DECISION NUMBER:

20220029

OBJECTING PARTY:

WORKER

REPRESENTED by:

REPRESENTATIVE

RESPONDENT:

EMPLOYER

REPRESENTED by:

EMPLOYER REPRESENTATIVE

HEARING:

HEARING IN WRITING

HEARD by:

L. MANSUETI, APPEALS RESOLUTION OFFICER

Dated: March 23, 2022

ISSUE

The worker objects to the Eligibility Adjudicator (EA) decision dated June 17, 2021 denying ongoing entitlement to benefits for a left hand injury.

BACKGROUND

February 2020 the worker was lifting a steel frame with co-workers when the frame slipped and their left 4^th^ digit became hyperextended. The worker reported the accident to the employer immediately, and sought medical attention that day. They were diagnosed with a left finger strain/sprain, and returned to work, resulting in a no lost time claim. The worker was 40 years of age at the time of injury, working as an Equipment Operator. They had worked with the employer for approximately 1 year. The worker is right hand dominant.

Entitlement was granted for a left 4^th^ digit strain/sprain for health care benefits. In October 2020 the worker claimed they had not fully recovered from their work injury, and sought further entitlement to benefits for the left 4^th^ digit, as well as entitlement to the left hand and wrist.

The decision letter dated June 17, 2021 denied further entitlement to benefits for the left hand as well as the left wrist. The operating area reconsidered and upheld the decision to deny further entitlement, as per the letters dated July 19, 2021 and November 29, 2021. The worker continued to object to the denial of further entitlement to benefits under this claim, and this is now the issue before the Appeals Services Division.

AUTHORITY

Section 13 of the Workplace Safety and Insurance Act (WSIA), 1997

Operational Policy Manual

Published

15-02-05 Recurrences

April 9, 2021

ANALYSIS

I have carefully considered all of the available information, legislation and relevant operational policy in reaching this decision. For the reasons that follow, I find entitlement to benefits for a left upper extremity recurrence is in order.

Initial Entitlement

The Employer’s Report of Injury (Form 7) indicated the worker injured the palmar area of the left hand in a “snowmobile accident” the weekend prior to the work accident, and requested entitlement to benefits be limited to the left 4^th^ digit only. The worker representative indicated in their submission the worker was involved in a snow machine incident the weekend prior to the workplace accident. The worker explained a shock mount on the frontend of the snow machine had cracked; however, no accident took place. The worker representative indicated the crack was due to a manufacturing defect, not an accident. The worker indicated the story of the snow machine was discussed upon their return to work prior to the work accident; however, at no time did the worker advise any co-workers they had injured their hand. It is the view of the worker representative the story of the snow machine became misconstrued when it was relayed to the employer.

Following the work accident, the worker experienced pain in their left 4^th^ digit and sought immediate emergency medical attention. The triage report dated February 2020 indicated the worker was holding a weight and felt something pop, causing reduced flexion and some pain. Upon examination there was some tenderness around the volar metacarpophalangeal (MCP) joint and weakness. It was unknown whether the worker had sustained a tendon rupture or perhaps a volar plate injury. The x-rays yielded normal findings. The worker was diagnosed with a left 4^th^ digit sprain/strain injury rule out tendon injury. The worker’s finger was splinted and they were cleared to resume modified duties with restrictions for lifting, pushing and pulling. The worker was referred to Dr. Woolner.

February 2020 the worker sustained a non-work-related toe injury, rendering them unable to work.

Dr. D. Woolner, Plastic Surgeon, assessed the worker on March 2020. The reports indicated the worker lifted a heavy object a few weeks prior and felt a snap in their left 4^th^ digit. The worker reported having reduced range of motion (ROM), pain, and swelling. Dr. Woolner indicated the worker may have a missed volar plate injury. The report indicated the worker was currently off work due to a fractured toe injury. In March 2020, the worker returned to see Dr. Woolner. They reported no numbness or tingling, and there was indication of some limitation with ROM. The worker received a cortisone injection.

A Functional Abilities Form (FAF) dated September 2020 completed by Dr. L. Caputo, the worker’s family doctor, indicated the worker was capable of returning to work with no restrictions. The worker resumed full regular duties in light of this FAF.

Recurrence Information

In October 2020 the worker sought medical attention. The Health Professional’s Report (Form 8) for this visit indicated the worker had sustained left wrist, hand, and left middle finger and ring finger injuries in February 2020. The diagnoses were subacute left middle finger/ring finger tendon/wrist injury.

