symptoms are referable to this. His symptoms are intermittent but his major complaint is that he cannot play golf because of the pain in his wrist.” He proceeded with an attempt at surgical correction of the claimant’s chronic ongoing left wrist problem on November 27th, 1997.
The surgeon was of the view that a Sauve-Kapandji limited wrist fusion would be the most appropriate way to go. During the course of the operation, he “…found that the extensor carpi ulnaris tendon had been essentially destroyed and replaced with scar tissue, and at the level of the ulnar styloid there was a complete hole filled with calcified material leading through into the lower end of the ulna. The appearances were highly suspicious of a gouty phenomenon, and this material was sent to the Pathology Department.” The histology report confirmed that this was, as suspected, gouty tissue: “Sections show subcutaneous tissue in which there is polarizable crystal deposition associated with a palisading granulomatous inflammatory process. The morphological features are most in keeping with those of a gouty tophus.” The surgeon concluded, “There is no question that the presence of gout had significantly made worse his original injury, and gouty deposits do occur in areas of injury in patients who are predisposed to it.”
Following the surgery, the claimant still continued to experience pain and clicking in his wrist. The attending physician concluded his covering letter to the WCB by stating:
“Complicating all of the aforementioned course is the fact, as noted in my progress notes, that Mr. [the claimant] was involved in several motor vehicle accidents in the early 1990’s. Mr. [the claimant] noted that while holding on to the steering wheel of his car that he did sustain some jarring injury to the wrist and that this may well have aggravated his underlying problem. I do feel, however, that the main difficulties that he has suffered with his wrist are as a result of his previous compensable injury which occurred at work on August 8, 1974.”
An adjudicator questioned a WCB medical advisor whether the claimant’s surgery was required as a direct result of the compensable injury. The medical advisor replied in a memo dated July 6th, 1998: “Partially, - the need of surgery is for both C.I. & pre-X gout.” In a memo bearing the same date, a second WCB medical advisor wrote: “The surgery was related to the C.I. In my opinion the gout is Not related.” Review Office then asked a third WCB medical advisor to comment on the relationship of the 1974 accident to the surgery and the development of gout. The medical advisor responded as follows:
“A Sauve-Kapandji procedure is somewhat extensive for an old fibrous union involving the ulnar styloid process which may have become painful due to further local trauma. I am not convinced the patient necessarily has gout involving the left wrist for reasons stated above and in any case it was not traumatically induced by an injury occurring in August 1974. Fibrous union of the ulnar styloid process can become painful with repetitive minor trauma to the area. Even a diagnosis of gout of the wrist if substantiated it did not occur as a result of the injury in 1974. Any surgery that was performed on the left wrist was performed for ongoing pain in the region of the ulnar styloid process related to fibrous union occurring as a result of the CI August 8, 1974.”
During the course of the hearing, the Panel was referred to an eight page medical opinion submitted by an orthopaedic consultant, who had been retained by the employer. Certain portions of that opinion are particularly noteworthy:
“Gout is a metabolic disease in which the breakdown of purine, an amino acid, is defective, resulting in an increase in the uric acid in the serum of the blood and, when deposited in joints or around tendons, is converted into urate crystals. Generally the disease first manifests itself around 40-50 years of age. The symptoms are usually spontaneous in origin, but may be provoked by a minor injury or alcohol ingestion. Once the symptoms commence, recurrence occurs at intervals if not treated with drugs to lower the uric acid level. Those intervals usually are a few months but can be as long as eight years. Very often only one joint is affected, but multiple joint involvement is not uncommon.”
“In all the textbooks I have referred to, involvement of tendons by gout is confirmed. The pathological process of deposition of urate crystals within the tendon followed by the inflammatory changes recorded in the pathologist’s report of 1 December 1997 weakens the tendon, which may rupture, as in Mr. [the claimant’s] wrist”
“In my opinion, the probable onset of gout in 1991 on (sic) March 16, 1992 was not provoked by the injury of August 8, 1974, due to the long symptom-free interval from 1974/75 to 1991.”
“A fibrous union (bony non-union) of the left ulnar styloid is very unlikely to be a cause of pain or discomfort and, in my opinion, the recurrent pain complained by Mr. [the claimant] since 1991 is probably due to gout. One attack of pain was provoked by a game of golf. As noted in the 1st paragraph of this report, attacks of gout occur every 2-3 months up to once every two years, and usually there is at least one attack a year.”
The Panel arranged for an external independent orthopaedic specialist to review the medical materials on file and thereafter to meet with us and to answer any questions that we had with respect to the medical evidence. Of significance were the following questions and answers:
Q. What would be the effect of a tear to this ligament [luno-triquetrial ligament]?
A. If the tear is complete, instability between the two bones can result, which may lead to pain in the wrist. If they’re incomplete, nothing may occur.
Q. And again, what would be the possible mechanisms for, to cause a tear of this ligament?
A. Once again, a fairly violent injury to the wrist where the wrist, we think, is moved either suddenly backwards or suddenly downwards to disrupt those ligaments.
Q. What is gout?
A. Gout is a metabolic disease caused by either an absence of an enzyme or so much material for the enzyme to digest that it can’t digest it all, and material is deposited in a variety of different places. There’s just too much of the material floating around in the body to be digested. It can occur for a whole variety of different reasons. It’s a metabolic disease.
Q. And what are the clinical signs of gout?
A. Well, the gouty crystals, which is the end product of the failure of the body to deal with the materials, are highly irritative. When they get deposited in joints or around joints, they cause an acute inflammatory response, which causes swelling, pain, redness and – well, swelling and pain and redness usually.
Q. And what about the location of the deposits of these crystals or the development of gout? There is some controversy as to where it will appear, where it won’t appear.
