APPEALS RESOLUTION OFFICER DECISION
decision number:
20220002
OBJECTING PARTY:
worker
REPRESENTED by:
worker representative
RESPONDENT:
employer (not participating)
REPRESENTED by:
employer representative
HEARING:
VIDEOCONFERENCE – December 3, 2021
HEARD by:
C. goegan, appeals resolution officer
ISSUE
The worker is objecting to the March 22, 2018 decision of the Eligibility Adjudicator denying entitlement to a subcapital fracture of the left hip.
BACKGROUND
On January 9, 2018, this then mid-50 year old registered nurse lost her balance while quickly descending a flight of stairs to respond to a patient emergency. While the worker did not fall, she landed with her body weight on her left leg and immediately felt left hip and leg pain. The worker completed her shift and experienced an increase in left hip pain later that evening. She sought medical attention the next day and was diagnosed with left hip and knee strains. An x-ray of the left hip completed on January 12, 2018 did not show an acute fracture or dislocation. The worker returned to modified duties and the Eligibility Adjudicator allowed initial entitlement to health care benefits for the left hip and knee strains.
The worker remained on modified duties and attended physiotherapy treatment. Her left hip symptoms progressively worsened and she attended the emergency department of a hospital on February 14, 2018. A repeat x-ray showed a mildly impacted subcapital left hip fracture. The emergency room doctor immediately referred the worker to an orthopaedic surgeon and she underwent left hip surgery to repair the facture on February 16, 2018.
In a decision dated March 22, 2018, the Eligibility Adjudicator denied entitlement to the left hip fracture. The Eligibility Adjudicator determined that since the fracture was not evident on the January 12, 2018
x-ray, it did not result from the accident.
The worker objected to the March 22, 2018 decision and the matter was referred to the Appeals Services Division for consideration.
AUTHORITY
Operational Policy Manual
Published
11-01-01 – Adjudicative Process
November 3, 2008
15-02-01 – Definition of an Accident
October 12, 2004
18-03-02 – Payment and Reviewing LOE Benefits (Prior to Final Review)
January 2, 2018
ANALYSIS
I find, on a balance of probabilities that the January 9, 2018 accident contributed significantly to the left hip fracture. I carefully considered all of the available information, legislation and relevant operational policies in reaching this decision and the reasons for my decision are set out below.
The Worker’s Position
The worker’s representative provided detailed submissions dated June 22, 2021 in advance of the hearing. The representative reiterated her submissions at the hearing and I have summarized the arguments contained in submissions as follows:
The accident on January 9, 2018 involved a significant transmission of force through the left hip noting both the mechanism of the injury and the worker’s body habitus.
The worker was active before the accident. There is no evidence she had a pre-existing left hip condition that prevented her from performing any recreational activities or her regular job duties as a registered nurse prior to the accident.
After the accident, the evidence confirms the worker walked with a limp and required ongoing treatment, medication and the use of a cane. The evidence establishes the worker experienced ongoing clinical symptoms that were of greater severity than would be expected if the diagnosis was a hip strain.
Given the left hip fracture was a non-displaced fracture, it is not unusual the fracture would not immediately be evident on the January 12, 2018 x-ray. The representative submitted the description of the fracture in medical documents in the record as an “occult” fracture is supportive of her argument.
There is no evidence of a significant intervening event occurring between the date of the accident and subsequent appearance of the left hip fracture on x-ray on February 14, 2018.
The orthopaedic surgeon that examined the worker and performed the left hip surgery provided his opinion it was possible the January 9, 2018 accident contributed to the fracture. The surgeon confirmed the February 14, 2018 x-ray showed the fracture was not a new fracture and he indicated it was probably “occult” and not visible on x-ray. The representative submitted there is no medical opinion that contradicts the opinion of the surgeon and as such, the opinion should be afforded significant weight.
The representative submitted two articles from the internet titled Hip Fractures (from the Merck Manual) and Proximal Femoral Fractures: What the Orthopaedic Surgeon Wants to Know (from radiographics.rsna.org) in support of her argument.
The Worker’s Testimony
The worker testified she began her career as a registered nurse in 2000. At the time of the accident, she was working for the employer as a charge nurse in a long-term care facility. She described her job responsibilities that included providing patient care, administering medications to patients, supervisory duties over personal support workers and responding to patient emergencies that may occur within the facility.
