1. The applicant sustained consequential conditions at his left wrist and elbow as a result of the injury on 15 October 2018.
2. The left endoscopic carpal tunnel release and ulnar nerve decompression surgery proposed by A/Prof Nicholas Smith is reasonably necessary as a result of the injury on

1. The respondent to pay the costs of and incidental to the proposed surgery in accordance with s 60 of the Workers Compensation Act 1987 and the applicable SIRA Fees Order.
2. The respondent to pay the applicant's reasonably necessary past medical and related treatment expenses related to the consequential conditions in accordance with s 60 of the Workers Compensation Act 1987 upon production of accounts, receipts and/or valid Medicare Notice of Charge.

A brief statement is attached setting out the Commission's reasons for the determination.

1. Mr Saeed Jorfi (the applicant) was employed as a truck driver by GLC Civil Pty Ltd (the respondent). On 15 October 2018, the applicant sustained an injury to his left middle and ring fingers, liability for which has been accepted by the respondent's insurer. Liability was also accepted for a consequential right shoulder condition sustained following a brief return to work.
2. On 5 March 2024, A/Prof Nicholas Smith wrote to the insurer seeking approval for the applicant to undergo a left endoscopic carpal tunnel release and ulnar nerve decompression surgery.
3. On 24 April 2024, the insurer disputed liability to pay the costs of the surgery in a notice issued pursuant to s 78 of the Workplace Injury Management and Workers Compensation Act 1998 (the 1998 Act).
4. Liability for the proposed surgery, left carpal tunnel and ulnar nerve conditions and various incurred expenses was disputed in further notices issued on 1 August 2024 and

6 September 2024 and, following internal review, on 28 March 2025. 5. The present proceedings were commenced by lodgement of an Application to Resolve a Dispute on 7 May 2025. The applicant seeks compensation pursuant to s 60 of the Workers Compensation Act 1987 (the 1987 Act) for the surgery proposed by A/Prof Smith and various past medical and related treatment expenses.

PROCEDURE BEFORE THE PERSONAL INJURY COMMISSION

1. The parties appeared before the Personal Injury Commission (Commission) for conciliation conference and arbitration hearing on 14 July 2025. The applicant was represented by

Mr Luke Morgan of counsel and the respondent was represented by Ms Kavita Balendra of counsel. The applicant was assisted by an interpreter in the Arabic and English languages. 2. During the conciliation conference, the applicant was granted leave to amend the Application to Resolve a Dispute to omit the reference to an injury to his left shoulder in the description of injury and any claim for treatment expenses in relation to the left shoulder. 3. For reasons given orally and recorded, the Commission determined that the documents attached to an Application to Lodge Additional Documents lodged by the respondent on

8 July 2025 ought to be admitted in the proceedings. 4. I am satisfied that the parties to the dispute understand the nature of the application and the legal implications of any assertion made in the information supplied. I have used my best endeavours in attempting to bring the parties to the dispute to a settlement acceptable to all of them. I am satisfied that the parties have had sufficient opportunity to explore settlement and that they have been unable to reach an agreed resolution of the dispute.

1. The parties agree that the following issues remain in dispute:

(a) whether the applicant sustained an injury or consequential condition to the left carpal tunnel and ulnar nerve;

(b) whether the surgery proposed by A/Prof Smith is reasonably necessary as a result of the injury on 15 October 2018, and

(c) whether the incurred medical and related treatment expenses claimed were reasonably necessary as a result of the injury on 15 October 2018.

1. The following documents were in evidence before the Commission and considered in making this determination:

(a) Application to Resolve a Dispute and attached documents;

(b) Reply and all attachments,[1] and

(c) documents attached to the Application to Lodge Additional Documents lodged by the respondent on 8 July 2025.

1. Neither party applied to adduce oral evidence or cross-examine any witness.

1. The applicant's evidence is set out in written statements made by him on 30 October 2019, 30 August 2024, 2 October 2024 and 27 November 2024.
2. In his first statement, the applicant described the incident on 15 October 2018 as follows:

"On 15 October 2018, whilst I was working, a large steel hook on a crane violently swung and hit my fingers on my left hand. It made direct impact with my middle and ring finger. I was wearing work gloves at the time. The pain was excruciating. I immediately reported the incident to the supervisor and went to see my practitioner."

1. The applicant said his fingers were put in a steel splint and he was certified unfit for work for approximately three weeks. The applicant continued to wear the splint on his left fingers when he returned to work and therefore did everything with his right hand. As a result of this, the applicant sustained an injury to his right shoulder. The applicant said he continued to experience occasional pain and numbness in his fingers.
2. In his second statement, the applicant said that he consulted A/Prof Nicholas Smith in regard to symptoms at his left elbow, hand and fingers on 18 September 2023. A/Prof Smith recommended a corticosteroid injection to the left hand and wrist which partially settled the applicant's pain for about a week. When the applicant was reviewed by A/Prof Smith, he considered the applicant may have carpal tunnel syndrome and recommended nerve conduction studies. Nerve conduction studies were performed on 5 December 2023 and showed a left sided ulnar nerve dysfunction.
3. The applicant returned to see A/Prof Smith on 8 January 2024, reporting continuing numbness from the wrist down the side of his hand and into his little finger. An MRI scan performed on 9 February 2024 showed nerve dysfunction which was highly likely to correlate with carpal tunnel syndrome.
4. On 4 March 2024, A/Prof Smith recommended the applicant undergo an endoscopic carpal tunnel release and ulnar nerve decompression. The applicant said he was very eager to undertake the surgery as his pain was unbearable and was affecting both him and his family.
5. The applicant said he was taking Seroquel, Lyrica, Nexium, Panadeine Forte, Celebrex and Cymbalta as a result of the injury.
6. In his third statement, the applicant described the incident on 15 October 2018 in the following terms:

"As explained in my prior statements, on 15 October 2018, I fractured my middle and ring fingers at work after a large steel crane hook violently swung and hit my left hand. The hook impact my whole hand, however, it seems it was those two fingers which were affected most by the force. Though I felt pain in my whole hand after the incident."

