Decision #149/11 - Type: Workers Compensation
Preamble
The worker is appealing the decision made by the Workers Compensation Board ("WCB") which determined that her T6 compression fracture was unrelated to her compensable right wrist injury that occurred on November 28, 2010. A hearing was held on September 20, 2011 to consider the matter.Issue
Whether or not the worker's T6 compression fracture is related to her compensable injury of November 28, 2010.Decision
That the worker's T6 compression fracture is not related to her compensable injury of November 28, 2010.Decision: Unanimous
Background
The worker filed a claim with the WCB for an injury to her right wrist that occurred on November 28, 2010 when she tripped over a bed alarm cord and fell to the floor. The worker stated that her right wrist "bubbled up" and she immediately went to urgent care.
Medical information dated November 28, 2010, indicated that the worker sustained a Colles' fracture of the right wrist.
On December 2, 2010, a WCB adjudicator called the worker by telephone to discuss her claim. The worker indicated that she tripped over the call bell cord in a resident's room. She fell onto her right side with her right hand in a "FOOSH" (fall on outstretched hand) position. She had a bruise on her right leg on the outside edge of the kneecap. Her hand and top of her wrist swelled up instantly. The worker noted that she had trouble dressing and had no use of her right fingers. Her hand still felt swollen.
On December 2, 2010, the worker's claim for compensation was accepted based on the diagnosis of a right wrist fracture.
On December 16, 2010, the worker advised her adjudicator that her back was bothering her from the fall. The worker noted that she told the orthopaedic surgeon but he would not treat her back. The worker thought she may have developed pneumonia or possibly a back strain or rib injury due to the fall. The worker noted that she went to a walk-in clinic on December 8, 2010 because of the pain in her back and arm. She was prescribed painkillers but they were not helping. The worker noted that the pain went from her fingers, up the arm, into the back and down into her tailbone. On December 29, 2010, the worker advised the adjudicator that when she initially fell, she fell onto her buttocks with her hands extended beside her.
A WCB medical advisor reviewed the file on December 29, 2010. She noted that the worker underwent x-rays on December 18, 2010 for chest wall and buttock complaints, as reported in the December 17, 2010 doctor's progress note. The chest, left ribs, sacrum and coccyx x-rays were unremarkable. The thoracic spine x-rays demonstrated a compression fracture of T6 with about 60% collapse, described as being of uncertain duration. The medical advisor opined that based on the medical information on file, it was unlikely that the compression fracture was related to the November 28, 2010 workplace accident. She noted that thoracic spine compression fractures are generally osteoporotic in nature, meaning that they can occur without evidence of trauma. They are not generally associated with the mechanism of injury described for the November 28, 2010 workplace accident.
On January 4, 2011, the worker advised the WCB that she delayed in seeking medical treatment for her back and ribs because everyone was focusing on her wrist injury. She felt that the physician at the walk-in clinic did not take her seriously and that was why she booked an appointment with her family doctor.
On January 12, 2011, the WCB medical advisor reviewed new medical information that was placed on the worker's file. She noted that the worker complained of pain in her arm and back when she saw her physician on December 8, 2010. The physician's examination revealed no significant abnormal findings related to the back. The orthopaedic surgeon's progress notes dated December 6, 2010, December 13, 2010, December 31, 2010 and January 10, 2011 made no mention of back pain. The January 6, 2011 doctor's progress report did note tenderness over the thoracic spine but the back pain symptoms referred to in the earlier file were not localized to the thoracic spine.
The medical advisor further noted that the worker reported to her physiotherapist on January 10, 2011 that her workplace accident resulted from a machine shorting out, with her being thrown to the right, falling onto her wrist and back. She reported to another physiotherapist on January 21, 2011 that she was electrocuted in her workplace accident and was "thrown back onto the floor." The medical advisor noted that a review of the earlier file did not make reference to a possible electrocution injury nor did it make any reference to the worker being "thrown."
