LMMS, LLC
Kinematic Specialists
Dr. Allen S. Miller
411 E. Huntington Dr. 107-285
Arcadia CA 91006
(626) 399-6834
E-Mail Drasmiller@Earthlink.net ·
May 3, 2008
Laureen Alvarez
CNA Claims
P.O. Box 6500
Brea, CA 92822
RE:
Patient: Jose Smith
Claim Number: mmmmmm
Date of Birth: May 5, 1965
SS# 555-55-5555
Date of Injury: May 18, 2005
Employer: Jensen Precast
Peer Review: May 1, 2008
PEER REVIEW REPORT
The following is a Peer Review Evaluation based on medical records received from CNA on Jose Smith. This evaluation was requested by CNA and will address the following issues in dispute: Causality, Diagnosis, Excessive treatment, MMI, Necessity of treatment, Pre-existing condition, and Need for future medical care. The following report contains my opinions and conclusions, in regard to this case.
It should be duly noted that all records reviewed, (as delineated in the following report), were done by myself without delegation of tasks to other parties or individuals. Similarly, the entire body of this report was authorized solely by myself and all sources of historical facts mentioned in this report were obtained through a review of medical records as provided by CNA. Further, let it be known that I have not violated Labor Code Section 139.3 and the contents of the report and bill are true and correct to the best of my knowledge. This statement is made under penalty of perjury and is reiterated at the end of this report.
RECORDS REVIEWED:
- 5/28/2005-Doctors First Report; Mazin R. Sabri, MD
Doctor’s Hospital Medical Center of Montclair
- 5/28/2005-Post-Operative Report; Mazin R. Sabri, MD
Doctor’s Hospital Medical Center of Montclair
- 8/28/2005-Doctors First Report; Paul M. Umof, MD
- 9/22/2005- Interim Progress Report; Mazin R. Sabri, MD
- 5/29/2007 Primary Treating Physicians Request for Authorization; John B. Smith, MD Orthopaedic Medical Group of Riverside
- 7/5/2007 EMG and Nerve Conduction Study Report; Filemon R. Quinio, Jr., MD.
- 8/9/2007 Primary Treating Physicians Request for Authorization; John B. Smith, MD Orthopaedic Medical Group of Riverside.
- 9/18/2007 Primary Treating Physicians Progress Report; John B. Smith, MD Orthopaedic Medical Group of Riverside.
- 9/28/2007 Primary Treating Physicians Progress Report; John B. Smith, MD Orthopaedic Medical Group of Riverside.
HISTORY OF INJURY:
On May 18, 2005 the subject, Jose Smith, while working within the scope of his employment for Jensen Precast was “pulling cable” and “cut his pinky”. The subject presented to Doctor’s Hospital Medical center of Montclair via the emergency room with a complex laceration which was in a circular fashion across the distal portion of the right fifth finger at a level of the base of the nail. It was elected at that time to re-attach the torn tissue rather than amputate it. No information was documented how the accident occurred other than he was pulling cable. On 9/22/2007 Dr. Sabri, reported that the patient was doing well and presented with a healed right fifth finger tip. The finger was slightly contracted at the tip approximately 0.5 cm off the palmar aspect of the hand. The report states that the patient was to continue his regular work and scheduled for a re-examination in 6 weeks for release Permanent and Stationary.
HISTORY OF PRIOR INJURY AND/OR DISABILITY:
There is no history of prior injury and/or disability by way of recordation. However, x-rays taken by Dr. Smith on 5/29/2007 reveal a fracture of the right 3rd phalanx. If any additional records become available concerning prior injuries and/or disability, I would be glad to review them and offer additional opinions if necessary as to whether or not there is a pre-existing condition.