The worker testified that prior to January 9, 2018 she was an active person that enjoyed walking, gardening and cycling. She testified that before January 9, 2018 she never had a left hip problem, had never been involved in a motor vehicle accident, had not been on modified duties and had never filed a claim with the WSIB.
The worker was questioned by her representative about documentation in the record from her nurse practitioner referencing pain in the left leg before the accident. The worker testified she had experienced bilateral leg pain in her quadriceps muscles periodically that she described as aching. She indicated she treated the quadriceps pain with non-prescription Tylenol and Epsom salts baths but it did not stop her from working or performing any of her regular activities. The worker stated the nurse practitioner ordered blood work and ultimately attributed the aching to dehydration and dietary insufficiencies.
The worker testified that despite her history of bilateral leg pain, she was not experiencing any quadriceps pain when she started work on January 9, 2018. She testified that during the shift, one of the personal support workers she was responsible for became ill. The worker stated she had to call an ambulance and accompany the staff member to the ground floor of the long-term care home until the ambulance arrived. After the ambulance departed with the ill staff member, the worker testified she then took the elevator to the fourth floor of the facility. While on the fourth floor, she was notified there was an emergency on the second floor that required her immediate response. The worker testified she chose to take the stairs since it was the quickest way for her to attend the emergency. The worker described descending the stairs while holding on to the railing in a hurried manner. She testified that while she was descending the flight of stairs between the second and third floors she lost her balance and began to fall forward. The worker indicated she missed several steps and while she did not fall, she landed with all of her body weight on her left leg while her right leg trailed behind. The worker testified she is 5’9” tall and weighed approximately 250 lbs at the time. She indicated that she felt immediate pain in her left hip and leg as far as her knee.
The worker testified that after the accident on the stairs, she proceeded to attend to the emergency that involved a patient with dementia attacking another patient’s spouse. The worker stated she had to ensure the safety of the patient with dementia as well as attend to the injured spouse. The worker testified her left hip was significantly painful and she was limping during the emergency; however, she remained at work because the facility did not have sufficient staffing that day and she could not leave the situation.
The worker testified she went home after the shift and went to bed. The next day she had significant left hip pain and groin pain and difficulty standing and walking. She sought medical attention at the emergency department and testified she told the doctor the left hip and groin pain she experienced was much different that the cramping her in legs she had experienced in the past. She testified the doctor at the emergency ordered blood work and asked her if she wanted to see the physiotherapist but did not order x-rays. The worker indicated she was prescribed Dilaudid and saw the physiotherapist who instructed her on the use of a cane. She stated she had a friend bring her a cane and she began using it immediately because of a continued difficulty with weight bearing. The worker indicated she subsequently had an x-ray taken of the left hip on January 12, 2018 that did not show any fractures.
The worker testified she reported the injury to the employer and immediately began working modified duties. The worker stated she continued limping and used her cane while performing modified work. When questioned on her modified work duties, the worker indicated she was on the floor attending to light patient responsibilities such as administering medications for approximately 15 minutes at a time before taking frequent rest breaks. The worker stated she was not assisting with heavier patient care tasks, did more delegating and was not able to respond to emergencies. The worker testified that in addition to performing modified duties, she also had difficulty managing at home and her sisters and daughters did her grocery shopping and her laundry.
The worker testified she attended physiotherapy treatment and continued taking Dilaudid. She noted that while the medication and physiotherapy helped reduce the intense hip pain she was experiencing for brief periods, it did eliminate it. The worker testified that by February 14, 2018, the pain in her left hip became unbearable and she could not walk. She explained that she returned to the emergency department that day for further investigation. The worker testified that she was in distress while at the emergency department. She testified she saw the doctor who ordered another hip x-ray and gave her more Dilaudid to ease the pain. The worker stated the doctor later informed her that while nothing was visible on the x-ray, he would refer her to an orthopaedic surgeon given her symptoms. The worker testified the emergency doctor wanted her to remain in the hospital given the severity of her symptoms; however, agreed to let her go home given the close proximity of her residence to the hospital.
