SMITH v. LITTLE ROCK SHEET METAL, 1999 AWCC 283

CLAIM NO. E714398

DOUGLAS SMITH, EMPLOYEE, CLAIMANT v. LITTLE ROCK SHEET METAL, EMPLOYER, RESPONDENT and UNION STANDARD INSURANCE COMPANY, INSURANCE CARRIER, RESPONDENT

Before the Arkansas Workers’ Compensation Commission
OPINION FILED SEPTEMBER 14, 1999

Upon review before the FULL COMMISSION in Little Rock, Pulaski County, Arkansas.

Claimant represented by the HONORABLE JASON FILES, Attorney at Law, Little Rock, Arkansas.

Respondents represented by the HONORABLE WILLIAM C. FRYE, Attorney at Law, Little Rock, Arkansas.

Decision of administrative law judge: Affirmed.

[1] OPINION AND ORDER
[2] The respondents appeal to the Full Worker’s Compensation Commission an administrative law judge’s opinion filed December 30, 1998. The administrative law judge found that as a result of the compensable injury the claimant developed carpal tunnel syndrome and trigger thumb, and that the respondents are liable for these conditions as compensable consequences of the claimant’s compensable injury. The administrative law judge found that Dr. Weber’s treatment is reasonable and necessary, and she directed the respondents to pay permanent partial disability benefits equivalent to an 11% rating to the upper extremity. In addition, the administrative law judge ordered the respondents to pay temporary total disability compensation from December 3, 1997 through January 27, 1998. After reviewing the entire record de novo, the Full Commission affirms the opinion of the administrative law judge. [3] The claimant, age 38, began working for the respondent-employer in approximately 1994. The claimant testified that the majority of his work involved welding and grinding metal. The claimant’s work required a great deal of back-and-forth wrist motion with a hand-held “gun.” After the claimant’s welding was complete, he “dressed up” the metal by manually bearing down on a “grinder.” The claimant testified, “The only time I haven’t got a gun in my hand . . . if I’m not welding, then I’m grinding.” The parties stipulated that the claimant sustained a compensable injury to his right thumb on April 6, 1996. On that date, the claimant began cutting filler pieces with a new machine:

The coping blade on it was not . . . wasn’t quite able to get our pieces cut to the sizes we wanted, that we needed, so I went to the old machine and got a piece cut on it, and I had my doubts as to whether it would cut it or not so I was going down slow with the blade and I got about halfway down and one of the guys came up behind me and hollered at me and I turned to see who it was and when I turned, I come on down with the blade . . . with the foot pedal that works the machine, and when I turned to look, I put pressure on the pedal without realizing it and when that happened, it did not cut the piece of angle . . . it stood up into my arm.

[4] The claimant testified that the metal was “forced up” into his hand, and “It cut me kind of like a half-moon shape across the pad of my thumb there.” The claimant testified that the accidental injury pushed back his entire arm at the elbow. The claimant was treated conservatively on the date of injury at Baptist Medical Center Emergency Room, where x-ray showed evidence of soft tissue injury to the thenar eminence (outer side of the palm, base of the thumb). The final emergency room diagnosis was “Two-inch laceration of the right thenar space.” The record shows that the claimant complained of numbness and pain from his fingertips to his elbow. The emergency room doctor reported no injury to the wrist, elbow, or shoulder, and while suturing the wound, the doctor noted no evidence of tendon, joint, or muscle involvement. The claimant was not thoroughly examined in the emergency room, as he testified, “Basically, all they did that day was numb it and sew me up, sent me on my way.” A physician saw the claimant on April 19, 1996, ten days after the compensable injury, and diagnosed paresthesia of the right thumb. The claimant was referred to an orthopedic surgeon, Dr. David Gilliam. Dr. Gilliam began treating the claimant on April 24, 1996, and he noted that the claimant complained of burning pain and swelling of the right thumb. Despite the claimant’s swelling and continued pain, Dr. Gilliam assessed a “healed” right thumb laceration at the thenar eminence and “probable neuroma incontinuity versus laceration of the radial digital nerve right thumb.” Dr. Gilliam recommended non-operative treatment, and he prescribed a thumb abduction wrist splint on the right. The claimant testified that Dr. Gilliam “Put me in a splint and that’s basically about it.” The claimant testified that his thumb was “completely numb” at this time, and that “the whole hand hurt.” [5] Dr. Gilliam noted on May 15, 1996 that the claimant’s symptoms had not improved. The claimant still had dyesthesias in the right thumb, as well as numbness on the radial border of the right thumb. Dr. Gilliam planned exploration of the wound with either excision of neuroma incontinuity and re-approximation of the nerve ends, or repair of a laceration of the radial digital nerve, right thumb. The claimant testified regarding Dr. Gilliam’s treatment plan:

At one point he was going to do exploratory surgery and then I don’t remember the date they had it set for . . . I know it was on a Friday. And the Monday of that week he called me into his office because he was going to have a major knee surgery or something that was going to have him tied up that Friday and he basically brought me there to meet this other doctor that he was going to have do it. And it was at that time that I started getting a little bit of feeling back in my thumb so they called it off.