1. The applicant said he was required to wear steel splint until early 2019 at which point he commenced physiotherapy treatment.
2. The applicant complained of ongoing left hand pain to his general practitioner in 2019 and was referred for an ultrasound and MRI. These identified a cyst in the applicant's wrist pressing down on tendons in his ring finger. The applicant was referred for a fenestration steroid injection.
3. In September 2019, the applicant complained of severe left forearm pain. The applicant was referred for ultrasound and CT scans of his forearm. The applicant continued with physiotherapy and chiropractic treatment. The applicant said:

"My left hand, wrist and forearm pain were ongoing. I mainly felt numbness and consistent pain in my left arm. I would discuss all these issues with my general practitioner, though he did not refer me to see a specialist for my left arm until the middle of 2022. He would refer me to undergo scans, consume pain medication, complete steroid injections. I would feel very short periods of improvement in my pain in this period but then the pain would return and worsen."

1. After receiving approval from the respondent's insurer, the applicant consulted Dr Warren Kuo in July 2021 who recommended a right shoulder arthroscopy and subacromial decompression with rotator cuff repair. The applicant underwent the surgery in October 2021. The applicant continued to experience significant pain and restriction in his right shoulder.
2. In February 2022, the applicant was referred for a further MRI scan of the left wrist due to ongoing wrist and hand pain. The applicant was referred further scans after complaining of pain in his left middle finger and ring finger radiating to his elbow. The applicant was also referred to A/Prof Smith but did not see him until sometime later because he had not received approval to do so from the insurer.
3. In September 2022, the applicant's general practitioner referred him for a steroid injection to his wrist after imaging revealed a ganglion. Following the injection, the applicant felt greater pain in his wrist and hand, radiating into his arm and shoulder.
4. In January 2023, the applicant complained of ongoing elbow, wrist and finger pain. After further ultrasound and MRIs, the applicant was provided with approval to see A/Prof Smith.
5. The applicant said that prior to his work injury on 15 October 2018, he did not experience any pain, discomfort or restriction in his left hand, wrist, forearm, elbow or shoulder.
6. In his fourth statement, the applicant provided some further details of the incident on

"I would like to clarify that on the date of my work injury, 15 October 2018, a metal hit my entire hand, but especially impacted two of my fingers and palm.

My hand was lying on its side on the flatbed of a truck and it was open at the time the hook hit my hand.

I felt severe pain and numbness in my fingers, hand, wrist and shoulder following that injury.

The impact from the hook jarred my entire arm. I felt as though my arm was going to fall off."

1. Clinical notes recorded by general practitioner, Dr Ismael Albadran, on 15 October 2018 recorded that a heavy crane hook had hit the applicant's left ring and little fingers. The applicant was referred for a left hand X-ray. The X-ray showed fractures of both fingertips.
2. The applicant was prescribed Endone on 19 October 2018 and, on 26 October 2018, was referred for physiotherapy to have a splint.
3. On 1 November 2018, Dr Albadran noted that the applicant had numbness of his fingers. Finger pain was noted again on 3 and 10 November 2018.
4. The condition at the applicant's right shoulder was noted on 15 November 2018.
5. The applicant continued to complain of finger pain and swelling in December 2018 and January 2019.
6. The report of an ultrasound of the left hand performed on 6 August 2019 indicated no abnormality. In particular, it was noted that there was no evidence of carpal tunnel syndrome.
7. On 23 August 2019, the applicant was referred for an MRI of his left ring and middle finger after reporting that they were still tender.
8. The report of an MRI of the left hand performed on 28 August 2019 noted a cyst arising from the volar aspect of the distal capitate-hamate articulation abutting the ring finger flexor tendon.
9. On 2 September 2019, Dr Albadran noted that the applicant had a left wrist cyst abutting the ring finger flexor tendon. The applicant was referred for ultrasound guided fenestration and steroid injection.
10. On 13 September 2019, Dr Albadran noted that the applicant had developed left forearm pain and referred him for radiological scans of the left forearm.
11. The report of a CT scan of the left forearm dated 16 September 2019 found moderate inflammation posterior to the olecranon in keeping with mild olecranon bursitis. No other abnormality was detected.
12. An ultrasound of the left forearm, dated 18 September 2019, recorded no findings of interest.
13. On 17 January 2020, it was noted that the applicant's left wrist and fingers were still sore. The applicant was again referred for ultrasound of the left wrist and hand.
14. Finger pain was again noted on 11 April 2020. On 14 August 2020, the applicant reported that his fingers were still sore and numb.
15. On 21 February 2022, Dr Albadran noted that the applicant's left wrist was still sore and he was referred for an MRI of the left wrist.
16. On 6 June 2022, Dr Albadran noted:

"has been complaining of left middle and ring finger numbness and pain at night

pain and numbness at night , limitation in using the hands

1. The applicant was referred for radiological investigations of the left middle and ring finger and forearm, noting pain radiating from the fingers to the elbow.
2. The applicant was referred for an ultrasound guided left wrist capito-hamate joint injection and ganglion aspiration on 2 September 2022.
3. On 25 January 2023, Dr Albadran noted:

he had cortisone injection wrist with no improvement

1. The applicant was referred for ultrasounds of the left elbow, wrist and fingers.
2. The report of an ultrasound of the left elbow, wrist and hand dated 1 February 2023 noted:

"1. Median nerve is noted to be bifid in relation to the wrist and mild prominence of the median nerve is noted which can be seen with carpal tunnel syndrome.