The report indicated the worker had received a cortisone shot, then COVID-19 started. The treatment plan consisted of physiotherapy and left wrist support splint.

The worker provided a detailed written statement dated November 2020. The worker indicated their finger was splinted in February 2020 following the work accident, and they were referred to Dr.

Woolner. The worker stated there was little improvement, thus Dr. Woolner administered a cortisone injection. The worker advanced they had been off work due to a toe fracture sustained at home in February 2020. The worker explained they were only using their hand for minor day to day activities at home during this time, and it seemed their hand had improved but not completely healed. The worker indicated they tried to see Dr. Woolner again; however, they were informed he had retired. The worker attempted to see Dr. Caputo; however, she was not seeing patients in person due to COVID-19 restrictions. The worker explained they were “left in limbo” without any kind of treatment. In August 2020 the worker was able to get physiotherapy for their toe, at which time, they asked for their hand to be looked at, but their concerns were dismissed. The worker indicated they hardly used their left hand for several months while they were recovering from the toe injury. They believed they were fine to return to their full duties, and Dr. Caputo cleared them to return to work in September 2020 for both injuries. The worker noticed a dramatic decreased in strength in the left hand and an increase in pain once they returned to work. The worker indicated they reported their increased pain and soreness to the employer, and they were encouraged to work at their own pace and avoid strenuous work. The worker sought physiotherapy treatment in October 2020 and was advised their wrist was not properly supported and had not fully healed. The worker was advised to obtain a referral to see a specialist through the family doctor. The written statement indicated the worker was bombarded with questions from their employer as to when they hurt their hand and if it was a new injury. The worker explained they had not experienced a new accident. The worker also indicated the employer tried to convince them to lie about how and where the injury occurred by stating it happened while operating a snow machine.

Dr. Caputo submitted a report dated November 2020 indicating the worker injured their left hand in February 2020. The mechanism of injury was hyperextension, as the worker picked up a heavy object and it slipped while their left 4^th^ finger was still hanging on to it. Dr. Caputo indicated the worker’s left hand had not fully recovered, citing they were still experiencing pain in their hand, loss of grip strength, and function. The worker was set to see a plastic surgeon for a possible missed volar plate injury. Dr. Caputo reiterated the worker’s complaints were in keeping with the February 2020 work accident. The report stated the worker was to observe restrictions for their left hand, including avoid climbing, pushing, pulling, and operating heavy equipment.

The employer indicated the worker was off work from November x to x, 2020 inclusive due to a non- work-related illness. The worker returned to work performing modified duties as of November x, 2020.

Dr. T. J. Best, Plastic Surgeon, assessed the worker in January 2021. The report indicated the worker injured their left hand in February 2020 while lifting a heavy steel frame. The left hand bore the weight, and the worker suffered a hyperextension injury of the ring and small fingers. The report indicated the worker’s left hand/fingers were not too bad while they were off work; however, it became worse when they returned to work. The worker reported pain on the ulnar side of the hand, worse in the ring finger, intermittent numbness of the ring finger, reduced grip strength, radiating pain up to the neck, and headaches. Dr. Best indicated he was unsure of the worker’s diagnosis and wondered if there was

some evidence of ulnar neuropathy. The worker was referred to Dr. B. Nolan for consultation and nerve conduction studies.

Dr. Best’s report dated February 2021 indicated the worker saw Dr. Nolan in February 2021, and the nerve conduction studies did not show any evidence of compression neuropathy. It was unclear as to whether the worker had incurred a trapezius muscle injury at the time of accident. Dr. Best indicated there were no findings involving the hand or peripheral nerves, thus he could not offer any treatment.

The worker was encouraged to follow-up with Dr. Caputo.

The worker underwent a magnetic resonance imaging (MRI) of the left hand and wrist in May 2021. The report indicated there was no evidence of fracture, dislocation, or destructive lesion. There was evidence of an ulnar neutral variant and a small amount of joint effusion in the radiocarpal and ulnar carpal, first MCP and carpometacarpal (CMC) joints, as well as a triangular fibrocartilage complex (TFCC) tear.

Dr. Caputo submitted a report dated July 2021 indicating the worker was still having left hand pain, loss of grip strength, and decreased function. The report indicated the worker was referred to Dr. Elder, Orthopaedic Surgeon, wherein it was confirmed the worker had a left wrist TFCC tear and other cartilage damage. The worker underwent surgery in June 2021 to address the tear. Dr. Caputo submitted the worker’s injury appeared to be related to the work accident of February 2020.