In a decision dated February 1, 2011, the worker was advised of the WCB's position that her low back difficulties were not compensable. The adjudicator noted:
A review of your file was completed in conjunction with consultations with a WCB Health Care Advisor. There is no mention in any medical reports about low back difficulties until the treatment of December 8, 2010. X-rays were taken and the diagnosis provided at that time is that of a compression fracture. No significant abnormal findings related to the back were described at that time. There is no mention of ongoing back difficulties in the subsequent medical reports until the report of January 6, 2011.
The adjudicator advised the worker that there was no evidence of a workplace injury which led to her low back difficulties. The worker's symptoms began after her absence from work and were not reported for 10 days after the workplace accident.
On February 9, 2011, the worker requested reconsideration of the decision to deny responsibility for her back difficulties. The worker indicated that after the initial shock of her broken arm, she became aware of pain and pressure around her ribs. On her visit to the specialist on December 6, 2010, she mentioned this pain to him and he referred her to Urgent Care or her family doctor. The next day she called her doctor and received an appointment for December 17, 2010. On December 8, 2010 she went to a walk-in clinic complaining of back pain and was given a prescription for pain medication. The worker indicated that her family doctor was willing to provide any documents to establish that the compression fracture did not exist prior to the November 28, 2010 work incident.
On March 3, 2011, the worker's appeal was considered by Review Office. Review Office noted that it obtained the following opinion from its medical consultant:
Medical evidence at hand indicates the claimant sustained a fracture of the radius with the event in question. This was originally described as a fall on the outstretched hand. Subsequently, the claimant has been documented as having thoracic spine pain, as well as a 60% compression fracture of T6.
By way of background information, as women age, they often manifest thoracic spinal compression deformities. These can occur with episodes of trauma, or they can occur spontaneously without much provocation. To relate the appearance of a compression fracture to a particular episode of trauma, there would typically need to be a close relationship between the trauma and the complaints of pain. In this case, there appears to be a time lag of more than seven days from the event in question, and the documentation of back pain. The first documentation of back pain appears to be about 10 days after the compensable event.
I agree with the rest of the logic expressed by [the medical advisor in her December 29, 2010 opinion].
To relate this compression fracture to the event in question, one would require it to become acutely painful with the event in question. Otherwise, one lacks the ability to relate the appearance of a compression deformity on x-ray, to a particular episode of trauma. There are records of the claimant havin (sic) three physician visits without complaints of back pain being documented.
At this time, in my opinion, the T6 compression fracture is not probably related to the event in question. Its date of onset can be described as being uncertain.
Based on a balance of probabilities, Review Office determined that the weight of evidence supported the position that there was no causal relationship between the worker's November 28, 2010 accident and her T6 compression fracture. On March 22, 2011, the worker appealed Review Office's decision to the Appeal Commission and a hearing was held on September 20, 2011.
Reasons
Applicable Legislation
The Appeal Commission and its panels are bound by The Workers Compensation Act (the “Act”), regulations and policies of the Board of Directors.
Under subsection 4(1) of the Act, where a worker suffers personal injury by accident arising out of and in the course of employment, compensation shall be paid to the worker by the WCB. Subsection 4(1) provides:
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.
The key issue to be determined by the panel deals with causation and whether the worker’s T6 compression fracture was caused by an accident arising out of and in the course of employment.
The Worker’s Position
The worker appeared at the hearing accompanied by her husband. Her position was that the T6 fracture occurred when she suffered the fall at work.
The worker described the incident on November 28, 2010 as follows. When she went to work that day (which was a Sunday), she was healthy and normal. After her morning coffee break, she came back to her assignment and as she was stripping one of the beds, she all of a sudden flew to one side as she stepped on a bed alarm cord. She said that she could not be sure whether she was electrocuted or otherwise as she just found herself on the floor. She felt she missed a minute or so. She looked at her hands, and one of her hands was huge. Her partner was coming into the room and the worker asked her to bring her some ice. The worker went to urgent care and said she had "pain everywhere." A cast was applied to her hand, which the worker indicated was done improperly and felt caused nerve damage to her hand.
On Monday, she went back to see an orthopedic surgeon in the cast clinic who readjusted her cast. For the next week, the worker could not move and she lay on the couch at home all the time. Within a few days of the accident, she felt like she had pressure in the front of her ribs and she had difficulty breathing.
