Decision #43/08 - Type: Workers Compensation

Preamble

A hearing was held at the Appeal Commission on January 10, 2008 at the request of a worker advisor, acting on behalf of the worker. Following the hearing, the panel met to discuss the case and requested additional medical information. On February 22, 2008, the panel met and rendered its final decision with respect to the issue under appeal.

Issue

Whether or not a causal relationship exists between the worker’s left wrist osteoarthritis and a fall at work and/or the general nature of the employment duties.

Decision

That a causal relationship does exist between the worker’s left wrist osteoarthritis and a fall at work.

Decision: Unanimous

Background

On April 27, 2005, the worker filed a claim with the WCB for an injury to his left wrist. The date of accident was recorded as being August 1, 2004 and his last day of work was March 4, 2005. The accident description was carpal tunnel syndrome. The worker outlined his work duties as an aircraft refueller which consisted of repetitive twisting of his wrist when handling fuel hoses.

On December 19, 2005, the worker filed another claim with the WCB for a left wrist injury that occurred at work on February 15, 2003. The worker indicated that he was on a ladder fueling an aircraft when the ladder’s leg broke and he fell to the ground injuring his left wrist. He did not seek medical attention at the time as he thought it was a minor injury and continued with his regular duties. The pain would come and go since February 2003. As time went on, he would get sharp pains in his wrist and found that he started to drop things at work because of the numbness and pain. The worker noted that he told his employer of the accident on February 15, 2003.

Medical History

The following is a brief summary of medical information noted on both claims:

  • October 16, 2002 – left wrist x-ray revealed degenerative changes at the radiocarpal joint. There was no recent fracture or other actual bony process detected. Impression was mild wrist osteoarthritis.

  • December 12, 2002 – an orthopaedic specialist reported that he saw the worker for generalized soreness in his wrist. The worker advised that after being off work for a couple of days, his wrist seemed to get better. The worker did not recall a specific injury. Treatment suggestions included a cortisone injection and a splint.

  • March 20, 2003 – x-ray of the left wrist revealed narrowing at the radial carpal joint associated with some adjacent bony sclerosis. The impression was osteoarthritis.

  • June 28, 2004 – the attending physician reported that the worker had pain and swelling in his left wrist for 10 months. There was no history of recent trauma. The worker had pain at the lateral aspect of his wrist with decreased flexion and extension and decreased wrist power.

  • July 1, 2004 – a left wrist x-ray revealed moderate degenerative changes of the radial aspect of the radiocarpal articulation.

  • August 10, 2004 – the attending physician reported that the worker was seen by an orthopaedic surgeon in 2002 with degenerative disease of the wrist.

  • November 5, 2004 – a second physician reported a diagnosis of carpal tunnel syndrome (CTS).

  • November 26, 2004 – nerve conduction studies show evidence of moderate left carpal tunnel syndrome.

  • March 4, 2005 – the attending physician notes that the worker’s wrist symptoms from June 2004 to the time of reporting were related to the repetitive motion of his work duties.

  • June 17, 2005 – a WCB medical advisor said it was unclear from the medical information whether or not the worker’s CTS was the main cause of his current problems. He said the worker had pre-existing unrelated degenerative changes in his left wrist and a previous fall on the wrist.

  • June 27, 2005 – a plastic surgeon indicated that the worker had three years duration of symptoms. X-rays of the hands revealed bilateral radiocarpal joint space narrowing, more pronounced on the left and marked narrowing of the radioscaphoid component of the joint. Osteophyte formation was seen along the radiostyloid and adjacent scaphoid.

  • November 24, 2005 – a physiotherapist reported that the worker’s pain began when he fell onto his left hand from a ladder at work in approximately August 2004. At the time, the injury did not feel very severe but the pain never fully resolved. His wrist was weaker after the fall and has continued to get weaker as time went on. The report indicated that specialist tests for CTS were negative as were tests for tendonitis/tenosynovitis.

  • February 9, 2006 – the plastic surgeon stated that the worker’s EMG showed moderate carpal tunnel. He said x-rays showed evidence of radial scaphoid osteoarthritis which he believed was the worker’s main concern. An MRI was arranged to rule out ligamentous damage.

