FROM THE ARKANSAS WORKERS' COMPENSATION COMMISSION [NO.
Michael E. Ryburn, for appellants.
Davis, for appellee.
W. GRUBER, Judge.
Ambulance Services brings this appeal from the decision of
the Arkansas Workers' Compensation Commission
(Commission) that awarded a forty percent permanent
impairment rating to David Pritchard, a paramedic supervisor
for appellant. Appellant challenges the sufficiency of the
evidence to support the award, arguing that the Commission
ignored pertinent case law and improperly relied on an
impairment rating that was based on subjective complaints and
testing. We affirm.
injured employee is entitled to compensation for the
permanent functional or anatomical loss of use of the body as
a whole whether his earning capacity is diminished or not.
Wayne Smith Trucking, Inc. v. McWilliams, 2011
Ark.App. 414, at 13, 384 S.W.3d 561, 568. "Permanent
impairment" is "any permanent functional or
anatomical loss remaining after the healing period has
ended." Thompson v. Mountain Home Good Samaritan
Vill., 2014 Ark.App. 493, at 8, 442 S.W.3d 873, 879.
Under Arkansas Code Annotated § 11-9-102(4)(F)(ii)
(a) Permanent benefits shall be awarded only upon a
determination that the compensable injury was the major cause
of the disability or impairment.
(b)If any compensable injury combines with a
preexisting disease or condition or the natural process of
aging to cause or prolong disability or a need for treatment,
permanent benefits shall be payable for the resultant
condition only if the compensable injury is the major cause
of the permanent disability or need for treatment.
Pritchard suffered a compensable injury to his right wrist on
April 15, 2014, while performing chest compressions on a
patient being transported to a hospital. The ambulance driver
slammed on the brakes, causing Mr. Pritchard's right hand
and arm to become trapped and twisted by a strap securing the
patient to the gurney. Mr. Pritchard received medical
treatment in the hospital's emergency room and was seen
by orthopedic surgeon Dr. Richard Wirges on April 29, 2014.
Dr. Wirges observed that Mr. Pritchard was right-hand
dominant and presented with "a lot of pain and
swelling." Dr. Wirges dictated the following notes:
He felt pops immediately on the radial and ulnar side of his
wrist. He was treated conservatively at first . . . .
Unfortunately, he just has not gotten any better. He had an
MRI that showed he has radiocarpal arthritis with also some
arthritic changes consistent with possible ulnar abutment
syndrome on the ulnar side and some cystic changes in the
bone but no obvious tears of any structure. At this point
though his hand is very painful and very sore. He has
swelling. He has stiffness. It is already going into his
fingers. He does occasionally have a little bit of numbness
and tingling, although it is minimal. He states that when the
injury first happened, immediately his thumb went numb. That
has improved a little bit. Occasionally he has a little
burning electricity but not much. It is mostly a throbbing
pain. . . . No signs of compartment syndrome. There are soft
tissue changes that are different from the contralateral
side. It is very sensitive even to light touch. X-rays do
show a little bit of osteopenic changes. He does have the
radiocarpal arthritis and I wonder if this is not from
possibly an old scapholuntate interosseous ligament tear, but
there is no major DISI deformity on the lateral film. He also
has a little bit of ulnar positive variation that would be
consistent with the possible ulnar abutment syndrome. . . .
[H]e had no symptoms prior to the injury though. Now he has
symptoms and clinically the patient is concerning [sic] not
only for all of these soft tissue changes but also for the
possibility of RSD/chronic regional pain syndrome.
diagnosing "right-wrist blunt trauma with soft tissue
musculoskeletal symptoms as well as neurologic concern for
reflex sympathetic dystrophy/chronic regional pain syndrome,
" Dr. Wirges ordered an MR arthrogram and a three-phase
Wirges noted at a May 6, 2014 return visit that the bone scan
and arthrogram showed inflammatory changes. The arthrogram
showed a torn "lunotriquetral ligament [and] TFCC with
concern for widening of the DRUJ, " along with "a lot
of soft tissue ligament tears and contrast going into the
midcarpal joint as well as the DRUJ." It also showed a
partial tear with severe tendonosis of the ECU tendon and
marked synovial thickening with "some chronic arthritic
change there that definitely would have been made worse
because of this injury and now looks more significant with
inflammation." Dr. Wirges stated that although the bone
scan did not show a "classic picture" for RSD,
there was a very high risk for it. He noted that some
symptoms remained, but immobilization, Neurontin, and vitamin
C had helped; that the hand looked better and the swelling
had improved; that pain was still an issue but improving; and
that Mr. Pritchard had done everything he had been asked to
do. Dr. Wirges planned surgical exploration and stabilization
in the form of possible ligament repairs, salvage procedures,
or reconstruction. Again noting that Mr. Pritchard previously
had been without pain or symptoms in the wrist, Dr. Wirges
stated "all this" was directly related to Mr.
Pritchard's injury, that he was still at risk for RSD,
and that close monitoring was required.
Wirges wrote in a May 11, 2014 letter that Mr.
Pritchard's "last chart note as well as reports from
his MRI and CT scan findings" showed "several
injuries in his wrists" [sic]. Dr. Wirges stated that
there were "several injuries to that wrist that need to
be repaired, . . . subluxation of his carpal bones, and . . .
this is something that is absolutely related to the injury
and without repair will absolutely deteriorate and cause him
more problems in the future." Dr. Wirges added that he
was "baffled" that coverage was being denied, and
he opined that approval should be given "sooner rather
than later . . . in the best interests of the patient and his
was ultimately approved and was performed on June 10, 2014.
Surgical notes describe the procedure as right wrist
exploration with partial wrist denervation, excision of the
posterior interosseous nerve; right wrist synovectomy; right
distal radioulnar joint reconstruction using free tendon
graft; harvest of free tendon graft from partial thickness of
the flexor carpi radialis tendon, ipsilateral arm; right
lunotriquetral ligament repair; and right lunotriquetral
fusion with hardware. A week later, Dr. Wirges's clinic
note reflects that swelling was present and that, although
not approved by workers' compensation, Mr. Pritchard was
taking vitamin C for prevention of RSD, a development that
would be "devastating." Swelling, range of motion,
hypersensitivities, color, and pain levels had improved at
two weeks. Swelling, motion, and overall appearance had
improved at three months; Mr. Pritchard could grasp a mustard
bottle; his motion and strength were limited; strengthening
exercises could be started; and pain, although improved,
remained unresolved. Fusion never occurred. At four months,
Dr. Wirges wrote that after "right wrist DRUJ
reconstruction with . . . lunotriquetral ligament repair and
a screw placed . . . for an attempted fusion, " the
patient was "neurovascular grossly intact with the
exception of numbness in the median nerve distribution
area"-which was waking him at night.
December 16, 2014, six months after surgery, Dr. Wirges wrote
that Mr. Pritchard had "plateaued in his improvements,
" was at maximum medical improvement (MMI), and did not
want additional surgical treatment despite the risk for
arthritis from posttraumatic changes and the possible need
for "additional treatment in the future." On