[6] Dr. Gilliam’s clinic note dated June 10, 1996 confirms the claimant’s account of events. Dr. Gilliam assessed stab wound right thumb, with possible early recovery of right radial digital nerve sensory function, and surgery was deferred indefinitely. Dr. Gilliam pronounced maximum medical improvement on July 1, 1996 and discharged the claimant from further care. The claimant tried to gradually work back into his regular job following Dr. Gilliam’s release, but testified that he continued to have burning sensations and “just a messed-up feeling in my hand.” The claimant testified that his impression from Dr. Gilliam was that he had sustained nerve damage which would take time to heal. [7] The claimant’s symptoms continued to worsen, however, until he was forced to seek further medical treatment in June, 1997. After complaining to his family physician of an aching right thumb, where the claimant had experienced symptoms since the compensable injury, he was referred to Dr. Edward Weber, an orthopedic hand surgeon, on June 24, 1997. The claimant testified that his symptoms had not changed since previously treating with and being released by Dr. Gilliam. Dr. Weber diagnosed flexor tenosynovitis and initially treated the claimant conservatively with injections into the flexor tendon sheath. Dr. Weber testified that the claimant’s flexor tenosynovitis cleared after these injections. [8] A nerve conduction study conducted October 8, 1997 gave the impression of “right carpal tunnel syndrome with evidence of APB denervation.” (Dorland’s Illustrated Medical Dictionary, 28th Edition, indicates that “APB” is the abductor pollicis brevis muscle which abducts the thumb.) Dr. Weber corresponded with the carrier on October 28, 1997:

Answering the question of how hyperextension injury is related to carpal tunnel — Mr. Smith’s hand was forcibly hyperextended as was his wrist which puts unusual stress on the tendon causing bleeding into the peritenon sheath. The peritenon sheath then swells. The swelling is confined in the carpal tunnel which puts pressure on the median nerve which causes the carpal tunnel syndrome.

