The Appeal CommissionThe Workers Compensation Act of Manitoba

Preamble

A hearing was held at the Appeal Commission on September 10, 2007. The worker appeared and provided evidence. He was assisted by a worker advisor. The employer’s advocate also appeared and provided argument.

Following the hearing, the panel decided to obtain additional medical information about the worker’s right wrist condition. It also requested that the worker advisor and employer’s advocate provide documentation that they referred to at the hearing regarding the etiology of scaphoid fractures. The information the panel received was provided to the worker advisor and employer’s advocate for comment. On October 19, 2007, the panel met and made its decision with regard to the issue under appeal.

Issue

Whether or not the worker is entitled to wage loss benefits beyond May 9, 2003.

Decision

That the worker is entitled to wage loss benefits beyond May 9, 2003.

Decision: Unanimous

Background

The worker sustained a laceration to his right wrist on May 8, 2003 when his wrench slipped while tightening bolts inside the housing of an industrial fan. The worker attended a hospital emergency facility on the date of accident and received WCB benefits for one day. He then returned to his regular work duties.

In May 2006, the worker advised the WCB that he was having further difficulties with his right wrist that he related to the 2003 accident.

Medical reports showed that the worker sought treatment on May 18, 2006 with complaints of right wrist pain and pain, numbness and decreased strength in his right thumb. An x-ray of the right wrist taken May 19, 2006 revealed “Suspected remote fracture through the waist of the right scaphoid. This presumed fracture has not been well assessed. A scaphoid view could be performed for better evaluation…”. On June 12, 2006, an orthopedic specialist diagnosed the worker with tenosynovitis.

On June 20, 2006, a WCB medical advisor reviewed the file and could not relate the worker’s symptoms, i.e. loss of strength in the right thumb, possible tenosynovitis and a scaphoid fracture, to his 2003 compensable laceration injury. Based on this opinion, the WCB case manager, on June 26, 2006, determined that the worker was not entitled to further WCB benefits as it was felt that he had recovered from his original right wrist laceration injury and that his current symptoms were not related to that injury or the workplace.

The WCB then received information that the worker was treated by an orthopaedic specialist on July 24, 2006 and had x-rays taken which showed a fracture line through the right scaphoid.

On August 9, 2006, a WCB medical advisor reviewed this information and was unable to establish a causal relationship between the scaphoid fracture and the compensable injury. On August 14, 2006, the case manager advised the worker that his scaphoid fracture was not related to his compensable right wrist laceration and therefore she could not accept responsibility for any medical treatment or wage loss payments. On August 25, 2006, the worker appealed this decision to Review Office.

The Review Office sought a medical opinion from the WCB’s orthopaedic consultant. The consultant agreed that the worker’s scaphoid fracture was not related to the original laceration injury.

On September 19, 2006, Review Office confirmed that there was no entitlement to wage loss benefits beyond May 9, 2003. Based on the mechanism of injury, the initial diagnosis of a laceration and the three years that passed with the worker not seeking medical treatment, Review Office was unable to find a causal relationship between the May 8, 2003 compensable injury and the current diagnosis of a scaphoid fracture.

On February 28, 2007, a worker advisor asked Review Office to reconsider the above decision based on new medical information. The worker advisor contended that the worker was not properly diagnosed following his 2003 workplace injury and his medical practitioners have now provided opinions which clearly establish a relationship between the worker’s ongoing symptoms to his 2003 compensable injury.

In a report dated February 8, 2007, the orthopaedic surgeon responded to questions posed by the worker advisor. He stated,

1. “I believe the hypertrophic callus is the cause of his current symptoms and this is the result of an injury to his right wrist back in 2003. I do believe he had a scaphoid fracture. I do not think that the fracture is completely healed but I think his symptoms are more related to his hypertrophic callus. I felt that doing an operation to try and get the nonunion to heal was not warranted as the balance of probabilities suggest that the bone that (sic) is impinging on the radiostyloid because of his symptoms.