2. Soft tissues otherwise normal, Ulnar nerve appears normal."

his pain from the wrist radiating to elbow and hand"

1. The applicant was referred for left elbow, wrist and hand MRIs.
2. The report of a left wrist and elbow MRI dated 5 July 2023 noted a clinical history of constant left elbow pain radiating to the left hand with limited left arm movement associated with numbness of the left third and fourth fingers. The report said the scan of the elbow was essentially normal with no degenerative change involving the elbow joint and no abnormality seen of the ulnar nerve within the cubital tunnel. At the wrists, there was some altered signal and thickening involving the dorsal distal radioulnar ligamentous component of the triangular fibrocartilage complex (TFC) as well as altered signal involving the ulnar foveal and ulnar styloid attachment of the TFC.
3. A letter of referral to A/Prof Nicholas Smith from Dr Albadran, dated 13 July 2023 noted that the applicant had been complaining of ulnar styloid wrist pain as well as ring and middle finger pain radiating to the wrist and lower forearm. The applicant's fingers had been predominantly numb since a crush injury.
4. The applicant was seen by hand and wrist surgeon, A/Prof Nicholas Smith, on 18 September 2023 and reported an injury to his left ring and little fingers and wrist in 2018. A/Prof Smith noted that the applicant was seen with a support person to help with English. A/Prof Smith reported that he was unclear as to the exact mechanism of injury but the applicant's current problems included weakness, minimal sensory change, ulnar sided volar wrist pain as well as some middle and ring finger volar pain.
5. After reviewing various radiological investigations taken on the same day, A/Prof Smith diagnosed a left pisiform non-union with irritability and recommended a corticosteroid injection to the area.
6. On 1 November 2023, A/Prof Smith noted that the corticosteroid injection made the applicant's symptoms 40 to 50% better for about a week. The applicant also reported symptoms consistent with carpal tunnel syndrome. A/Prof Smith referred the applicant for a nerve conduction study.
7. Nerve conduction studies performed by A/Prof Nimeshan Geevasinga on 5 December 2023 were reported to be remarkable for prolonged ulnar nerve motor responses at the elbow on the left side. The study was said to be consistent with left sided ulnar nerve dysfunction at the level of the elbow graded mild in severity.
8. At a further review with a translator, on 8 January 2024, A/Prof Smith reported:

"On examination, he has tenderness over the transverse carpal ligament, and the thumb CMC joint is not really irritable. He has had a corticosteroid injection which did help to a degree for 10 days.

He has had nerve conduction studies which demonstrate changes in the ulnar nerve distribution.

1. A/Prof Smith recommended a repeat MRI noting issues with the previous investigation.
2. The report of an MRI of the left wrist performed on 9 February 2024 noted findings highly likely to correlate with carpal tunnel syndrome and the presence of a small distal carpal ganglion.
3. At a review on 4 March 2024, Dr Smith reported:

"He has a number of problems going on, probably pisotriquetral pain, left ulnar neuropathy at the elbow and probably left carpal tunnel syndrome, which has been improving following guided corticosteroid injections. Because of the neurological irritability, it is difficult to pinpoint mechanical problems, and I have therefore recommended we proceed with nerve decompression surgery initially, in the form of endoscopic carpal tunnel release and ulnar nerve decompression. We will see how his symptoms respond to these procedures before considering more extensive interventions such as excision of the pisiform."

1. A/Prof Nicholas Smith prepared a report responding to a series of questions from the applicant's legal representatives on 24 June 2024.
2. Asked whether the proposed surgery was reasonably necessary as a result of the applicant's work injury, A/Prof Smith responded:

"First of all, does the problem relate to his work injury? As far as I can tell it does. He had an injury to his left ring and middle fingers and wrist in 2018 while in the workplace. He found it difficult to explain to me the exact mechanism of injury, though clearly the problem happened while he was in the course of his duties and he had a clear injury. He has had ongoing diffuse symptoms including pain related to his right shoulder, which was also injured. I have spent a fair amount of effort trying to localise the source of his symptoms, and it is not completely watertight in terms of attributing the symptoms to his probable carpal tunnel syndrome and ulnar neuropathy, though to the best of my ability, these two problems are the top of the list. This basically has been suggested by the improvement of his symptoms following guided corticosteroid injections, which only offer temporary relief.

The next step in trying to improve his symptoms would be definitive treatment which is where the endoscopic carpal tunnel release and ulnar nerve decompression play a part. Therefore, in a nutshell, yes, the proposed left endoscopic carpal tunnel release and ulnar nerve decompression are reasonably necessary as a result of his employment."

