On June 26, 2008, the claimant, a transport driver, delivering loads of new trucks and cars for the past 25 years, fell off his truck, and suffered a low back injury. While loading his first vehicle that day onto the top deck, the claimant lost his balance and fell 13 feet from the top rail onto the concrete below, trying to land on his feet, but not succeeding. In the process, he fractured his pelvis, his SI joint, a few transverse processes in the lumbar spine and injured his low back. After falling, the claimant went to the St. Joseph's Hospital emergency room, by ambulance. X-rays revealed that he had fractured the right side of the L3 and L4 transverse processes as well as fracturing the sacral ala extending into the SI joint with mild SI widening. It was observed that there appeared to be a symphysis pubis diastasis less than 2 cm (suggesting a pelvic fracture). After being stabilized in the emergency room and spending a day admitted to
Issued by DIVISION OF WORKERS' COMPENSATION
Employee: Kenneth Spencer
Injury No.: 08-056051
the hospital, Dr. Albus, orthopedist, provided conservative care, from chair to walker to cane.
Dr. Albus foresaw no need for surgical intervention. The claimant's primary complaint of pain
was in the low back, and he was unable to lie down.
On August 25, 2008, Dr. King, another orthopedist, examined the claimant and ordered
progressively more challenging physical therapy. The claimant appeared to make significant
progress in terms of getting back on his feet and getting around, although throughout Dr. King's
treatment the claimant complained of pain in his groin and hip, low back, buttock and SI region.
Other than clinical examinations, there did not appear to be any determination by Dr. King as to
the root cause of the claimant's pain. He characterized it as "residual discomfort".
On October 27, 2008, Dr. King opined the claimant was at maximum medical improvement
noting that he continued to take Darvocet, Naprosyn, and Ambien for pain and that the claimant's
lumbar flexion was 50% of normal. Dr. King imposed permanent restrictions of limited
squatting and bending to 10 minutes every hour. No lifting or carrying more than 30 pounds. No
standing or walking for more than 20 minutes of every hour. At that he was released from
medical care and the employer's workers' compensation medical benefit program initially
refused any further medical treatment.
On November 18, 2008, Dr. Ricci, chief of the orthopedic trauma service at Washington
University Orthopedics, examined the claimant and ordered various X-rays, CT and MRI scans,
revealing a pelvic shift of 2 cm. On December 23, 2008, Dr. Ricci noted that the claimant had
experienced severe pain walking on uneven ground. Dr. Ricci diagnosed pelvic ring injury with
instability caused by the work injury and recommended an open reduction internal fixation of the
anterior pelvis which he believed would substantially improve but not eliminate the pain. Dr.
King concurred with the diagnosis and treatment plan. Surgery was performed on April 30,
2009, after the claimant was able to get his diabetes blood sugar under control. In essence the
surgery fused the fractured pubic bone using allograft bone and the right sacroiliac joint fracture
was reduced by screw fixation. The repair was stabilized with a surgically applied multiplanar
external fixator, which the claimant described to be in the nature of an external halo cast around
the area of his abdomen. He was discharged from surgery to his home with a prescription for a
hospital bed and a wheel chair. The claimant testified that his wife took care of him at home.
On June 16, 2009, the external fixator was removed, and x-rays showed that two surgical
screws had loosened in the area of the pelvic fusion but overall a "healing symphyseal fusion".
On July 21, 2009, the claimant reported that his pelvic pain was "much improved", and x-rays
again showed the pelvic fusion was healing. Dr. Ricci ordered physical therapy for range of
motion and strengthening. After 8 weeks of physical therapy, x-rays showed a non-union of the
pelvic fusion and a loose and fractured surgical screw. On September 22, 2009, Dr. Ricci
realized that the fusion had failed and he was uncertain whether an additional fusion surgery
would be successful. He prescribed two additional months of physical therapy and a week later
provided the claimant with a hydrocodone prescription for pain. On November 24, 2009, Dr.
Ricci noted that physical therapy was helping the claimant to walk without assist devices, that his
greatest complaint at this point was back pain, and that he had developed urinary incontinence.
X-rays showed no interval change in the non-united pelvic fracture, therefore Dr. Ricci believed
the condition to be stable. Dr. Ricci ordered more physical therapy as well as work hardening
and released the claimant to return to work four hours a day with restrictions of no climbing and
to avoid bending, kneeling, and squatting. He recommended that the claimant consult a
WC-32-R1 (6-81)
Page 4
physiatrist for back pain. The employer declined physiatry treatment on the basis that "the back was never authorized".
On February15, 2010, Dr. King examined the claimant for an independent medical examination and noted that although the surgery failed to reunite the pelvis, he had achieved stability in both the posterior and anterior aspects of the pelvic ring with physical therapy to a point where his ability to walk "significantly improved" and "nearly all of his pubic discomfort has gone way". Dr. King noted that throughout the claimant's "entire treatment course from the time of his injury on June 29, 2008, he has complained of low back pain." He opined that the claimant suffered a 22 % permanent partial disability to the body as a whole related to the pelvic ring injury, but that his low back pain should be evaluated by a physiatrist and that diagnostic and therapeutic injections would be appropriate to determine the exact origins of the pain. He opined that in such circumstances "it is very common that [the] focus is solely on the pelvic ring injury and the lumbar spine is overlooked." As to the pelvic ring injury alone