  • March 26, 2006 – an MRI of the left wrist showed chondromalacia of the radial aspect of the radiocarpal articulation. The scapholunate ligament was not visualized and may be torn. There was dorsal tilting of the lunate present. The impression was dorsal intercalated segmental instability.

  • June 9, 2006 – a WCB medical advisor stated that the probable diagnosis was ligamentous tear of the left wrist and degenerative wrist changes. He stated the attending physician’s chart notes of June 28, 2004 suggested a fall 10 months prior with pain and swelling on and off at work from before the reported fall at work in August 2004.

  • August 9, 2006 – a WCB orthopaedic consultant indicated that he reviewed the worker’s two WCB files and felt that the worker’s ongoing symptoms were due to a pre-existing degenerative arthritis of the wrist. He did not think the worker’s ongoing problems with the left wrist were related to his work injuries of February 15, 2003 and August 1, 2004.

  • August 10, 2006 – a plastic surgeon reported that the worker’s most likely problem is primarily his osteoarthritis as opposed to CTS. He suggested either a wrist fusion or limited wrist fusion along with a second opinion from another specialist.

  • January 8, 2007 – nerve conduction studies revealed mild left CTS with no evidence of left ulnar neuropathy or right CTS.

  • January 8, 2007 – the worker’s wrist was examined by a WCB medical advisor. In his examination report, the medical advisor outlined that the worker had clinical symptoms, physical findings and radiologic evidence of right wrist pain secondary to degenerative disease and possible intercarpal ligamentous instability of a DISI type. There were no clinical evidence of carpal tunnel syndrome as the primary symptom generator. With regard to causation and work relatedness, the medical advisor’s opinion was that the worker’s present symptoms were generated by his wrist osteoarthritis which was already active prior to any specific work related injury. He said the etiology of osteoarthritis was multifactorial. He also commented that it was impossible to decide when the intercarpal ligamentous instability actually occurred and therefore it was not possible to weigh the contribution of the intercarpal ligamentous instability into his decision on causation and relationship to his work.

  • April 13, 2007 – an orthopaedic specialist reported that the worker presented with left wrist radioscaphoid arthritis after an injury a couple of years ago. He had no symptoms prior to an accident at work when he fell from a ladder height. There was some confusion regarding diagnosis and the worker was treated for CTS. He said he explained to the worker that he had scaphoid arthritis which was likely aggravated from the injury. The worker stated he had no symptoms prior to the injury so he did not think that this could be blamed on wear and tear alone.

Adjudicative History

On July 5, 2005, the worker advised the WCB that he had an old injury to his left wrist at summer camp but it healed within a month. The worker indicated that he had a poor grip that caused him to fall off the ladder at work a couple of times.

On December 5, 2006, the worker was advised that the WCB was not accepting responsibility for his left wrist injury that was reported on December 19, 2005 (February 15, 2003 injury). The adjudicator made reference to the medical information dated August 10, 2006 and advised that it was reviewed in consultation with a WCB medical advisor. It was the adjudicator’s position that there was no cause and effect relationship between the diagnosis of osteoarthritis in his left hand and the fall that he sustained to his left wrist at work. She stated that she could not establish a relationship between his osteoarthritis of his left hand and his employment, therefore the claim had been denied.

In a decision dated February 6, 2007, the worker was advised that his claim for compensation was accepted and that he would receive wage loss benefits from May 12, 2005 to February 13,

2007. The worker was further informed that his pre-existing osteoarthritis was not related to the diagnosis of CTS, that his plastic surgeon stated that although he had a diagnosis of moderate carpal tunnel, x-rays showed evidence of radial scaphoid osteoarthritis which was his primary issue. After consulting with a WCB medical advisor, the adjudicator determined that the worker’s carpal tunnel was not his primary medical issue stopping him from returning to his pre-accident duties, rather his difficulties were related to his pre-existing osteoarthritis.