The operative report dated June 2021 referenced the work accident of February 2020, citing the worker had ongoing pain and weakness in their hand and wrist.

Dr. O. Dessouki, Orthopaedic Surgeon and Medical Consultant (MC), reviewed the record in November 2021 and provided a medical opinion with respect to this case. It must be noted Dr. Dessouki did not assess or treat the worker at any time. The MC noted the torn appearance of the TFCC as per the operative report had a more of an acute look to it than a chronic degenerative appearance which would be in keeping with the work trauma 1.5 years ago. Furthermore, it was suspected that the cartilaginous changes of the proximal hamate were also non-degenerative in nature and secondary to an acute load to the ulnar column such as in a traumatic event.

Dr. Dessouki indicated the mechanics of the injury in February 2020 could reasonably have resulted in the pathology that was seen and addressed in October 2020; however, the absence of clinical symptoms around the wrist until October 2020 does not fit with an acute wrist injury of February 2020. The MC submitted if there was an acute injury to the wrist in February 2020, there should be symptoms and pain in the wrist at that time. Given the symptoms immediately post-injury were finger dominant, and the issues with the wrist were not symptomatic and addressed until much later, the wrist related injuries and pathology cannot reasonably be considered compatible with the claim. The MC opined the diagnoses of TFCC tear and effusion to the radiocarpal joint, ulnar carpal joint, and CMC joint were not compatible with the claim.

Assessment of the Evidence

Operational policy 15-02-05 states, in part:

A worker may be entitled to benefits for a recurrence of a work-related injury/disease if the worker experiences a significant deterioration that

• does not result from a significant new incident/exposure, and

• is clinically compatible with the original injury/disease.

The questions to be determined include whether the worker suffered a significant deterioration of their left hand injury, whether the significant deterioration resulted from a new accident/exposure, and whether the left hand and wrist condition is clinically compatible with the original injury.

Operational policy 15-02-05 indicates a significant deterioration refers to a marked degree of deterioration in the work-related impairment that is demonstrated by a measurable change in the clinical findings. Indicators of such include, the need for active treatment, a change in functional abilities, or a change in the ability to perform a job or suitable occupation.

The evidence in the record supports the worker experienced a significant deterioration of their left hand injury. While the worker was initially diagnosed with a left 4^th^ digit sprain/strain injury, it must be noted this diagnosis was not definitive, confirmed by the fact the worker was referred to see a specialist. The worker resumed modified duties until February 2020 when they experienced a non-work-related injury which rendered them unable to work. It would appear the worker had fully recovered from the workplace injury as per the September 2020 FAF; however, the worker’s left hand symptoms worsened when they returned to full regular duties which suggests the worker’s injury had not fully recovered. The subsequent medical reports in the record support the worker’s left hand had not healed, and the area of injury expanded to include the left wrist. The medical evidence supports there was a measurable change in the clinical findings. This is evidenced by the fact the worker’s functional abilities decreased when they returned to full regular duties, additional treatment was needed, and they required further medical intervention including surgery. All of the worker’s treating health care providers cited the left upper extremity injury was related to the February 2020 work accident.

The employer representative is of the view the worker’s compensable left 4^th^ finger injury completed resolved by September 2020 as per Dr. Caputo’s FAF, and the subsequent left hand/wrist complaints are not within the scope of this claim. The employer representative indicated if the worker was in fact experiencing ongoing symptoms and had been since February 2020, restrictions would have been indicated on the FAF, as well as a referral for further examination. It is further noted the worker returned to work in September 2020 performing full regular duties without any complaints or medical attention. While I appreciate the employer representative’s position, I have placed more significant weight on the worker’s explanation of the events, as provided in their November 2020 submission. The worker explained they had fractured their toe in February 2020 and stopped working. The worker did not use their left hand very much during this period of recovery, and while the left hand injury improved, it had not recovered. I accept the worker had difficulty in obtaining medical attention from Dr. Caputo during this time due to the COVID-19 crisis, as well as the fact Dr. Woolner had retired. The worker believed they could return to work for both injuries by September 2020, evidenced by Dr.

Caputo’s FAF. It was not until the worker resumed full duties in September 2020 that they realized a dramatic decrease in strength in the left hand and increase in pain. While the employer representative indicated the worker continued to work for over one month without any complaint, this does not appear to be case. The worker indicated they advised the employer of their difficulties, and the worker was encouraged to work at their own pace and avoid strenuous work. In October 2020 the worker received physiotherapy, was advised to see a specialist, and ultimately required surgery.