The worker's evidence at the hearing was that on Friday, she went back to see the orthopedic surgeon and at that time, she said that something was wrong with her back. She was crying because she could not stand up or sit in the chair because of the pain. The orthopedic surgeon told her to see her family doctor. Her family doctor was away on holidays so the next day the worker went to see a doctor at a walk in clinic. The date was December 8, 2010.
In response to questions from the panel, the worker elaborated on the mechanics of her fall. While stripping the bed, she stood on the left side of the bed with the front of her thighs up against the edge of the bed. She was holding the sheets in her hands when she stepped on the cord with both feet. She then fell to the side and landed on the floor. The worker was not sure which part of her body hit the floor first, but felt it may have been her right hip. She had bruising on her right leg on the outside of her kneecap and about six inches above her knee. When on the floor, she was lying on her right side with most of her body contacting the ground except for her hip. It was then that she realized that her hand was swollen and she slowly got up and walked out of the room to get help.
The Employer's Position
An advocate appeared on behalf of the employer. The employer's position was that it agreed with the WCB's decision that the worker's compression fracture is not work related but rather was due to an osteoporosis condition. The mechanism of injury, falling onto an outstretched hand, was not consistent with a T6 compression fracture and there was no documentation of any back difficulties until December 8, 2010, despite intervening visits to doctors. It was noted that two WCB doctors had reviewed the matter and concluded that the T6 compression fracture was not work-related. There was evidence that the worker did have osteoporosis and it was submitted that spinal compression fractures are most often caused by this condition.
Analysis
The issue before us is whether or not the worker's T6 compression fracture is related to her compensable injury of November 28, 2010. In order for the appeal to be successful, the panel must find that the worker suffered the fracture to her thoracic spine when she fell down at work on November 28, 2010. On a balance of probabilities, we are not able to make that finding.
After reviewing the evidence as a whole, the panel is not satisfied that the worker's T6 compression fracture was sustained when she fell at work. In coming to this conclusion, the panel relies on the following:
- The December 29, 2010 report of the WCB medical advisor indicates that a T6 compression fracture would generally present with local pain and tenderness directly over T6. The medical advisor concludes that it is unlikely that the compression fracture is related to the workplace accident.
- Similarly, the medical advisor to Review Office states in his February 18, 2011 opinion that to relate the compression fracture to the event in question, one would require it to become acutely painful with the event in question. After reviewing the documentation, he was also unable to relate the T6 compression fracture to the workplace fall.
- The panel agrees with both medical advisors' review of the evidence, and we find that there were no reports of difficulties with her back until December 8, 2010, which is when the worker went to the walk-in clinic. Even at that attendance, the physician's examination appears to be focused on the low back with straight leg raise testing and range of motion examined. The complaint did not appear to be specific to the T6 area.
- At the hearing, the worker described the back pain as starting a few days later, and was in the front ribs, rather than the T6 area. The worker felt that the rib pain was because the T6 bone was broken and it was pressuring her ribs. The medical evidence, however, is that the pain would be expected to be localized in the T6 area.
- The worker's explanation for the delay in reporting was that the focus was on her wrist injury so she did not report the back pain. While the panel accepts that the wrist injury may have attracted the most attention, this does not adequately explain why no mention of back pain was made when the worker had multiple opportunities to report this pain during conversations with both medical practitioners and the WCB.
- The mechanism of injury described by the worker at the hearing was that she fell on her right side and suffered a bruise to her right outer leg and a fracture of her right wrist. In the panel's opinion, this mechanism of injury is not suggestive of a compression trauma to the thoracic spine.
Overall, the evidence does not satisfy the panel on a balance of probabilities that the worker suffered more than a right wrist fracture when she fell at work on November 28, 2010. We are unable to relate her T6 compression fracture to her compensable injury.
The worker's appeal is therefore denied.
Panel Members
L. Choy, Presiding OfficerA. Finkel, Commissioner
P. Walker, Commissioner
Recording Secretary, B. Kosc
L. Choy - Presiding Officer
Signed at Winnipeg this 16th day of November, 2011