On May 10, 2007, a worker advisor appealed the WCB decision that was made on December 5, 2006 that the worker’s claim for osteoarthritis of the left wrist was not acceptable. The worker advisor contended the worker’s fall off the ladder met the definition of ‘accident’ as defined under the Act and established the acceptability of the claim. The worker advisor stated that the true issue was not whether the claim was acceptable, but whether there was a cause and effect relationship between the diagnosis of osteoarthritis and the fall from the ladder at work.

In a decision dated August 19, 2007, Review Office determined that there was no cause and effect relationship between the osteoarthritis and the fall at work or the worker’s job duties. Review Office stated that to accept the worker’s ongoing left wrist problems are a result of work related injuries, the weight of evidence must support the position that the degenerative changes were aggravated or enhanced by a work related incident. It stated that the evidence in this case supports the position that the worker had ongoing problems with his left wrist with symptoms in keeping with the natural progression of degenerative disease and osteoarthritis, since at least October 2002 (when the worker fell on his left hand/wrist at his summer camp and a subsequent x-ray reported degenerative changes in the radio carpal joint with mild wrist osteoarthritis.) On October 11, 2007, the worker advisor appealed Review Office’s decision and a hearing was arranged.

The worker was seen by a specialist on December 14, 2007 regarding his wrist. He outlined in his report that x-rays confirmed radioscaphoid arthritis which was likely a stage II SLAC wrist secondary to a scapholunate ligament injury and that this ligament injury likely occurred from the fall from the ladder. Treatment suggestions included scaphoid excision, four-corner fusion or proximal row carpectomy.

Following the January 10, 2008 hearing, the appeal panel requested additional information from the worker’s treating orthopaedic specialist. This information was later received and was provided to the interested parties for comment. On February 22, 2008, the panel met to render its final decision.

Reasons

The issue when this appeal was filed was whether or not a causal relationship exists between the worker’s left wrist osteoarthritis and a fall at work and/or the general nature of the employment duties. At the hearing of this matter the issue was narrowed to focus on whether there is a causal relationship between the worker’s condition and a fall at work.

For the reasons that follow, the Panel finds that such a causal relationship does exist.

As set out in the background, there was some confusion in the processing of this claim, as to when the accident occurred and as to the nature of the injuries sustained. This confusion was not attributable to the fault of anyone involved whether it be the worker, WCB staff or medical consultants.

Ultimately the worker’s claim was accepted as arising from an accident which occurred in February of 2003 and wage loss benefits were paid from May 12, 2005 to February 13, 2007.

It was decided by the WCB that wage loss benefits beyond February 13, 2007, however, were not warranted because it was determined that the worker had recovered from the effects of his compensable injury, that his other medical matters related to pre-existing issues and that there was no cause and effect relationship between the diagnosis of osteoarthritis in the worker’s left hand and the worker’s fall on his left wrist at work.

The panel, in reviewing the file noted there was also some confusion as to the number of employment related falls claimed to have been sustained by the worker. There was also limited evidence as to the nature of the worker’s prior, non-employment related fall. Finally, there was, as stated above, confusion from a medical perspective regarding the diagnosis and treatment of the worker’s condition as it related to his left wrist symptomology.

At the hearing of the appeal, however, the panel had the benefit of listening to oral testimony from the worker. It also received an informative submission from the worker’s representative. Following the appeal, the panel requested further medical information, all of which enabled the panel to make a fully informed decision based on the best evidence available.

THE EVIDENCE

Fall in July of 2002

The worker testified that in July of 2002 while walking up a set of stairs at his summer fishing camp, he tripped and fell. When he fell he was carrying a grocery bag in his left hand. He fell a couple of feet and landed on his left hand. He testified that he fell on a closed fist, having fallen on the hand which was still holding on to the grocery bag. He said he sought medical treatment perhaps 2-3 weeks or a month later and that while he had some pain at the time it was not anything he could not live with.

Fall on February 15, 2003

The worker testified that on February 15, 2003 he fell off a ladder while in the course of his employment duties. His evidence was that he fell 8-10 feet after the ladder he was on collapsed. When he hit the ground he said he fell with his hands outstretched in front of him, in an effort to break his fall. His left hand made the first contact with the ground. He said at the time he felt pain, like a snap or pop.

