Decision #23/19 - Type: Workers Compensation
Preamble
The worker is appealing the decision made by the Workers Compensation Board ("WCB") that responsibility should not be accepted for his current radial collateral ligament difficulties as being a consequence of the December 5, 2012 accident. A hearing was held on December 18, 2018 to consider the worker's appeal.
Issue
Whether or not responsibility should be accepted for the worker's current radial collateral ligament difficulties as being a consequence of the December 5, 2012 accident.
Decision
That responsibility should not be accepted for the worker's current radial collateral ligament difficulties as being a consequence of the December 5, 2012 accident.
Background
The worker reported to the WCB that on December 5, 2012, he slipped on ice at his work unit and fell on his right wrist, breaking it. The worker was taken to the local emergency room where he was diagnosed with a distal radial fracture and a cast was placed on his right wrist.
The worker attended a clinic on December 7, 2012, where the attending sports medicine physician diagnosed him with a distal radius fracture and ulnar collateral ligament sprain. The cast was changed and it was recommended he remain off work until December 14, 2012.
On January 9, 2013, the worker was seen by an orthopedic surgeon. The worker's cast was removed and he was advised to start physiotherapy.
On February 6, 2013, the worker returned to the clinic, complaining of increased symptoms. He was seen by a second sports medicine physician, who referred him for an MRI of his right wrist and thumb. The MRI, performed on February 28, 2013, showed in part: "High-grade partial thickness tearing of the ulnar collateral ligament of the first metacarpophalangeal joint. Mild sprain of the radial collateral ligament."
On June 26, 2013, the worker was seen by a plastic surgeon who specializes in hands. The plastic surgeon recommended the worker attend for a further trial of six to eight weeks of physiotherapy, then return for reassessment.
On August 21, 2013, the worker was reassessed by the treating plastic surgeon, who noted no change in his symptoms. Various treatment options were discussed, including a surgical procedure to repair the ulnar collateral ligament of the thumb. The surgeon noted the worker wished to think about his options and was leery to proceed with surgery.
On September 11, 2013, a WCB plastic surgery consultant reviewed the worker's file and opined, in part:
Based on the medical information on file, the probable diagnoses related to the workplace injury are i) a non-displaced intra-articular right distal radius fracture and ii) right thumb metacarpophalangeal (MCP) joint sprain with partial tear of the ulnar collateral ligament (UCL).
The natural history of a non-displaced distal radius fracture is typically that of healing of the fracture with cast immobilization, often followed by a course of physiotherapy.
The natural history of a thumb sprain with a partial UCL tear (and no Stener lesion, as in this case) is typically that of a period of immobilization and healing of the tear, typically followed by a course of physiotherapy. In the event that healing/thumb stability is not satisfactory, surgery may be considered.
The worker returned to see his treating plastic surgeon on June 19, 2015, with complaints of continuing pain in his right thumb and right wrist. The plastic surgeon noted, in part:
On examination, the patient has full range of motion of the fingers. He has flexion deformity of the right thumb MTP joint. The patient has instability of the MCP joint in that he has an ulnar collateral ligament tear when testing the ligament in resistance at 30 degrees of flexion as well as in extension. With regards to his wrist, the patient has radiocarpal joint pain. He has had a previous minimally displaced distal radius fracture. The patient has slightly reduced range of motion in his right wrist compared to his contralateral left wrist in both flexion-extension and radial and ulnar deviation.
The plastic surgeon discussed treatment options with the worker, including conservative management with topical and oral anti-inflammatories versus steroid injection, and surgery, including reconstruction of the ulnar collateral ligament of the thumb versus fusion. The worker indicated that he was not keen to pursue surgery at that time.
On December 9, 2015, following receipt of a request for a new medication, the WCB plastic surgery consultant reviewed the worker's file and provided a further opinion to file.
On March 14, 2016, the worker was referred to a second plastic surgeon. The worker advised the plastic surgeon that he had ongoing pain in his wrist and thumb. He said he was continuing to work, but had "limited capacity" with his right hand. The second plastic surgeon reported, in part:
Clinical examination shows a normal looking wrist. He has good range of motion and extension and radial and ulnar deviation. There is some limitation in flexion and pronation and supination are good. Examination of the thumb MCP joint shows ulnar deviation present and some laxity of the radial collateral ligament of the MP joint. The ulnar collateral ligament is good. There is no instability of the CMC joint. He does have some pain with axial loading of the MCP joint. Examination of the wrist shows some generalized tenderness but no instability of the carpal bones.