A. Well, it will appear almost anywhere, first of all. There are locations which are more common than others, but gout deposits will occur in almost any tissue in the body. So in the big toe is the commonest location to have an acute attack of gout, but we know full well that it occurs in many other areas of the body, including in the upper extremity, the area of the wrist.
Q. There is a reference in the file to something called posttraumatic gout. Can you comment on what that is or what it --?
A. It’s a propensity for uric acid crystals to be deposited in damaged tissue - - whether the damage has occurred in this instance as a result of trauma or whether it’s occurred for other reasons.
Q. In the file it appears that there is some uncertainty at least as to whether this posttraumatic gout would be very shortly subsequent to the trauma or sometime afterwards. Is there any pattern to this one way or the other, when that term is used?
A. It’s usually - - remember that after injury occurs, there is a response by the body to try and heal that injured tissue, in one way or another. In some instances it’s through regeneration, in other words replacement of the damaged tissue with tissue of a like type. In other instances it’s repair of the damage with scar tissue. In tendon, for example, there is the ability for at least some regeneration to occur, in other words for the damaged tendon to be replaced with at least tendon-like tissue, as opposed to pure scar tissue. It is believed by most people, I think, and having done some additional reading around this spurred by this, that the gout, the crystals have the greatest propensity to be deposited in the tissue relatively soon after it’s been injured, or at least while there is still damage present, before either regeneration or repair has gone on. If the tissue has been regenerated or repaired, it’s less susceptible to the deposition of those crystals.
Q. And just one other question, and this is related to the surgery. There is a finding that the extensor carpi ulnaris tendon is essentially destroyed. Could you perhaps explain where this is and why it would occur?
A. Why could it have been destroyed?
Q. This is the finding by the surgeon and it appears to be replaced with scar tissue at the, it says at the level of the ulnar styloid.
A. Well, I have to presume that that’s the material that was submitted to the pathologist and we know that tissue of any type, whether it be cartilage, as in the toe, or tendon, as in wherever, that has crystals of uric acid deposit in - - deposited within can undergo this kind of destruction.
Q. So the crystals have a certain - - are they the cause of the damage?
A. I don’t think it’s the crystals per se that cause the damage. When the crystals are deposited in an area, what they do is set up a very dramatic inflammatory response. The inflammatory response to the presence of the crystals is what causes the destruction. That inflammatory response is mediated - - is mediated by cells, which carry with them enzymes of a whole variety of types, and it’s - - and they are attempting to remove those crystals. In doing so, they release their enzymes and it’s the enzymes which cause the destruction of the surrounding tissues, whatever that tissue might be.
Q. Just before we move from the area, can you repeat the symptomatology of what - -
A. Severe pain, swelling and redness
Q. Okay. Now without having had the opportunity to examine the claimant - - would you care to provide an overall opinion with respect to his current difficulties involving his left wrist and the compensable injury, based on the materials provided to you by the medical examiner to the Appeal Commission?
A. Dr. [surgeon’s] note, and if I might refer to it - - of - - let me just try and find the - - because to me it’s critical and I think has been overlooked in the past. … However, it is the next statement that I think that has been overlooked, “On examination, however, he also has an extremely unstable end of the ulna and I feel that most of his symptoms are referable to this.” I think that this man, probably as a result of his motor vehicle accidents and possibly as a result of subsequent inflammatory episodes occurring, perhaps because uric acid crystals were deposited not only in the tendon, but also in surrounding ligamentous tissue, that this man has developed instability in the joint between his radius and his ulna, leading Dr. [the surgeon] to perform the surgical procedure that he did. And, as such, it is my opinion that this is unrelated to his initial 1974 injury.
The worker advisor acting on behalf of the claimant maintained that the weight of evidence established a causal relationship between the claimant’s compensable injury and his current wrist problems including the surgery. After having thoroughly reviewed all of the evidence, we do not come to a similar conclusion for several reasons.
The first of which is the mechanism of injury itself. We do not feel that the mechanism of injury was closely scrutinized at the time when the worker submitted his claim. The worker’s claim for injury form clearly stated that he was struck on the radial side and not the ulna side of his wrist (“stricking (sic) my wrist on the thumb side). The x-ray, taken on the same day as the injury, recorded that the separation of the ulnar styloid did not have the appearance of “a recent bone injury”. In addition, the description of the trauma site by the treating orthopaedic specialist dealt strictly with the radial side of the wrist, “On examination he has got a puncture wound with a swelling of the synovial sheaths of the abductor pollicis longus.” There was absolutely no mention of the ulna side of the claimant’s wrist in his report. It seems inconceivable to us that if the ulnar styloid had been fractured at the time of the compensable injury, then surely there also would have been noticeable swelling and pain on this side of the wrist. As well, the diagnosis rendered by the treating physician to the WCB was a fracture of the left ulnar head and not a left ulnar styloid fracture. We find, based on a preponderance of evidence that the claimant’s compensable injury did not, on a balance of probabilities, result in a fracture to the left ulnar styloid.
Secondly, we accept the consensus of medical opinions on file that a fractured ulnar styloid, which has healed by fibrous union, seldom causes symptoms.
Thirdly, we find, based on the weight of evidence that the claimant’s gout did not develop as a consequence of his compensable injury.
Lastly, we prefer to adopt the external independent orthopaedic specialist’s opinion that the claimant’s wrist surgery was “unrelated to his initial 1974 injury.”
Panel Members
R. W. MacNeil, Presiding Officer
A. Finkel, Commissioner
R. Frisken, Commissioner
Recording Secretary, B. Miller
R. W. MacNeil - Presiding Officer
(on behalf of the panel)
Signed at Winnipeg this 24th day of March, 2000