SUBJECTIVE FINDINGS:
Subjective findings noted in Dr. Smith report, dated 5/29/2007 indicate that the patient noticed “numbness and tingling in the right hand and seems to be worsening since the time of original 5/18/2005 injury”. Dr. Smith at that time referred the patient for an EMG and Diagnostic Testing which was performed on 7/5/2007 by Filemon R. Quinio, Jr., MD. The testing revealed evidence of bilateral moderate carpal tunnel syndrome, with prolonged latencies of the median motor and sensory nerves across the wrist. There is no evidence of ulnar neuropathy, radial nerve injury or cervical radiculopathy. Note: Median-Ulnar/Martin Gruber anastomosis noted in both forearms.
On 8/9/2007 Dr. Smith makes note that the patient has bilateral moderate carpal tunnel syndrome, with prolonged latencies of the median motor and sensory nerves across the wrist. There is no evidence of ulnar neuropathy, radial nerve injury or cervical radiculopathy. The patient is noted to have a Median-Ulnar/Martin Gruber anastomosis noted in both forearms. Dr. Smith with this information scheduled the patient for left carpal tunnel release of flexor tenosynovectomies. On 9/18/2007, Dr. Smith in his interim report acknowledges the patients arthritis of the 5th proximal interphalangeal joint and right carpal tunnel syndrome. However, states the patient is progressing well with his left postoperative carpal tunnel release and did not want to proceed with carpal tunnel release of the right wrist. The patient was returned to his regular work on 9/18/2007. On 2/12/2008, Dr. Smith reports that the patient now wants to proceed with the right carpal tunnel release and states that he anticipated another left carpal tunnel release. The patient exhibits swollen volar aspects of both wrists, and positive Tinel’s and Phalen’s bilaterally. There is dryness and decreased moisture in the median distribution of both hands as compared to the ulnar distribution. Dr. Smith diagnoses the patient with bilateral carpal tunnel syndrome with flexor Tenosynovitis bilaterally.
OBJECTIVE TESTS:
X-ray Findings: May 29, 2007
Three views of the right hand and wrist reveal normal anatomy of the wrist with the exception of the fifth finger. We note there is a well healed middle phalanx fracture with contour changes to the articular surface at the PIP joint. Narrowing of the PIP joint is noted. We also note there is a middle finger distal phalanx old tuff fracture also on this middle finger on the ulnar side there is a large osteophye at the proximal phalanx of the PIP joint.
EMG and Nerve Conduction Study Report- July 5, 2007
Filemon R. Quinio, Jr., MD.
Patient has evidence of bilateral moderate carpal tunnel syndrome, with prolonged latencies of the median motor and sensory nerves across the wrist. There is no evidence of ulnar neuropathy, radial nerve or cervical radiculopathy. No radiographic studies were performed on the patient. Note: Median-Ulnar/Martin Gruber anastomosis noted in both forearms.
CAUSATION:
The patient was released Permanent and Stationary with a fully healed laceration of the right 5th PIP joint in October of 2005. The patient presented May 29, 2007 complaining of bilateral numbness and tingling of his right hand. It was only upon EMG and Nerve Conduction Studies was it revealed the patient had latencies consistent with left carpal tunnel syndrome. The patient following left carpal tunnel release continued to present with symptomology consistent with bilateral median nerve entrapment. Dr. Smith at that time scheduled the patient for right carpal tunnel syndrome and was considering a second carpal tunnel release.
On 7/5/2007 the Diagnostic Studies performed by Filemon Quinion, MD diagnosed the patient with Median-Ulnar/Martin Gruber anastomois in both forearms. Martin Gruber anastomois is a neural connection between the median and ulnar nerves in the forearm1. This diagnosis is consistent with median nerve symptomology consistent with the patient’s complaints and is not a result of the 5/18/2007 injury involving the 5th PIP joint. As discussed below Median-Ulnar Martin Gruber anastomosis is a genetically inherited condition.