The worker testified that the next day she received a phone call from the emergency room doctor and advised she had a compressed subcapital fracture of the left hip. She stated the doctor told her not to weight bear and asked her to return to the emergency department for consultation with an orthopaedic surgeon. The worker testified she saw the orthopaedic surgeon on February 16, 2018 and was given the option of letting the hip fracture heal conservatively or having surgery. The worker explained that she chose surgery because the surgeon advised her it would relieve her pain. The worker testified she remained off work after surgery until approximately May 2018 and then returned to modified duties and hours. She testified she was still using a cane when she returned to work and resumed regular hours approximately one month later.
Entitlement to the Left Hip Fracture
According to Operational Policy 11-01-01 (Adjudicative Process), an allowable claim must have the following five points:
An employer
A worker
Personal work-related injury
Proof of accident, and
Compatibility of diagnosis to accident or disablement history
Operational Policy 15-02-01 (Definition of an Accident) states the definition of an accident includes both a chance event and a disablement. A “chance event” is an identifiable unintended event that results in an injury while an injury itself is not a chance event. A “disablement” includes both a condition that emerges gradually over time or as an unexpected result of working duties.
There is an important difference between an injury that results from a chance event and a disablement. When a chance event results in an injury during the course of employment, it is presumed the injury arose out of the employment (unless the contrary is shown).
In the case of disablement, that presumption does not exist. The evidence must show the injury not only occurred during the course of employment but also that it occurred because of work. The fact that a worker has symptoms at work does not mean the work activities caused the injury or aggravated an underlying condition responsible for the symptoms. It is not enough to speculate on the possibility of a relationship between work and an injury.
I will begin by pointing out there is no dispute concerning the worker and employer, a personal work-related injury involving the left hip or proof that an accident occurred. The Operating Area accepted the worker injured her left hip when she lost her balance while descending a flight of stairs to attend to a patient emergency on January 9, 2018. The question before me in this appeal is whether the diagnosis of a subcapital fracture of the left hip is clinically compatible with the accident, as Policy 11-01-01 (Adjudicative Process) requires compatibility between a diagnosis and an accident or disablement history. Since the accident in this case is a disablement and not a chance event, Policy 15-02-01 (Definition of an Accident) requires that the evidence must demonstrate the injury arose out of the employment since the presumption does not exist.
After considering the evidence in the case file as well as the worker’s testimony at the hearing, I find the worker has established the necessary criteria in both Policy 11-01-01 (Adjudicative Process) and Policy 15-02-01 (Definition of an Accident) to grant entitlement to the hip fracture. I reaching that conclusion, I have taken particular note of the following:
The worker provided her testimony in a straightforward and credible manner. In her testimony, the worker acknowledged that while she experienced what she described as occasional cramping in both quadriceps before the accident, she had never injured her left hip and was able to carry out her regular job duties. I find this consistent with the evidence in the record. A January 4, 2018 chart note from Ms. C, a nurse practitioner referenced left leg pain, however, there is no mention of a left hip problem. There is also no evidence before me to suggest the worker was unable to carry out all of her job duties as a registered nurse. As such, I accept the worker did not have an ongoing left hip condition that affected her ability to work before January 9, 2018.
In her testimony under questioning, the worker described the mechanism of injury in detail. She also testified she is 5’9” and weighed approximately 250 lbs at the time of the accident. As noted above, the Operating Area has accepted the worker lost her balance while rapidly descending a flight of stairs causing her to land on her left leg. In my view, landing abruptly with the full weight of one’s body on one leg while descending stairs would reasonably result in the transmission of force through the hip joint. Given the worker’s height and weight, I find it more probable than not the amount of force would be significant.
The worker testified that after the accident, the pain in her left hip was substantially different from the periodic quadriceps pain she had previously experienced. This is consistent with the January 10, 2018 emergency report from Dr. Lamfookon that describes in inability to weight bear and pain much different from the intermittent muscle cramping.
The worker testified that Dr. Lamfookon arranged for her to see a physiotherapist who instructed her on how to use a cane. She testified she remained on modified duties, attending physiotherapy treatment and continuously used the cane since she could not walk without limping. The record confirms the employer provided modified duties following the accident and I find the worker’s testimony is also consistent with reports in the record from Ms. F, a physiotherapist. In a Musculoskeletal Program of Care Initial Assessment Report dated February 7, 2018, Ms. F described the worker limping with a significantly reduced range of motion of the left hip.