Operational policy 15-02-05 indicates if the significant deterioration results form a significant new incident/exposure (work-related or not) a recurrence is not considered. If the significant

deterioration occurs when there is no new accident/exposure or results from an insignificant new incident/exposure (work-related or not) a recurrence is considered.

The employer representative indicated the worker injured their left hand in a snow machine accident prior to February 2020, and the only compensable diagnosis in this claim ought to be limited to the left 4^th^ digit. The worker acknowledged they were involved in a snow machine accident the weekend prior to February 2020; however, they denied incurring any injuries as a result. The worker indicated co-workers were made aware of the snow machine accident; which was likely how the story was misconstrued to the employer. I accept the worker’s statement on this matter as there is no medical evidence in the record indicating the worker injured their left hand before or after February 2020, and there is no indication the worker required modified duties or restrictions following the snow machine accident. In review of the evidence before me, I find there is no evidence to support the worker experienced a new accident either before or after February 2020 to which their left upper extremity condition could be attributed. I find the worker’s significant deterioration only became apparent after they returned to full regular duties September 2020, and experienced difficulties in performing job duties, in other words, there was no new accident.

Operational policy 15-02-05 indicates to establish that the significant deterioration is clinically compatible with the original injury, it must be determined the body parts and/or functions affected now are the same as, or related to, those affected by the original injury, and there is a causal link between the significant deterioration and the original injury. The employer representative indicated there was no initial report of the left wrist as being an area of injury, as this only became an area of complaint in October 2020. I acknowledge the left wrist was not included as an initial area of injury; however, I find the medical evidence supports it is in fact related to the original injury, thus ought to be included as a compensable area of injury. It must be noted the initial diagnosis for the worker’s left hand injury was not definitive. This is evidenced by the fact the worker was seen by Dr. Woolner in March 2020, at which time the diagnosis was not clarified.

The record contains a medical opinion from Dr. Dessouki. The MC agreed the appearance of the TFCC tear as per the operative report was acute, which was in keeping with the work injury.

Furthermore, the cartilaginous changes of the proximal hamate were also non-degenerative in nature, secondary to an acute load to the ulnar column, which was also in keeping with the work accident. Dr. Dessouki agreed the mechanics of the February 2020 work accident could have reasonably resulted in the pathology that was seen and addressed in October 2020; however, it did not fit with an acute wrist injury in February 2020 given the lack of symptoms and pain at that time.

I partially accept the medical opinion provided by Dr. Dessouki. I agree the mechanics of the February 2020 work accident could have reasonably resulted in the worker’s subsequent left hand/wrist significant deterioration. While I agree with the MC that the worker’s symptoms immediately post-accident were finger dominant and the issues with the left wrist were not apparent until much later, I have placed significant weight on the surrounding facts of this case. It is not known whether Dr. Dessouki was aware the worker was off work from February to September 2020 for a non-compensable injury as there is no mention of this in his review. I find this is an important point, as the worker was not using their left hand very much during this time which would explain the lack of reported symptoms. Furthermore, the worker indicated in their November 2020 submission there was some improvement in the left hand/wrist; however, it had not completely healed. This leads me to find the worker was continuing to experiencing left wrist/hand symptoms. It is also noted the worker had difficulty accessing health care due to the

COVID-19 crisis, leaving them “in limbo” without any kind of treatment. The employer representative indicated the worker could have reasonably sought medical attention at a walk-in clinic or emergency health care treatment; however, I do not agree with this argument. It would appear the worker’s symptoms did not require emergency medical attention and given the COVID-19 restrictions to stay home, I find the delays in seeking medical attention are reasonable in this case. In summation, I find the worker’s significant deterioration is clinically compatible with the original injury as the left wrist is related to the original injury, and I also agree the evidence supports there is a causal link between the significant deterioration and the original injury. As such, I find entitlement is in order for the left TFCC tear and effusion to the radiocarpal joint, ulnar carpal joint, and CMC joint.

CONCLUSION

I conclude entitlement is in order for a recurrence. The accepted diagnoses include left TFCC tear and effusion to the radiocarpal joint, ulnar carpal joint, and CMC joint.

The operating area shall determine the extent and duration of benefits flowing from this decision.

The worker’s objection is allowed.

DATED March 23, 2022

L. Mansueti

Appeals Resolution Officer Appeals Services Division