DISCUSSION OF ISSUES IN DISPUTE:
The question of bilateral specifically left carpal tunnel syndrome and how it relates to a complex laceration to the right 5th PIP suffered in the 5/18/2005 injury. First, it should be noted that the patients’ complaints of numbness and tingling in the right hand did not present until two years following the initial 5/18/2005 Injury. Secondly, the diagnosis of left carpal tunnel syndrome did not come until the electodignosistic studies were performed and discussed with the patient on 8/9/2007. Dr. Smith on 8/9/2007 upon his review of the EMG, consulted with the patient concerning his carpal tunnel syndrome and recognized the Martin-Gruber anastomosis bilaterally and subsequently recommended surgery to both wrists. The patient declined surgery to the right wrist consenting to surgery to the left wrist. Thirdly, Dr. Smith makes note in the radiologic exam contained within his 5/29/2007 report “there is a well healed fracture of the middle phalanx fracture of the right hand. However, there the patient denies any prior injuries to his right hand and wrist in prior reports dating back to 5/18/2005. Additionally, Dr. Sabri’s post-operative report dated 5/18/2005 do not make mention of any other injuries to the right hand other than the laceration. Furthermore, there are not reports of left hand symptomology, until after the 8/9/2007 examination by Dr. Smith following the diagnostic testing.
Following left wrist carpal tunnel surgery on 2/12/2008, Dr. Smith reports that the patient currently requests surgery to the right wrist and makes note that the patient has bilateral swelling of the volar aspect and positive Tinel’s and Phalen’s tests bilaterally. He diagnosis’s the patient with bilateral carpal tunnel syndrome. Dr. Smith, at that time agreed with the patient to relase the right flexor tenosynovectomies and is considering yet another surgery to the left wrist due to the patient’s complaints of numbness and tingling. On 7/05/2007, Dr. Quinio diagnosed the patient with Martin Gruber anastomosis of the forearms bilaterally. Martin-Gruber occurs in 10-30% of individuals and 60-70% of those affected show the anomaly bilaterally. In some families, an autosomal dominant inheritance is possible, although a gene controlling this occurrence has not been identified. Martin-Gruber anastomosis can be caused by a variety of indices none of which are a laceration to the a finger on the contralateral hand. Martin-Gruber anastomosis causes sensory changes in the nerves it involves and mimics carpal tunnel syndrome. Many patients complain of sensory changes in the fourth and fifth digits. Rarely, a patient actually notices that the unusual sensations are mainly in the medial side of the ring finger (fourth digit) rather than the lateral side, corresponding to the textbook sensory distribution. Sometimes the third digit is also involved, especially on the ulnar (ie, medial) side. The sensory changes can be a feeling of numbness or a tingling or burning as this patient exhibited. In this case the patient began to experience numbness and tingling of right hand, 2 years post surgery consistent with diagnosis of Martin Gruber anastomosis. As stated, it does not appear that the patient complained of numbness and tingling in the left hand however, when the EMG test results were brought to the patient’s attention he, consented to left carpal tunnel release, still not relieving the symptomology. It appears that this syndrome was discarded and the diagnosis of carpal tunnel syndrome was embraced. The patient was scheduled and a surgical release of the left flexor tenosynovectomy was performed. The patient returns 6 months post surgical with increasing symptoms in his right hand and the same symptoms in the left hand even in the lite of surgery. Dr. Smith still scheduled the patient for right carpal tunnel release and was considering yet another surgery to the left hand still ignoring the diagnosis of bilateral Martin-Gruber anastomosis.
In assessing the diagnosis given of Median-Ulnar/Martin Gruber anastomosis and the subsequent treatment and surgeries for carpal tunnel syndrome received by the patient, it was not related to or a direct result of the 5/18/2007 injury. Martin-Gruber anastomois was properly diagnosed by Dr. Quinio on 7/5/2007 is a condition that is not related to the 5/18/2005 injury or even a work related injury for that matter. It is my opinion, supported by the documentation and medical fact, that the original diagnosis given was reasonable based on the findings, however the new diagnosis made in 2007 is one that is of genetic origin and the treatment rendered was not consistent with the diagnosis given or the examination findings recorded. Based on the findings recorded, the treatment rendered was excessive and not medically necessary to cure and/or relieve the effects of the condition sustained by this patient. It is my opinion, given the minimal subjective and objective findings that the diagnosis of carpal tunnel syndrome is not work related and the carpal tunnel like symptoms are a direct result of the Martin-Gruber anastomosis, which is part of the patient’s genetic pathology and not work-related. We can deduce that the left carpal tunnel surgery failed as the patient was still symptomatic after the release of the left flexor tendon demonstrating that surgery was not successful in relieving the symptomology and further the objective signs were still present. There is no cause and effect relationship between the diagnosis carpal tunnel syndrome, Martin-Gruber anastomosis, all treatment rendered by Dr. Smith, and the 5/18/2005 injury. As stated, there is no evidence to support that the patient’s Median-Ulnar/Martin Gruber anastomosis is even work related. The patient has the genetic marker for this syndrome and most likely would have developed it regardless of the type and frequency of work he performed. It is also evident that the left wrist carpal tunnel release did not resolve the carpal tunnel syndrome of the left hand and most likely will not when performed on the right if the Martin Gruber anastomosis is not addressed.