A February 14, 2018 emergency report from Dr. Davis stated an x-ray of the left hip did not show a fracture; however, Dr. Davis immediately referred the worker for a bone scan to rule out an “occult” fracture. It is my understanding that an “occult” fracture is one that does not appear well on an x-ray and needs to be confirmed by other diagnostic tests such as a bone scan or MRI.
In a February 14, 2018 addendum to the emergency report, Dr. Davis indicated the x-rays showed a mildly impacted subcapital fracture of the left hip.
There is no evidence to suggest there was a non-work-related significant intervening event between January 9, 2018 and February 14, 2018 that could reasonably have resulted in a hip fracture.
In a February 16, 2018 report, Dr. Elkurbo, an orthopaedic surgeon, indicated that while the initial x-rays did not show a hip fracture, it had likely been present for approximately six weeks given the appearance of the fracture on the February 14, 2018 x-ray. In a May 17, 2021 letter to the worker’s representative, Dr. Elkurbo opined it was possible the January 9, 2018 accident contributed to the fracture. The explained the initial injury was probably an “occult” fracture that was not visible on an x-ray. Dr. Elkurbo explained that once the fracture started healing, it became more obvious and visible on the February 14, 2018 x-ray. I placed significant weight on the opinion of Dr. Elkurbo, since he is an orthopaedic surgeon is an expert in the diagnosis and treatment of hip injuries. I find his explanation for the reason the subcapital hip fracture did not appear on the initial x-ray is consistent with the emergency report of Dr. Davis, who also suspected the worker may have an “occult” fracture.
While medical evidence is always preferred over generic information from the internet, I note the article submitted by the worker’s representative titled Proximal Femoral Fractures: What the Orthopaedic Surgeon Wants to Know (from radiographics.rsna.org) indicates that impacted subcapital fractures are frequently missed on x-rays owing to the subtlety of the femoral head-neck junction and the relatively mild fracture angulation. I find the article supports Dr. Elkurbo’s opinion that the “occult” fracture had likely been present since the index accident given the February 14, 2018 emergency report described a mildly impacted subcapital fracture.
In conclusion, based the absence of a pre-existing left hip injury, the mechanics of the accident, the worker’s progressively worsening left hip symptoms after the accident, the absence of a significant intervening event involving the left hip, the description of the fracture as “occult” and the opinion of
Dr. Elkurbo, I find it more probable than not the accident contributed significantly to the subcapital fracture of the worker’ left hip. Accordingly, as I find the diagnosis is medically compatible with the accident, each of the five points required for an allowable claim in Policy 11-01-01 (Adjudicative Process) have been satisfied and entitlement for the hip fracture appropriate.
Entitlement to Loss of Earnings Benefits
According to Operational Policy 18-03-02, a worker is entitled to receive full loss of earnings (LOE) benefits if the nature of the injury completely prevents the worker from returning to any type of work. A worker who can return to some form of work is entitled to full LOE benefits if suitable work is not available providing the worker co-operates in health care measures and all aspects of the work-reintegration process. A worker who returns to work at reduced hours or at less than regular wages following an injury may be entitled to partial LOE benefits.
As I find the worker has entitlement to the subcapital fracture of the left hip and she underwent surgery to treat the fracture, I find the worker is also entitled to full LOE benefits from the date of the surgery. I find she is entitled to full LOE benefits from the date of the hip surgery until the date she returned to modified duties with the employer. The Operating Area is directed to determine the exact date of the worker’s return to modified duties.
Entitlement to partial LOE benefits following the worker’s return to modified duties is left to the discretion of the operating area, as is the reimbursement of any health care expenses incurred by the worker following the left hip surgery.
CONCLUSION
I conclude the following:
- The worker has entitlement for a subcapital fracture of the left hip as the result of the
January 9, 2018 accident.
The worker is entitled to full LOE benefits from the date of the February 16, 2018 left hip surgery to the date she returned to modified duties with the employer. The Operating Area is directed to determine the exact date the worker returned to modified duties with the employer.
The reimbursement of any health care expenses incurred by the worker after surgery and the payment of partial LOE benefits following the worker’s return to modified duties is left to the discretion of the Operating Area.
The worker’s objection is allowed.
DATED December 7, 2021
C. Goegan
Appeals Resolution Officer
Appeals Services Division