The Appeal CommissionThe Workers Compensation Act of Manitoba

Preamble

The worker is appealing the decision made by the Workers Compensation Board ("WCB") to deny responsibility for the proposed right middle finger surgery. A file review was held on June 21, 2017 to consider the worker's appeal.

Issue

Whether or not responsibility should be accepted for the proposed right middle finger surgery.

Decision

That responsibility should not be accepted for the proposed right middle finger surgery.

Background

The worker filed a claim with the WCB on January 3, 2013 for injury to both his hands (accident date of December 17, 2012) that he related to the nature of his job duties as a pipefitter. The worker advised that he has worked as a pipefitter for 35 years. The worker indicated that December 17, 2012 was "a day that I had a really bad day with my hands."

On August 29, 2013, a WCB medical advisor stated:

He has appropriate investigations including x-rays, CT, bloodwork and two negative NCS's to rule out an underlying rheumatic or neurological etiology for his reported ongoing hand/wrist symptoms. His 2013 x-ray notes osteoarthritis in several joints of his right hand (radiocarpal joint, MCP joint, IP joint, and 1st MCP), not evident on previous x-rays from 2001 and 2002. Per [plastic surgeon's] interpretation, this x-ray is "consistent with a SLAC I, II, and perhaps even a SLAC III wrist", and the subsequent CT shows migration of the capitate between the scaphoid and lunate.

The current diagnosis is a right SLAC wrist on a background of generalized right hand/wrist osteoarthritis.

SLAC (scapholunate advanced collapse) wrist refers to degenerative changes in the wrist resulting from untreated chronic scapholunate dissociation or chronic scaphoid non-union. It is a form of degenerative arthritis of the radiocarpal and midcarpal joints, related to scaphoid or scapholunate ligament injury. Chronic untreated SLAC wrist can present with decreased wrist ROM, pain at rest and with activity, decreased grip strength.

…The claimant's job duties consisting of highly repetitive, forceful gripping and twisting over a prolonged period (35 years) are, on balance, the likely cause of his right SLAC wrist.

In a report dated January 7, 2014, the plastic surgeon noted that the worker presented with complaints of ongoing pain to the dorsum of his right hand in line with his CMC joint as well as a burning sensation in his palm. The worker denied any clicking or locking and described difficulty with movement of his fingers as well as pain with bumping his fingers. The surgeon stated there were no objective findings aside from CMC arthritis that warrant any surgical intervention.

On June 2, 2015, an orthopedic surgeon reported that the worker complained of stiffness in his right wrist with inability to make a fist. He had pain in the dorsum and mid MP joints of his middle and ring finger. He had a previous chemical burn with propane years ago while at work and there was now features of neuritic pain on the dorsum of his hand. The surgeon indicated that he arranged for nerve conduction studies as the worker had features consistent with complex regional pain syndrome (CRPS) on his dorsum of his hand.

On June 16, 2015, a WCB medical advisor noted to the file that the CMC osteoarthritis was not a new diagnosis, as osteoarthritis was demonstrated in the April 2, 2013 x-ray of the right hand/wrist; and, that the diagnosis of osteoarthritis was not accounted for in relation to the workplace injury.

In a July 21, 2015 report, a physical medicine and rehabilitation specialist noted that the worker "does not have CRPS. He has focal tenderness of the right base of thumb and to a lesser degree wrist. I suspect this is an articular problem possibly due to ligament instability and the arthritis of the first CMC joint. I would therefore suggest…a leather gauntlet splint fashioned for him with a thumb spica…"

On June 21, 2016, an MRI of the right wrist revealed:

1. Tearing of the membranous portion of the scapholunate ligament from its scaphoid attachment resulting in a dorsal intercalated segment instability pattern. 

2. Mild first carpal metacarpal joint osteoarthritis. 

3. Normal median and ulnar nerves.

On July 19, 2016, a WCB plastic surgery medical advisor noted to the file that after reviewing the July 21, 2015 neurology report and the right wrist MRI, there was no new diagnosis apparent on file since the prior June 16, 2015 medical opinion. The surgeon noted that the diagnosis of right SLAC wrist had been accepted on the claim and it was confirmed in the June 21, 2016 MRI report. The diagnosis of hand osteoarthritis was not accounted for in relation to the workplace injury. The updated medical information did not provide a basis on which to alter the previous decision.