[9] Dr. Weber performed a right carpal tunnel release on December 3, 1997, at which time he noted a Grade III compression of the median nerve at the mid-portion of the transverse carpal ligament. The claimant remained off work until January 27, 1998. Dr. Weber assessed an 11% anatomical impairment rating to the upper extremity, which converted to a 7% rating based on theGuides. [10] The employee filed a claim for additional workers’ compensation benefits. The claimant contended that he developed carpal tunnel syndrome as a result of his work duties, or that his condition developed through a combination of his work duties with the compensable (hyperextension) injury. The claimant sought medical expenses, temporary total disability, a 7% anatomical impairment rating, and attorney’s fees. The respondents contended that there was no causal connection and/or major cause between the claimant’s present condition and the compensable injury. [11] Counsel deposed Dr. Gilliam on July 22, 1998. Dr. Gilliam testified that the claimant did not relate a history to him of a hyperextension injury to his hand or arm, and that the claimant’s complaints had been isolated to the right thumb area. The claimant had related to Dr. Gilliam no symptoms compatible with a trigger thumb condition or carpal tunnel syndrome, there were no physical findings of same, and these symptoms would have manifested themselves during Dr. Gilliam’s ten weeks of treatment. Dr. Gilliam stated that he did not find an injury to the flexor tendon sheath, but that such a diagnosis might have to be made intraoperatively when the wound is explored. Dr. Gilliam testified that a hyperextension injury could cause carpal tunnel syndrome, and in fact, “any kind of relatively minor trauma can induce carpal tunnel symptoms.” Dr. Gilliam admitted that the claimant’s description of injury to him had been “fairly superficial.” Dr. Gilliam also opined, however, that the injury as described by the claimant would be considered “passive hyperextension, so it would be more likely than active hyperextension to lead to injury.” [12] Dr. Weber was deposed on July 29, 1998, and was queried with regard to when carpal tunnel symptoms would appear after the traumatic compensable injury. Dr. Weber testified that the symptoms could arise “fairly soon,” or they could come on gradually and masquerade as other symptoms “for a long time” until the carpal tunnel condition develops. Dr. Weber testified that carpal tunnel syndrome and trigger thumb were related, in that the tendons and nerve go through the same confined area. If the tendons were injured, symptoms might not appear until the hand was mobilized again. Dr. Weber opined that Dr. Gilliam, the previous treating orthopedic physician, might not have been able to detect swelling in the sheath or tendon area. [13] The administrative law judge opined that the claimant was a poor historian. However, “Dr. Gilliam’s opinion is persuasive only if the emergency room records showing numbness in the fingertips and forearm are ignored and only if the injury had resolved in July 1996, which is not supported by Dr. Gilliam’s own records or the claimant’s testimony. . . . Despite the able defense presented by respondents’ counsel, it is more than mere coincidence that the claimant has developed problems in the same hand that was injured.” The administrative law judge directed the respondents to pay for Dr. Weber’s treatment and the assigned impairment rating in addition to temporary total disability compensation; respondents appeal to the Full Commission. [14] The claimant has the burden of proving by a preponderance of the evidence that he is entitled to compensation. Jordan v.Tyson Foods, Inc., 51 Ark. App. 100, 911 S.W.2d 593 (1995). When an injury arises out of and in the course of employment, the original employer or carrier is responsible for every natural consequence that flows from the injury. Bearden Lumber Co. v.Bond, 7 Ark. App. 65, 644 S.W.2d 321 (1983). When subsequent complications are the natural and probable result of the original injury, the employer remains liable. [15] On appeal, the respondents argue that the medical evidence does not indicate that the claimant suffered carpal tunnel syndrome or right trigger thumb as a result of the compensable injury. The respondents argue that the claimant initially did not relate a history of a “passive hyper-extension” injury, which Dr. Weber opined could cause carpal tunnel syndrome. The respondents find it clear that the claimant “had his arm pushed back and it came back at the elbow, wrist and hand, all together, rather than an actual hyperextension of the wrist area. In other words, the entire hand, wrist and arm were pushed back, not at the wrist which would be required to cause a traumatic carpal tunnel.” Further, Dr. Gilliam testified that the claimant displayed no symptoms of carpal tunnel syndrome during the ten weeks that he treated the claimant. [16] Nevertheless, we note that the claimant has worked in the sheet metal trade for two decades, and there is no previous medical report of record detailing hand, wrist, or finger numbness. The claimant sustained an admittedly-compensable traumatic injury to his right hand in April, 1996, when a cutting blade jarred his right hand and cut through a leather glove. We find the claimant’s testimony to be credible and persuasive in describing a “passive hyper-extension” injury, which both orthopedists testified could cause carpal tunnel syndrome. Dr. Gilliam testified that the claimant’s long, middle, and ring fingers should have been numb if the injury had affected the median nerve leading to carpal tunnel syndrome, and indeed the first medical record following the injury indicates that the claimant complained of numbness from his fingertips to his elbow. [17] Dr. Gilliam was skeptical that the compensable injury could have led to the documented carpal tunnel condition, but we note that Dr. Gilliam provided no testing for carpal tunnel syndrome. The claimant remained symptomatic despite Dr. Gilliam’s release in July, 1996. We do not find the claimant’s credibility diminished with regard to the 11-month gap in treatment between Dr. Gilliam and Dr. Weber. The claimant continued to diligently work during that time, yet his pain continued. The claimant provided the same credible history of injury upon presenting to Dr. Weber in June, 1997 as he has throughout this matter, and the only change in the claimant’s symptoms in the interim was the acuteness of the claimant’s pain. Dr. Weber at first treated the claimant for flexor tenosynovitis, and then diagnosed carpal tunnel syndrome, which was established through objective electrodiagnostic testing. Dr. Weber credibly opined that the accidental injury placed unusual stress on the tendon, which caused bleeding in the peritenon sheath, which in turn placed pressure on the median nerve, causing carpal tunnel syndrome. We note that Dr. Weber, an orthopedic hand surgeon, documented compression of the median nerve upon performing a right carpal tunnel release in December, 1997. When considering the preponderance of evidence, we must conclude that Dr. Gilliam simply mis-diagnosed the claimant’s condition in attributing the claimant’s symptoms only to his right thumb. [18] Accordingly, based on our de novo review of the entire record, and for the reasons discussed herein, we find that the claimant proved that he developed carpal tunnel syndrome and trigger thumb as a compensable consequence of his traumatic accidental injury. We find that Dr. Weber’s treatment was reasonable and necessary, and that the respondents are liable for an 11% rating to the upper extremity as assigned by Dr. Weber. We find that the claimant is entitled to temporary total disability compensation from December 3, 1997 through January 27, 1998. We thus affirm, in its entirety, the opinion of the administrative law judge. [19] All accrued benefits shall be paid in a lump sum without discount and with interest thereon at the lawful rate from the date of the administrative law judge’s decision in accordance with Ark. Code Ann. § 11-9-809 (Repl. 1996). [20] For prevailing on this appeal before the Full Commission, claimant’s attorney is hereby awarded an additional attorney’s fee in the amount of $250.00 in accordance with Ark. Code Ann. § 11-9-715(b) (Repl. 1996). [21] IT IS SO ORDERED. [22] _______________________________
ELDON F. COFFMAN, Chairman _______________________________ PAT WEST HUMPHREY, Commissioner [23] Commissioner Wilson dissents.