1. With regard to appropriateness, the alternatives available, cost, benefits and acceptance amongst the medical profession, A/Prof Smith said the surgery was fairly standard in all regards and was definitely effective in relieving compression. A/Prof Smith said there may be other pathologies present which may cause persisting symptoms.
2. In a further report for the applicant's solicitors dated 21 February 2025, A/Prof Smith was asked to consider the applicant's statement evidence and confirm his opinion regarding the cause of the applicant's left carpal tunnel syndrome and ulnar nerve problems. A/Prof Smith responded:

"In short, I do think his left carpal tunnel syndrome and ulnar nerve problems are related to the injury on 15 October 2018. As I have said previously, it is hard to 100% prove a correlation, though I think one is highly likely. It is notable the injury occurred on 15 October 2018 and I did not see him until 18 September 2023, certainly there is a fairly significant amount of time to allow some inaccuracy to develop when assessing retrospectively. Dr Gehr noted this on Page 26 of his report, in saying it is very hard to get an accurate mechanism of injury and determining which injuries were caused. However, it does appear that he has developed carpal tunnel syndrome and had a significantly forceful injury to his left hand in October 2018, and certainly he may have developed carpal tunnel syndrome and ulnar neuropathy secondary to this. In terms of how this may have eventuated, he may have had significant swelling in his hand and he probably was told to elevate the hand which means he would have to keep the elbow in a flexed position, which definitively pre-disposes people to developing ulnar neuropathy of the elbow. Carpal tunnel syndrome may also have eventuated secondary to overuse of the left side whilst recovering from his difficult right shoulder problem."

1. A/Prof Smith was asked to comment on Dr Courtenay's report:

"I evaluated our client very carefully, and considered the relative sensitivity and specificity of all the tests that have been used. It is not uncommon for people to have median nerve compression at the wrist level and have negative nerve conduction studies. Certainly, in people with so-called "irritative" carpal tunnel syndrome, nerve conduction studies are often normal. I found the guided corticosteroid injection helpful, in that it relieved a lot of his symptoms temporarily, which does suggest that this diagnosis is correct. In regards to his ulnar neuropathy, he has positive physical findings (on examination) as well as positive nerve conduction studies. This diagnosis is fairly clear."

1. A/Prof Smith provided an updated quote for the surgery on 11 April 2025 which specified the surgeon's fee as $2,907.50.

1. Dr George Hanna, a chiropractor and rehabilitation consultant prepared a report for the applicant's solicitors on 8 November 2024. Dr Hanna was asked whether the surgery proposed by A/Prof Smith was reasonably necessary as a result of the applicant's employment. Dr Hanna responded:

"In short, yes. The worker's initial left hand/finger fracture has caused dysfunction within the entire left upper limb as is common in chronic limb injuries due to the workers need to over rely/compensate on neighbouring joints/body parts. It is not uncommon to see a chronic injury in the hand create consequential injuries to the wrist including ligamentous, wrist and neural dysfunction."

1. Dr Hanna said the surgery would slow and prevent further damage to the ulnar nerve and provide a significant degree of alleviation. Alternative forms of treatment, including medication, physical therapy and corticosteroid injections as well as home exercises and stretches, had been exhausted. The treatment would increase the chances of a return to work and was cost beneficial. Most, if not all, orthopaedic surgeons would consider the surgical intervention proposed to be both appropriate and a very conventional choice for the applicant's condition.

1. The applicant relies on medicolegal reports prepared by orthopaedic surgeon, Dr Eugene Gehr, dated 28 March 2023 and 16 October 2024. It appears that Dr Gehr provided other reports on 6 January 2020 and 12 October 2024 but they are not in evidence in these proceedings.
2. Dr Gehr examined the applicant with the assistance of an interpreter.
3. In the first report, Dr Gehr noted that the applicant had a normal examination range of motion of the left shoulder and left elbow. The applicant reported tenderness over the left long and ring fingers but was able to bury the fingertips in the palm of his hand suggesting normal range of motion and function of the left hand.
4. In his later report, Dr Gehr considered a medicolegal report prepared by Dr Brett Courtenay for the insurer, dated 29 May 2024, as well as more recent treating evidence, imaging and the applicant's statement evidence. Dr Gehr noted that A/Prof Smith had recommended endoscopic carpal tunnel release and ulnar nerve decompression.
5. The applicant complained of numbness in the median and ulnar distribution of the nerves in the left hand and numbness on the ulnar border of the left forearm.
6. On examination, Dr Gehr found an equivocal Tinel's test over the carpal tunnel of the left hand. There was a positive Tinel's test 9 cm distal to the medial epicondyle consistent with involvement of the ulnar nerve.
7. Dr Gehr commented:

"Since my previous report what has become apparent is that he is reporting tingling sensation in the median and ulnar nerve distributions in the left hand and he has a positive Tinel's test distal to medial epicondyle consistent with a cubital tunnel syndrome involving the sensory component.

He has been under the care of an orthopaedic surgeon and there has been a proposal for left endoscopic carpal tunnel release and ulnar nerve decompression.

I do note nerve conduction and EMG report dated 5/12/2023 states that it is consistent with a left-sided ulnar nerve dysfunction at the level of the elbow. That is consistent with my physical examination today.

I do note an MRI of the left wrist dated 9/2/2024 reports increased cross-sectional area of median nerve related to bifid median nerve with persistent median artery is likely to correlate with carpal tunnel syndrome."

1. Asked whether the work injury materially contributed to the onset of the conditions in his left forearm and elbow, Dr Gehr responded:

"I do note that there was a crush-type injury involving his left hand. It is not unreasonable that that could have caused a left carpal tunnel syndrome and left cubital tunnel syndrome with a later presentation."

1. Asked to comment on the report of the respondent's medicolegal expert, Dr Courtenay,

"The nerve conduction studies do support an ulnar neuritis which is symptomatic and does require surgical attention at this stage. I do note that Dr Courtenay has said it is hard to correlate the crush-type injury of his finger with the injury on his elbow. However, my opinion is that is it very hard to put together the actual mechanism of injury and determining which injuries were caused. This is often done in a retrospective manner with a margin for inaccuracy. I do think it is of significance that his treating hand surgeon has made a proposal for surgery and I would support that recommendation."