In a consultation report dated November 3, 2016, a surgeon specializing in hand, wrist, elbow and peripheral nerve surgery stated:

…he has generalized complaints with regards to the right hand and wrist and certainly much of this is nonsurgical. He has early arthritic deformity at the third MCP, which correlates with his inability to make a full fist and pain. Given the radiographic findings, I would not be a (sic) overly interested in proceeding with surgical management. He had a poor result with previous corticosteroid injections and is not interested…As a result, I had a lengthy discussion with them that there are options in the form of MCP joint arthroplasty but again I would not recommend this based on his imaging or his function.

In a note to file dated November 29, 2016, the WCB plastic surgeon stated that:

The proposed surgery at the right middle finger MCP joint does not relate to the accepted diagnosis on file.

In a decision dated November 30, 2016, the WCB advised the worker that based on the November 29, 2016 medical opinion, the WCB was not accepting responsibility for the proposed surgery.

In a submission to Review Office dated December 21, 2016, the worker stated that he and his surgeon believed that his knuckle problem was created by his wrist problem and that he had tears in the membranous proximal portion of the scapholunate ligament. He believed that more problems may turn up when the surgery is performed.

On January 30, 2017, Review Office determined that there was no coverage for the proposed right middle finger surgery based on their review of the file evidence and the opinion provided by the WCB plastic surgery consultant. On February 10, 2017, the worker appealed Review Office's decision to the Appeal Commission and a file review was arranged.

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 27(1) provides that the WCB may provide the worker with such medical aid as the board considers necessary to cure and provide relief from a work injury.

The WCB Healthcare Department has a position statement regarding the "Authorization of Elective Surgery/Procedures" which states:

The requirement for a proposed surgery or procedure must be a direct manifestation of the workplace accident.

The worker is seeking coverage for surgery which he considers to be related to his workplace accident.

Worker's Position

The worker submitted an appeal to the appeal commission on February 2, 2017. In the appeal form, he indicated that:

It took 17 years of pain before a MRI showed a tear of the membranous portion of the scapholunate ligament…

By being a conscientious worker for 28 years for this company alone I deserve the right of protection from injuries received. [Spelling corrected]

In a written submission to the WCB Review Office dated December 21, 2016, the worker submitted, in part:

This has been an ongoing problem and slowly getting worse. Dr. [name] and myself believe that the knuckle problem was created by the wrist problem. I have tears in the membranous proximal portion of the scapholunate ligament. I believe more problems may turn up when dr. [name] does surgery.

Employer's Position

The employer did not participate in this appeal.

Analysis

The worker filed a claim with the WCB for a December 2012 injury to both hands that he related to his duties as a pipefitter. He specifically asked the WCB to cover surgery to his right middle finger. The WCB refused to provide medical coverage for the surgery. As a result, the worker is appealing the WCB decision to refuse to authorize medical coverage for the proposed right middle finger surgery.

For the worker's appeal to be approved, the panel must find that the proposed surgery is related to the workplace accident. For the reasons that follow, the panel is not able to make this finding.

The panel notes that the accepted injury on this claim is described as a right SLAC (scapholunate advanced collapse) wrist. The panel understands that this injury results from the non-union of bones in the worker's wrist. The panel notes that the worker is seeking approval for surgery to address degeneration in his right middle finger joint.

The panel has reviewed the medical information on file and notes that on November 29, 2016, the WCB plastic surgeon opined:

The accepted diagnosis on the file is right SLAC wrist. Surgery has not been proposed in relation to the SLAC wrist. Rather, the orthopedic surgeon proposed a possible third (i.e. middle finger) MCP joint arthroplasty in relation to arthritis at this joint, though the surgeon did not recommend it based on the imaging studies and his function. The proposed surgery at the right middle finger MCP joint does not relate to the accepted diagnosis on this file.

The panel relies upon this opinion in making our decision.

In conclusion, the panel finds, on a balance of probabilities, that the proposed right middle finger surgery is not related to the worker's accepted claim and accordingly the panel is not able to authorize medical coverage for the surgery. 

The worker's appeal is dismissed.

Panel Members

A. Scramstad, Presiding Officer
A. Finkel, Commissioner
M. Payette, Commissioner

Recording Secretary, B. Kosc

A. Scramstad - Presiding Officer
(on behalf of the panel)

Signed at Winnipeg this 3rd day of August, 2017