The second plastic surgeon further noted that the worker's wrist pain would be best managed with modified activities, anti-inflammatories and/or splinting. With respect to the worker's thumb, he suggested that surgical reconstruction of the radial collateral ligament might give the worker better stability and might relieve his pain. The plastic surgeon noted the worker would advise if he wished to proceed with the surgery.
On December 7, 2016, the worker returned to see the second plastic surgeon. The surgeon noted that "Clinical examination confirms continued laxity of the radial collateral ligament. There is some pain when stressing the MCP joint and obvious instability." The surgeon recommended reconstruction in the form of direct ligament repair, with or without a tendon graft, and noted the worker advised he would consider this.
On May 3, 2018, the WCB plastic surgery consultant reviewed the claim file and documented her opinion to file with respect to the surgery which had been proposed by the second treating plastic surgeon on December 7, 2016.
On May 7, 2018, the WCB advised the worker that a relationship between his December 5, 2012 compensable injury and the radial collateral ligament tear of his right thumb MCP documented by the second treating plastic surgeon in his December 7, 2016 report had not been established, and the surgery as proposed on December 7, 2016 was not approved.
By letter dated May 21, 2018, the worker requested that Review Office reconsider the WCB's May 7, 2018 decision. The worker expressed disagreement with the decision, and noted he had not had any problem with his right thumb prior to the workplace injury.
On June 5, 2018, Review Office determined that there was no coverage for the worker's current radial collateral ligament difficulties. Review Office placed significant weight on the information collected in close proximity to the workplace accident and the WCB plastic surgery consultant's May 3, 2018 opinion. Review Office concluded that the worker's current radial collateral ligament difficulties were not related to his workplace accident, as acute findings in close proximity to his accident which would be suggestive of a right thumb radial collateral ligament laxity injury were not medically substantiated.
On July 3, 2018, the worker appealed the Review Office decision to the Appeal Commission and an oral hearing 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 WCB's Board of Directors.
Subsection 4(1) of the Act provides that where a worker suffers personal injury by accident arising out of and in the course of employment, compensation shall be paid.
The worker has an accepted claim for an injury that occurred at work on December 5, 2012. The worker is appealing the WCB decision that his current radial collateral ligament difficulties are not a consequence of the December 5, 2012 accident.
Worker's Position
The worker represented himself. The worker provided a written submission in advance of the hearing. The worker explained his reasons for appealing the WCB decision at the hearing and responded to questions from the panel.
The worker's position was that the WCB is responsible for his radial collateral ligament issue and difficulties as they are a result of his December 5, 2012 workplace accident and injury.
The worker submitted that he had absolutely no problem with his right hand, wrist or thumb prior to his December 5, 2012 accident and no applicable pre-existing condition. As a result of his accident, he suffered a fracture and sprain to his right wrist and thumb. His right thumb became swollen immediately and developed a noticeable deformity which has affected him, and continues to affect him, physically, psychologically and emotionally.
The worker said that prior to the injury, his left and right hands, wrists and thumbs were normal, and he had the same range of motion and extension. They are no longer the same since the accident. He has much less mobility in his right hand and thumb.
The worker indicated that his position was supported by the reports from his second treating plastic surgeon. The plastic surgeon opined in his March 14, 2016 report that "his wrist pain is likely related to his previous injury." In his December 7, 2016 report, the plastic surgeon further confirmed that the worker continued to have "pain and ongoing deformity."
In conclusion, the worker submitted that his deformed right thumb and related difficulties are the result of his workplace accident and injury and the WCB has not proven otherwise.
Employer's Position
The employer did not participate in the appeal.
Analysis
The issue before the panel is whether or not responsibility should be accepted for the worker's current radial collateral ligament difficulties as being a consequence of the December 5, 2012 accident. For the worker's appeal to be successful, the panel must find, on a balance of probabilities, that the worker's current radial collateral ligament difficulties are causally related to his December 5, 2012 workplace accident. Having carefully reviewed all of the evidence which is before us, the panel is unable to make that finding.