1. Dr Gehr expressed the view that the particular surgery recommended by A/Prof Smith was reasonably necessary and would alleviate the consequences of the injury and slow or prevent the deterioration of the left median nerve and ulnar nerve injuries to the stage of motor involvement which could be irreversible.
2. Dr Gehr said that the surgery was generally 60 to 80% effective and alternative treatments had been exhausted. The treatments were cost beneficial and accepted surgical procedures for the treatment of the conditions.

1. Orthopaedic surgeon, Dr Murray Hyde Page, prepared a medicolegal report at the request of the respondent's insurer on 30 September 2019.
2. Dr Hyde Page recorded a history as follows:

"Mr Jorfi states that in the course of his work as a truck driver, his main job to load and unload industrial bins. However, on 15 October 2018, he was driving a flat truck that had a crane and he had to unload heavy steel and timber formwork with a co-worker. The crane hook hit against the tips of the fingers on his left hand. At the time he was wearing a work glove. He immediately experienced pain on the tip of the left ring and middle fingers."

1. Dr Hyde Page noted that X-rays were done of the left hand and fingers on the same day. The applicant then saw a hand therapist and the fingers were splinted. The applicant returned to work after a few weeks with the fingers still splinted. The splints were removed from the fingers after two to three months and the applicant had some physiotherapy to get fingers moving. The applicant had never been happy with the way the fingers had settled down and they continued to be painful. The applicant described feeling of "electric shocks" in the fingers.
2. Dr Hyde Page recorded an examination of the hand and fingers that was said to be "completely normal".

1. The respondent relies on medicolegal reports prepared by orthopaedic surgeon, Dr Brett Courtenay dated 3 March 2023, 29 May 2024 and 25 June 2025.
2. In his first report, Dr Courtenay took a history that included:

"He stated that he had an injury two weeks prior to 15 October 2018. He caught two fingers of his left hand in a hook which was lifting a skip and fractured those fingers. He was then able to return to work after about two weeks. The skin apparently was not broken. It was confirmed that there were fractures. He was limited in the use of his left arm at that stage..."

1. Dr Courtenay reviewed various radiological investigations and noted an examination of the left hand which showed no abnormality and no evidence of neurological deficit. Dr Courtenay gave the opinion:

"I have reviewed Mr Jorfi's investigations and with respect to the left hand there is no ongoing residual impairment related to anything that occurred in the injury in 2018. The fractures were at the tips of the fingers and they were healed. For him to return to work after two weeks was totally appropriate."

1. In his second report, Dr Courtenay noted that the applicant had been seen with an Arabic speaking interpreter. The history obtained on that date was as follows:

"He was working for a company, GLC Civil Pty Ltd, and was loading steel onto a truck. He described that they were using a crane and he went to move the hook being used to lift the steel and that came and struck him on his left hand, fracturing some of his fingers. He was little unclear which fingers were injured, and also unclear as to what part of the fingers, which would suggest that it may well have been just the tip of the ring finger and the index finger.

With respect to his left hand, he states that he has had altered sensation on the tips of those two fingers, the ring and the middle fingers, since the original injury. It was a crush injury and that was noted also by Dr Hyde Page, but no other neurological problems which his left hand were noted.

His original injury was a crushing of the fingers. There was no history given of any wrenching or stretching of his left arm at the time."

1. In recording the treatment to date, Dr Courtenay stated:

"He states that initially he had strapping of his fingers but nothing else and then had a bandage applied and it certainly does not appear that any other sort of splints were applied and he did get back to work after ten days..."

1. On examination, the applicant described soreness and pain into the middle of his hand and down the ulnar line of his forearm. The applicant said he got a burning and stinging sensation in his arm and pain radiated to the elbow. The applicant also reported diminished sensation in the tips of the two fingers since the original injury. Dr Courtenay observed different measurements at the left and right upper limbs but said this was consistent with the applicant being right hand dominant.
2. Dr Courtenay expressed the opinion:

"The MRI from 2019 confirms that the injury that this gentleman actually sustained was a crush injury to the tip of the middle and ring fingers. This is, in my opinion, consistent with the altered sensation on the tips of these two fingers.

There is nothing in his nerve conduction studies to suggest any median nerve symptoms and the bifid median nerve is constant throughout all of the imaging over the years. There is no wasting of the hand and MRI of the elbow has shown that the ulnar nerve is normal. The nerve conduction studies do show however that there may be some ulnar neuritis.

However, the original injury was clearly a crush injury of the tips of the fingers and in my opinion, is in no way related to any pathology in his elbow, by way of repeated use or any other activity."

1. With regard to the surgery proposed by A/Prof Smith, Dr Courtenay commented:

"...given the nerve conduction studies and the symptoms, the lack of any wasting of his arm, the fact that nerve conduction studies give potentially a mild severity for an ulnar neuritis but no abnormalities on the MRI, I do not believe there is any surgical indication that is going to assist this man by releasing his ulnar nerve. I certainly do not believe that in any way it is related to his work injury back in 2018. The same thing applies to the median nerve. There is no nerve conduction evidence of median carpal tunnel and there is only a possible implication, because of the developmental difference in the way the median nerve developed by being bifid and also having an associated median artery, there is no evidence for release of the carpal tunnel. There is also no wasting and if there had been an issue for that length of time, I would have expected some alteration in the thenar eminence, or at least in his forearm muscle bulk. The numbness of the tips of those two fingers that he is constantly referring to, in my opinion, is clearly related to the crush injury he had to the tips of those fingers that is confirmed by the MRI in 2019."