In response to being asked at the hearing which incident caused him the greatest pain, the fall in 2002 or the fall in 2003, the worker indicated: the fall in 2003. He testified that he continued to work after experiencing the fall at his summer camp in 2002. When asked when he stopped feeling symptoms from the 2002 injury, the worker replied that although he could not recall exactly, because it was so insignificant, his best recollection was that it was a month or a month and a half after the accident in July of 2002. He testified that all he knew was that “it was not hurting anymore and that it was fine”.

He said that it was not until October of 2002 that he had x-rays taken of his wrist and not until December of 2002 that he saw a specialist. He was asked by the Panel why he was still seeking medical treatment so many months after the fall in July of 2002. His response was that that was simply the length of time it took for the specialist to get to the northern community where he lived.

The worker also testified that by February of 2003 before he experienced the fall at work, his left wrist was fine. He said it was not until he incurred the work-related injury that he was brought to a point where he could no longer work because of the pain in his left wrist.

In terms of medical diagnosis and treatment after the 2003 fall, originally the worker’s physicians believed that the worker was suffering from symptoms relating to carpal tunnel syndrome. Ultimately, however, the worker was referred to a specialist who saw the worker in the spring of 2007. In that physician’s written report dated April 13, 2007 the physician began by acknowledging that there was some confusion in diagnosis and that the worker had essentially been treated for carpal tunnel syndrome. The specialist, however, agreed with the referring physician’s diagnosis of radioscaphoid arthritis rather than carpal tunnel syndrome.

The specialist went on to advise that the scaphoid arthritis was likely aggravated by the workplace injury. The specialist commented that he did not think the worker should work given his condition but that since the worker had advised he was going to retire anyway it would be “overkill to do surgery that does have some complications”.

The specialist saw the worker again on December 14, 2007. In the report prepared following that examination the specialist reported the worker had told him there was a WCB issue around the diagnosis of wrist arthritis and an injury the worker had sustained a couple of years prior to his injury at work.

The specialist acknowledged that the worker’s first injury was a slip and fall which caused wrist pain but which resolved, allowing him to return to work at full duties with no problems. The second injury was a fall from a ladder at work resulting in an injury to the wrist. The specialist reiterated the fact that although the worker was sent for nerve conduction studies due to a possible diagnosis of carpal tunnel syndrome, he was ultimately seen by a physician who agreed that this was not carpal tunnel syndrome and who, after doing an x-ray, confirmed radioscaphoid arthritis. That physician then referred the worker to the specialist who confirmed the diagnosis of radioscaphoid arthritis. The specialist stated that it was likely a stage II SLAC wrist secondary to a scapholunate ligament injury and that “this ligament injury likely occurred from the fall from the ladder.”

The ligament injury was also commented upon by a WCB medical consultant who examined the worker on January 8, 2007. In that consultant’s written opinion:

The intercarpal ligamentous instability of the wrist may be contributing to present symptoms and may have acted to accelerate the degenerative process. The etiology of a intercarpal ligamentous instability is usually a fall on an outstretched hand (FOOSH) type injury. The worker reported a non-work related FOOSH type injury in 2002. A work related left wrist injury on February 13, 2003 is also reported (it is not documented whether this was a FOOSH type injury). After reviewing all the medical information on file and interviewing [the worker] it is not possible to decide when the intercarpal ligamentous instability actually occurred. Therefore it is not possible to weigh the contribution of the intercarpal ligamentous instability into my decision on causation and relationship to his work. Based on this review the causal relationship of [the worker’s] current symptoms with the specific workplace injury cannot be established.

Analysis

The worker does not dispute the existence of a pre-existing degenerative wrist condition. In making this appeal, however, he is relying on reports from the specialist who saw him in April and December of 2007 and from the WCB medical consultant who examined him on January 8, 2007, all of which confirmed the existence of ligamentous instability of the wrist which is contributing to present symptoms and has acted to accelerate the degenerative process.

The WCB medical consultant acknowledged that the etiology of ligamentous instability is usually a fall on an outstretched hand (FOOSH) type injury. He was not, however, able to confirm the etiology of the ligamentous instability of the worker based on the evidence before him. Specifically, he was unaware as to whether the work related fall in 2003 involved a FOOSH type injury.