2. I do feel that [the worker’s] current symptoms are related to his 2003 injury…”.

In a rebuttal submission to Review Office dated May 2, 2007, the employer’s advocate provided argument that there was no reason to change the decision of September 20, 2006. The advocate felt the new medical information did not provide objective or clinical evidence of a cause and effect relationship.

On May 2, 2007, the worker advisor responded to the employer’s submission of May 2, 2007. He argued that the mechanism of injury was consistent with the diagnosis of a scaphoid fracture and that the worker reported his ongoing signs and symptoms to a first aid attendant.

A CT scan report dated October 30, 2006 was obtained by Review Office. It revealed a previous fracture of the scaphoid waist with non-union and hypertrophic bridging of the fracture margins, predominantly on the radial side. There was no evidence of avascular necrosis or other significant abnormalities.

Review Office then asked the WCB orthopaedic consultant to review the file along with photographs of the fan that the worker used when he was injured. The consultant stated on June 5, 2007 that the housing on the fan had a long sharp edge which caused a superficial laceration only. He felt it could not have penetrated the scaphoid bone or it would have cut the overlying tendons which did not happen. He was further of the opinion that the force generated by the sharp edge of the housing would be insufficient to create a fracture due to the short distance between the wrist and housing when the wrench slipped off the bolt.

On June 20, 2007, Review Office confirmed the worker was not entitled to wage loss benefits beyond May 9, 2003. Review Office felt the orthopaedic specialist’s opinion that the scaphoid fracture was the result of the workplace accident was based on the history provided by the worker. It felt the specialist did not provide a rationale to support his opinion that there was a relationship between the diagnosis of a scaphoid fracture and the compensable injury.

Review Office placed more weight on the opinion expressed by the WCB orthopaedic consultant. It found that a continuity of signs and symptoms had not been confirmed. It noted the worker did not seek medical treatment for three years and the employer was only able to confirm that the worker reported right wrist difficulties in May 2006. On July 25, 2007, Review Office’s decision was appealed by the worker advisor and a hearing was arranged. On August 23, 2007, the worker advisor provided new medical information for consideration.

The hearing took place on September 10, 2007. During the course of the proceeding, the worker provided an extensive description of the accident and of the mechanism of injury. He noted that the pictures provided did not accurately convey the picture of the fan at the time of injury.

The worker indicated that he was working on a fan and unable to use his impact wrench. As a consequence, he used a technique known as double wrenching which involved interlocking two wrenches end-to-end, in order to increase the torque with his hand. He indicated that in order to tighten the bolt his wrench would have to travel between six and eight inches in a clock-wise direction. It was on the second tightening using the double wrenching technique that his hand slipped and struck the edge of the fan housing.

The worker noted that there were no x-rays taken at the time of his initial injury. He testified that he always felt the pain after his initial injury “I always felt it. Like I didn't have my full strength in my hand. There was always...a little clicking and popping sensation and…I just thought it was the process of healing really.”

The worker advised that his supervisor, who was a first aider, and many of his co-workers were aware of his injury “you know, it was just in passing, outside having a smoke during lunch and you say ‘My wrist is getting sore’.”

Following the worker’s testimony, his advocate noted the medical information he reviewed suggested a fall is the most common cause for a carpal bone fracture, however a severe twist, direct blow or crush can also cause a fracture of the scaphoid bone. He also suggested that according to his research, a fracture of the scaphoid bone could go undiagnosed for weeks, months, or even years.

The advisor also argued that there was evidence of continuity of the injury in the workers 2006 accident report.

I had ongoing discomfort in the wrist since the accident. I also had decreased sensation in the thumb since the 2003 accident. My grip strength never recovered.

He suggested that the worker had “reported continuity of symptoms consistently to his attending physicians.” The advisor observed that the worker was a first aider who never sought treatment from the first aid attendant but that he had made “comments about his ongoing wrist difficulties in passing to this individual, which has been confirmed.”