1. Dr Courtenay said the investigations did not support surgical intervention and he did not believe the proposed surgery was in any way work-related.
2. In his most recent report, Dr Courtenay noted that there had been different and varied descriptions of how the original injury occurred in 2018. Dr Courtenay said,

"I have seen Mr Jorfi on two occasions, in 2023 and 2024. In 2023 he said he was in the process of loading steel onto a truck, and he was struck by the steel hook. In 2024 he said the hook was on a skip that was being lifted, and his fingers were jammed in that."

1. Dr Courtenay commented on the nerve conduction studies and stated:

"The median nerve is normal and certainly there is no indication of any carpal tunnel pathology at that stage. I note that Professor Smith speaks about an MRI, and some median nerve changes on that MRI. That is not an acute injury, and it certainly is not consistent with the work injury in 2018.

The same thing applies with the ulnar nerve. The ulnar nerve symptoms are described as mild, and again, an acute injury such as this worker had, from how he described it, even though there are variations to it, it was a very quick movement and a direct blow to the tips of some fingers. That does not lead to long term and chronic development of nerve pathology.

It is therefore my opinion that the workplace had nothing to do with those particular injuries. They are chronic in their nature and there was no evidence of any symptoms of that leading up to that particular injury that he had in 2018."

1. Asked to comment on the reports of Dr Hanna, Dr Gehr and A/Prof Smith, Dr Courtenay stated:

"I stand by my comments, and I also note that reviewing the comments from Dr Hanna, Dr Gehr and Associate Professor Smith that they cannot exactly correlate how it occurred, but they presumed automatically it was work-related. From my perspective that is incorrect as there was certainly a latency of at least three years before any symptoms more than to the tips of the fingers of the left hand were even identified. Again, I go back to the description of the injury. Even though there is some variation in it, it was always a very acute injury without any wrenching of the arm or any other injuries to the wrist, elbow or shoulder."

1. Dr Courtenay was asked to comment in particular on A/Prof Smith's view that the finger injury may have caused significant swelling for which the applicant was told to elevate the hand and keep the elbow in a fixed position, predisposing the applicant to neuropathy of the elbow. Dr Courtenay was also asked to comment on A/Prof's Smith's suggestion that carpal tunnel syndrome may have been secondary to overuse of the left side while recovering from the difficult right shoulder problem. Dr Courtenay responded:

"The comment from Associate Professor Smith, with respect, is entire supposition, and even if that was the case, the patient would have had acute symptoms of the elbow, and it would have been correlated and related at that time. It would not have gone on for some years before it would actually manifest itself. The carpal tunnel is not even confirmed on the nerve conduction studies.

With respect to the supposition that there was overuse, this man was very clear that he did very little activity at all. He could not do anything at home or any other activities. Given that he was working in construction and doing heavy work prior to that, it is my opinion that whatever he was doing with his left arm when he was recovering from his right shoulder was certainly significantly less than what he had been doing during any of the periods of time when he was working and therefore I do not believe that it can be assumed that it occurred due to overuse from the right shoulder.

I also find, from the nerve conduction studies, it is hard to even confirm that there is any carpal tunnel, or anything more than mild neuritis as indicated. However, that there, if it is correct, then it is constitutional and not related to the work injury which occurred some years earlier."

1. The applicant observed that there was clearly a language barrier in this case, which had created some misapprehension around the way the injury on 15 October 2018 occurred.
2. The applicant noted that Dr Courtenay had seen the applicant in March 2023, on which occasion he took a history of the applicant catching two fingers of his left hand in a hook which was lifting a skip bin, resulting in a "crush injury" and fractures.
3. The applicant contrasted the history recorded by Dr Courtenay with his statement evidence. The description of injury in the applicant's first statement in 2019 was of a metal hook swinging and impacting the fingers. The applicant referred in his first statement to a steel splint being applied to the fingers. In his second statement, the applicant referred to wearing the splint for several months.
4. The contemporaneous reporting confirmed the splinting and elevation of the applicant's hand. The general practitioner's notes referred to splinting and a referral to hand therapy and physiotherapy following the removal of the splint. The clinical records showed a continuity of complaints in relation to the left hand from the time of the injury, well into 2019. In 2019, the applicant was referred for ultrasounds of the wrist and forearm. The applicant reported ongoing pain and numbness.
5. The applicant submitted that the applicant's statement evidence and the contemporaneous medical evidence were inconsistent with Dr Courtenay's history of a crushing injury and his suggestion that there was a latency of at least three years before any symptoms more than to the tips of the fingers of the left hand were reported. Dr Courtenay also referred to strapping with a bandage and no splint being applied, which was in contrast to the other evidence that the applicant wore a splint for two to three months after the incident.
6. The applicant submitted that the history of the incident and the development of the condition taken by Dr Courtenay was wrong and as a result the weight that ought to be attached to his opinions was diminished.
7. The applicant noted that Dr Courtenay struggled to be satisfied, to a scientific standard, as to the cause of the applicant's symptoms. The applicant referred the Commission to the decisions in Tubemakers of Australia Ltd v Fernandez[2] and EMI (Aust) Ltd v Bes[3] and submitted that the Commission was entitled to look at the overall picture. Where the applicant's medical practitioners said there was a possibility of a causal relationship, that may be sufficient.
8. The applicant submitted that the injury involved a swinging, heavy metal hook. The applicant had undergone multiple investigations and made ongoing complaints to his doctors from the time of the injury onwards.
9. Eventually, the applicant had been seen by a respected hand and wrist surgeon, A/Prof Smith. A/Prof Smith had given an opinion that either the initial insult or the swelling that had resulted as a consequence had given rise to the symptoms which he proposed to treat by surgery.
10. The applicant urged an acceptance of the opinions of A/Prof Smith and, to the extent required, the consistent opinions of Dr Gehr and Dr Hanna.