FUTURE MEDICAL CARE:
The patient does have arthritis and oteophytic growth of the 5th PIP as identified by x-ray. This is an expected sequella of the laceration and 5/18/2005 injury. Dr. Sabri, did an exceptional job in saving the tip of the patient’s 5th finger. However, in that surgery, Dr. Sabri had to sacrifice the extensor tendon as Dr. Sabri notes, “reattaching it would have involved stabilization of the finger, possible compromising the blood supply and the finger”. This would have compromised the reattachment of the finger tip. In this process the finger lost some movement, due to Dr. Sabri’s inability to reattach the extensor tendon during the initial surgery 5/18/2007. The arthritis and oteophytic growth and any minimal loss of movement, if any, is a natural sequella and has minimal impact on the patient if any. The patient has returned to work full time unrestricted consistent with this injury and is in no need of future medical treatment. Additionally, the issue of future care is not a factor in this case as the patient was released permanent and stationary in 2005 for injuries sustained in the May 18, 2005 injury.
However, the patient does have diagnosed bilateral Martin-Gruber anastomois. That patient has one failed surgery to the left wrist and unless intervened will undergo another surgery to the right wrist without addressing the most likely cause Martin-Gruber anastomosis. The current symptoms and resulting left carpal tunnel surgery, and impending right carpal tunnel syndrome are not related to the 5/18/2007 injury or incident and are a sole and separate issue to be evaluated.
PROGNOSIS:
The patient’s prognosis is considered good as it results to the 5/18/2005 injury. The patient returned and continued to work full time unrestricted until he was evaluated by Dr. Smith.
REASONS FOR OPINIONS:
I have derived the above opinions from review of the medical records/diagnostic testing provided to me by CNA and clinical experience both in evaluating and treating individuals with the same or similar conditions.
COMPLIANCE STATEMENT:
“I personally prepared this report. If others have performed any services in connection to this report, outside of clerical preparation, their name and qualifications are noted herein. The time spent was in accordance with Industrial Medical Council (IMC) guidelines. I declare under penalty of perjury that the information contained in this report and its attachments, if any is true and correct to the best of my knowledge and belief, except as to information that I have indicated I received from others. As to that information, I declare under penalty of perjury that the information accurately describes the information provided to me and, except as noted herein that I believe it to be true. I have not violated Labor Code Section 139.3 and the contents of the report and bill are true and correct to the best of my knowledge. This statement is made under penalty of perjury.”
Thank you for allowing me to participate in the evaluation of this individual’s records. Should you have any additional questions or require any additional information, please do not hesitate to contact me directly.
Signed in Los Angeles County by:
5/3/2008
_____________________________________ _____________________
Dr. Allen S. Miller, DC, DACBSP Date
License Number 19031
(This signature will act as the original for the purposes of this document)
References:
- The median-ulnar anastomosis (Martin-Gruber) in normal and congenitally abnormal fetuses. R Srinivasan and J Rhodes Archives of Neurology Vol. 38 No.7 July 1981
- Ulnar Neuropathy, Article Last Updated: Jun 25, 2007 Stephen A Berman, MD, PhD
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Dr. Allen S. Miller's Reports 