In addition, he noted the comments of the worker’s doctor following an exam on July 24, 2006 that the worker:

“…continued to have pain over the right wrist over the past three years with a popping sensation. He had noticed a lump over the right wrist. He…also noticed numbness over the radial border of the right thumb.”

In the advisor’s view “this is an old fracture that developed a callus, which clearly was a nonunion,…something that didn't heal properly...”

The employer’s representative had a different perspective of the record. In her submission, there was “no objective evidence, either medical or anecdotal, that supports a causal relationship between the compensable laceration injury of 2003 and the scaphoid fracture noted three years later in 2006.” She noted that the employer appeared to be unaware of the right wrist difficulties and that the first aid attendant could only recall the worker mentioning difficulties with his wrist in May 2006.

Following the hearing held on September 10, 2007, the appeal panel requested and received documentation pertaining to the etiology of scaphoid bone fractures. On September 13, 2007, the worker’s advisor presented information supporting his assertion that:

(a) a scaphoid fracture can be caused by “a severe twist, direct blow or crush”;

(b) scaphoid fractures and non-unions may cause only minor symptoms and may not always be clearly identified by x-rays;

(c) scaphoid fractures can go undiagnosed for “weeks, months or even years”;

(d) the diagnosis of scaphoid fractures can be delayed “for weeks, months or occasionally even years after the original injury.”

The panel also requested and received a narrative report from the treating orthopedic surgeon regarding the worker’s right wrist condition. In his letter of September 18, 2007, the surgeon wrote:

“…the scaphoid bone is on the radial aspect of the wrist and the fracture/nonunion was through the waist of the scaphoid. These fractures can occur from a number of different means, most commonly through a fall on the outstretched hand. It seems reasonable to believe that being hit with an object directly on the wrist that would cause a laceration, such as the injury that [the worker] described could also cause a scaphoid fracture.”

Information provided by the employer’s representative on October 4, 2007supported her position that in terms of scaphoid fractures “usually the patient falls on the outstretched hand and hyperextends the wrist joint.”

On October 19, 2007, the panel met to make its final decision and consider final submissions from the worker advisor and employer’s representative.

Reasons

• the worker’s description of a continuity of concern with the wrist from the time of the injury until the diagnosis of the scaphoid fracture.

In reviewing the medical evidence and based on a balance of probabilities, the panel finds that scaphoid injuries typically occur from a fall. However, based on a balance of probabilities, the panel also accepts from the medical literature provided, that:

(a) a scaphoid fracture can be caused by a direct blow;

(b) scaphoid fractures and non-unions may cause only minor symptoms and can go undiagnosed for weeks, months or even years.

Based upon its consideration of the record as a whole, the panel finds, based on a balance of probabilities, that the worker suffered a sharp, fast blow to his wrist on the fan housing while torquing a double wrench. As a consequence of this injury, the worker suffered a scaphoid fracture.

In support of its conclusion, the panel notes there is a record of early swelling and tenderness to the worker’s thumb in 2003 which is corroborated by a continuity of complaints to doctors and co-workers. The panel notes the 2006 x-ray suggests degeneration and that the CT scan of the injury suggests the nonunion was not recent. The panel also observes that the orthopaedic surgeon considered it reasonable that the worker’s injury could result from the blow described. While his view differed from that of the board's orthopaedic consultant, the panel notes the board’s orthopaedic consultant does not appear to have had access to a complete and accurate description of the injury. Given the additional evidence provided at the oral hearing, the panel prefers the opinion of the worker’s orthopaedic surgeon.

Based upon the record as a whole, including the oral hearing, the panel finds that the worker sustained his current wrist injury as a result of a workplace accident, and that this has led to an inability to perform his pre-accident job duties, with a consequential wage loss. Accordingly, the appeal is allowed and the worker is entitled to wage loss benefits beyond May 9, 2003.

Panel Members

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

Recording Secretary, B. Kosc

B. Williams - Presiding Officer

Signed at Winnipeg this 12th day of December, 2007