1. The respondent submitted that a primary difficulty for the applicant was that it remained unclear whether he had sustained an injury or a consequential condition. The Application to Resolve a Dispute pleaded a consequential condition and relied on the opinions of A/Prof Smith.
2. The respondent submitted that the applicant bore the onus of demonstrating a consequential condition and there had to be evidence to support his claim.
3. The respondent noted that A/Prof Smith suggested different causal mechanisms applied for the carpal tunnel and ulnar nerve conditions. For the ulnar nerve, A/Prof Smith suggested that swelling of the fingers may have led to elevation of the hand, impacting upon the ulnar nerve. The respondent submitted that it was not known whether there was in fact elevation or swelling of the hand. A/Prof Smith suggested that the carpal tunnel condition may have eventuated secondary to overuse of the left limb whilst the applicant recovered from his right shoulder problem.
4. The respondent observed that an MRI taken in August 2019 showed no evidence of carpal tunnel syndrome. An MRI performed in February 2023 revealed a change in findings, suggesting a carpal tunnel syndrome may be present.
5. Although the applicant underwent surgery to his right shoulder in 2021, the applicant did not state anywhere in his evidence that he had overused his left arm as a result.
6. The respondent submitted that there was no evidence to support the suppositions made by A/Prof Smith.
7. The respondent referred to Dr Courtenay's reasoning, noting a lack of wasting of the left upper limb. Dr Courtenay said there was no evidence of overuse and observed that the applicant had done very little since the injury. Dr Courtenay did not consider that surgical intervention was appropriate.
8. Although the applicant had submitted that there was not a crush-type injury, the history recorded by Dr Gehr was of a crush-type injury.
9. At best, the applicant relied on a supposition that "it was not unreasonable" that the injury could have caused carpal and ulnar nerve conditions.
10. The respondent submitted that the Commission would not be satisfied on the evidence that the applicant's onus had been discharged.

1. The applicant submitted that the Commission would draw a lot of confidence from A/Prof Smith's reports. A/Prof Smith acknowledged that the causal mechanism was not straightforward but said he had spent a lot of time drilling down into the problem. In his most recent report, A/Prof Smith concluded that the principal cause of the conditions was the forceful injury. A/Prof Smith's opinions were said to be helpful and well considered.

1. Section 9 of the 1987 Act provides that a worker who has received an "injury" shall receive compensation from the worker's employer. The term "injury" is defined in s 4 of the 1987 Act:

(a) means personal injury arising out of or in the course of employment,

(b) includes a disease injury, which means:

(i) a disease that is contracted by a worker in the course of employment but only if the employment was the main contributing factor to contracting the disease, and

(ii) the aggravation, acceleration, exacerbation or deterioration in the course of employment of any disease, but only if the employment was the main contributing factor to the aggravation, acceleration, exacerbation or deterioration of the disease, and

(c) does not include (except in the case of a worker employed in or about a mine) a dust disease, as defined by the Workers' Compensation (Dust Diseases) Act 1942, or the aggravation, acceleration, exacerbation or deterioration of a dust disease, as so defined."

1. The test for establishing a consequential condition can be distinguished from that required to establish an "injury". In this regard, the comments of Roche DP in Moon v Conmah[4] at [45]-[46] are relevant:

"It is therefore not necessary for Mr Moon to establish that he suffered an 'injury' to his left shoulder within the meaning of that term in section 4 of the 1987 Act. All he has to establish is that the symptoms and restrictions in his left shoulder have resulted from his right shoulder injury. Therefore, to the extent that the Arbitrator and Dr Huntsdale approached the matter on the basis that Mr Moon had to establish that he sustained an 'injury' to his left shoulder in the course of his employment with Conmah they asked the wrong question."

1. In Bouchmouni v Bakhos Matta t/as Western Red Services,[5] Roche DP commented,

"The Commission has considered and explained the difference between an 'injury' and a condition that has resulted from an injury in several recent decisions (Moon v Conmah Pty Ltd [2009] NSWWCCPD 134 at [43], [45] and [50] (Moon); Superior Formwork Pty Ltd v Livaja [2009] NSWWCCPD 158 at [122]; Cadbury Schweppes Pty Ltd v Davis [2011] NSWWCCPD 4 at [28]-[32] and [39]-[42] (Davis); North Coast Area Health Service v Felstead [2011] NSWWCCPD 51 at [84]; Australian Traineeship System v Turner [2012] NSWWCCPD 4 at [28] and [29] (Turner); Kumar v Royal Comfort Bedding Pty Ltd [2012] NSWWCCPD 8 at [35]-[49] and [61]). ...

The injury to Mr Bouchmouni's right knee caused him to seek treatment in the form of surgery and physiotherapy. The evidence suggests that it was in the course of receiving that treatment, and/or as a result of an altered gait because of his knee symptoms, Mr Bouchmouni developed back symptoms. If that is accepted, and no reason has been advanced why it should not be, it is clear beyond doubt that his back condition has resulted from the treatment he received for his accepted knee injury and his altered gait. That does not, however, make the back condition an 'injury'."

1. In Trustees of the Roman Catholic Church for the Diocese of Parramatta v Brennan[6] Snell DP referred to the decisions in Moon v Conmah[7] and Kumar v Royal Comfort Bedding[8] and observed:

"The above do not suggest any need that a finding of a consequential condition necessarily involves the identification of pathology. It is sufficient to find (if the evidence supports it) a condition that results from an employment injury. I accept the respondent's submission that it is sufficient to find a consequential condition, pathology need not necessarily be identified."