The panel notes that medical reports from December 2012 through to 2015 repeatedly show findings of right thumb ulnar collateral ligament (UCL) pain/laxity.
Further to those findings, the treating sports medicine physician ordered an MRI. The panel places significant weight on the report of the February 23, 2013 MRI which identified a high grade partial tear of the ulnar collateral ligament (UCL) of the right thumb MCP joint. It also showed a mild sprain of the radial collateral ligament (RCL). The MRI did not identify a RCL tear.
Radial collateral ligament (RCL) laxity was first identified by the second treating surgeon on March 14, 2016, more than three years after the workplace accident. In his March 14, 2016 report, the second plastic surgeon further reported that "The ulnar collateral ligament is good." The treating plastic surgeon went on to recommend surgery to repair the radial collateral ligament in his December 7, 2016 report.
The panel notes that while the original treating plastic surgeon had previously discussed the option of surgery with the worker, those discussions had related to surgery to repair or address the ulnar collateral ligament (UCL) tear or laxity. The surgery as proposed by the second plastic surgeon was to repair the radial collateral ligament (RCL), which the panel notes is an entirely different structure. The panel is unable to account for this new diagnosis of right collateral ligament laxity in relation to the December 5, 2012 accident.
The panel places significant weight on the May 3, 2018 analysis and opinion of the WCB plastic surgery consultant, who reviewed the medical information on file and opined:
The aforementioned medical reports on file from 2012-2015 indicated UCL laxity at the right thumb MCP joint, concordant with the February 28, 2013 MRI finding of a high grade partial tear of the right thumb MCP joint UCL. Surgery to address the UCL was offered twice, as per the August 21, 2013 and June 19, 2015 treating plastic surgeon's reports.
The February 28, 2013 MRI noted no tear at the RCL of the right thumb MCP joint; rather, there was mild thickening at the RCL and it was noted that it may have been sprained. Subsequent March 12, 2013 and February 23, 2015 treating sports physician reports and June 26, 2013, August 21, 2013, and June 19, 2015 treating plastic surgeon's reports did not mention laxity or other findings in relation to the right thumb RCL; rather, findings were noted at the UCL. As such, it appears that, to the extent there was a possible mild RCL sprain as noted on MRI, it had clinically resolved in 2013.
The March 14, 2016 and December 7, 2016 reports from a second plastic surgeon proposed a new finding of right thumb RCL laxity at the MCP joint, and it was noted that the UCL was good. As, based on the medical information on file, a possible mild right thumb RCL sprain had clinically resolved by 2013, and right thumb RCL laxity at the MCP joint was not noted in the multiple medical reports on file prior to 2016, right thumb RCL laxity at the MCP joint in 2016 would be a new proposed diagnosis (and not part of the initially accepted diagnoses on file). A pathoanatomic basis to account for new onset RCL laxity at the right thumb MCP joint in relation to the workplace injury is not clear (particularly with no RCL laxity noted from 2012-2015).
The panel accepts the WCB plastic surgery consultant's opinion as being consistent with our review and understanding of the medical information on file.
Based on the foregoing, the panel is unable to link the worker's current radial collateral ligament (RCL) difficulties to his workplace injury. The panel therefore finds, on a balance of probabilities, that the worker's current radial collateral ligament difficulties are not causally related to his December 5, 2012 workplace accident.
The panel would note that the worker referred to a number of other issues in the course of the hearing which he felt had not been addressed or resolved by the WCB. Those issues were not properly before the panel on this appeal and have therefore not been addressed in this decision. The panel notes that it remains open to the worker to discuss those issues with the WCB.
In the result, the panel finds that responsibility should not be accepted for the worker's current radial collateral ligament difficulties as being a consequence of the December 5, 2012 accident.
The worker's appeal is dismissed.
Panel Members
M. L. Harrison, Presiding Officer
A. Finkel, Commissioner
M. Kernaghan, Commissioner
Recording Secretary, J. Lee
M. L. Harrison - Presiding Officer
(on behalf of the panel)
Signed at Winnipeg this 15th day of February, 2019