The evidence adduced at the hearing of this matter, however, confirmed that the work related injury in February of 2003 was a FOOSH type injury with the worker falling on his open left hand. Further, the worker’s evidence was that his non-work related injury which occurred in 2002 was not a FOOSH type injury. Rather, that injury involved falling on a closed fist.

Based on the evidence reviewed at the hearing, we find that there was a single work related injury which occurred in February of 2003 and that that injury did involve a FOOSH type injury or, in other words, a fall on an outstretched hand. We further find that the fall which the worker experienced in July 2002 did not involve a FOOSH type injury.

At the hearing it became apparent to the panel that the specialist who saw the worker and who provided the opinion in April and December of 2007 that the worker was suffering from scaphoid arthritis secondary to a scapolunate ligament injury which likely occurred from the work related fall, had never been provided with the medical information from October and December of 2002, relating to the worker’s left wrist.

The Panel wrote to the specialist, therefore, asking him to review that medical information and to advise whether the information changed his opinion as outlined in his report of December 14, 2007 with respect to the etiology of the worker’s wrist condition.

The specialist responded on January 20, 2008 confirming that he read the letter from the physician who saw the worker on December 12, 2002 which stated that the worker had some degenerative changes evident on the x-rays at that point. The specialist also confirmed that he reviewed the x-rays taken in 2002 which showed the same radioscaphoid joint narrowing.

The specialist then advised the Panel as follows:

The information provided would suggest that [the worker] had some degenerative changes in his wrist prior to the single work-related fall in February 2003. Despite this condition, he was able to return to work without any difficulty. His symptoms worsened after his fall. For this reason, I would suggest that the injury in February 2003 accelerated his condition.

Section 4(1) of The Workers Compensation Act states:

Compensation payable out of accident fund
4(1) Where, in any industry within the scope of this Part, personal injury by accident arising out of and in the course of the employment is caused to a worker, compensation as provided by this Part shall be paid by the board out of the accident fund, subject to the following subsections.

WCB Policy 44.10.20.10 (the “Policy”) addresses the subject of pre-existing conditions. The stated purpose of the Policy explains that the WCB will not provide benefits for disablement resulting solely from the effects of a worker’s pre-existing condition because a pre-existing condition is not “personal injury by accident arising out of and in the course of the employment”.

However, the Policy makes allowance for the situation where a worker’s loss of earning capacity is caused in part by a compensable accident and in part by a non-compensable pre-existing condition. The Policy states as follows:

A. POLICY

1. WAGE LOSS ELIGIBILITY

    1. Where a worker's loss of earning capacity is caused in part by a compensable accident and in part by a non compensable pre-existing condition, or the relationship between them, the Workers Compensation Board will accept responsibility for the full injurious result of the accident.

    1. Where a worker has:

      1. recovered from the workplace accident to the point that it is no longer contributing, to a material degree, to a loss of earning capacity, and
      2. the pre-existing condition has not been enhanced as a result of an accident arising out of and in the course of the employment, (emphasis added) and
      3. the pre-existing condition is not a compensable condition, the loss of earning capacity is not the responsibility of the WCB and benefits will not be paid.

… However, where it is determined that the worker's inability to work is a result of a compensable accident and evidence suggests, on a balance of probabilities, that the accident, or the accident in concert with the pre-existing condition, is causing the on-going loss of earning capacity the WCB would pay so long as the loss of earning capacity continues.

The Panel has determined, based on the totality of the evidence including the factual evidence and medical opinions before it, that on a balance of probabilities, the worker’s pre-existing condition was “enhanced as the result of an accident arising out of and in the course of the worker’s employment” within the meaning of the Policy.

For all of the above reasons, therefore, the Panel finds, on a balance of probabilities, that a causal relationship does exist between the worker’s left wrist osteoarthritis and a fall at work.

Panel Members

S. Walsh, Presiding Officer
A. Finkel, Commissioner
M. Day, Commissioner

Recording Secretary, B. Kosc

S. Walsh - Presiding Officer

Signed at Winnipeg this 26th day of March, 2008

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