1. A commonsense evaluation of the causal chain is required. The legal test of causation is that discussed by the Court of Appeal in Kooragang Cement Pty Ltd v Bates,[9] where Kirby P (as his Honour then was) said at [461] (Sheller and Powell JJA agreeing):

"From the earliest days of compensation legislation, it has been recognised that causation is not always direct and immediate...

Since that time, it has been well recognised in this jurisdiction that an injury can set in train a series of events. If the chain is unbroken and provides the relevant causative explanation of the incapacity or death from which the claim comes, it will be open to the Compensation Court to award compensation under the Act."

1. It is the applicant who bears the onus of establishing on the balance of probabilities that he sustained an injury or a condition which has resulted from the injury on 15 October 2018. In Nguyen v Cosmopolitan Homes (NSW) Pty Limited[10] McDougall J stated at [44]:

"A number of cases, of high authority, insist that for a tribunal of fact to be satisfied, on the balance of probabilities, of the existence of a fact, it must feel an actual persuasion of the existence of that fact. See Dixon J in Briginshaw v Briginshaw [1938] HCA 34; (1938) 60 CLR 336. His Honour's statement was approved by the majority (Dixon, Evatt and McTiernan JJ) in Helton v Allen [1940] HCA 20; (1940) 63 CLR 691 at 712."

1. This is a case where there have been clear challenges in identifying the mechanism of the initial injury on 15 October 2018 and the pathological consequences of that event.
2. In part, these challenges are attributable to language barriers. The applicant was assisted by an interpreter in the Arabic and English languages in the proceedings before the Commission and an interpreter or support person assisting with interpretation was involved in some, but not all, of the medical examinations associated with the applicant's injury. This has resulted in some ambiguity and different histories being recorded at different times.
3. The delay in referral of the applicant to a specialist, the passage of time, the elusive and diffuse nature of the applicant's symptoms and a supervening serious injury to the applicant's right shoulder may also have contributed to the difficulties faced by both the applicant and the doctors involved in this case.
4. After carefully reviewing the totality of the evidence, I am satisfied on the balance of probabilities that the initial incident on 15 October 2018 involved a heavy metal hook swinging and striking the applicant's open left hand, impacting particularly on the left ring and middle fingers.
5. This mechanism is consistent with the applicant's statement evidence over time. It is also consistent with the general practitioner's contemporaneous clinical notes, the history recorded in 2019 by Dr Hyde Page and the history ultimately elicited by A/Prof Smith.
6. I note that a different mechanism was recorded by Dr Courtenay at the time of his first examination of the applicant in March 2023. A different history again was provided to

Dr Courtenay at the time of his second examination that was more consistent with the mechanism I have accepted. Nonetheless, Dr Courtenay's reasoning continued to rely, in large part, on an assumption that the injury involved a "crushing" of the tips of the two fingers. 7. The respondent observed that Dr Gehr also referred to there having been a crush-type injury in his last report. I note, however, that neither of the reports from Dr Gehr before the Commission in these proceedings took a full history, presumably because this had been set out in Dr Gehr's 2020 report. In the last report, Dr Gehr was specifically asked to respond to Dr Courtenay's reports which referred to a crush injury. It is possible that Dr Gehr has simply picked up on the language used by Dr Courtenay. I note there was also reference to a crush injury in Dr Albadran's referral to A/Prof Smith. 8. Despite these variations in the accounts of the event on 15 October 2018, I find the weight of evidence favours the mechanism I have accepted above. 9. There is no doubt as to the forceful nature of the impact of the hook. The impact was sufficient to fracture two fingers. The applicant has consistently described the incident as causing excruciating pain. The incident was reported immediately and the applicant sought medical assistance on the same day. The applicant was prescribed strong pain relief and referred for X-rays which revealed the fractures. 10. The contemporaneous clinical notes from around the time of the incident confirm the applicant's evidence that his fingers were splinted. Dr Hyde Page referred to the applicant having been referred to a hand therapist, although no records from a hand therapist are in evidence. Dr Hyde Page also referred to the splint being worn for two to three months. 11. Dr Courtenay, on the other hand, took a history that the fingers were strapped and then bandaged but no other splints were applied. The applicant was said to have returned to work after 10 days. 12. Dr Courtenay's history with regard to the treatment of the fingers is inconsistent with the other evidence. Dr Courtenay's reports also fail to acknowledge the ongoing reporting of significant symptoms which appears in the treating evidence. 13. The general practitioner's notes recorded ongoing reports of pain and other symptoms in the applicant's fingers for an extended period after the incident on 15 October 2018. Numbness of the fingers was noted in November 2018. In December 2018 and January 2019, the applicant complained of pain and swelling. Persisting symptoms were noted in mid-2019, prompting further radiological investigations. An MRI performed on 28 August 2019 noted a cyst at the applicant's wrist abutting the ring finger flexor tendon. This appears to have been treated with ultrasound-guided fenestration and steroid injection, after which the applicant reported forearm pain. The forearm symptoms were also investigated radiologically. 14. Around the same time, the applicant was seen by Dr Hyde Page, who recorded that the applicant had never been happy with the way the fingers had settled down and they continued at the time of his report to be painful. The applicant also described feelings of "electric shocks" in the fingers. 15. Symptoms in the applicant's left wrist and fingers continued to be reported in the first half of 2020. 16. During 2021, the focus of the treating doctors' attention appears to have been on the applicant's right shoulder, which ultimately proceeded to surgery. In February 2022, however, the applicant again reported left wrist symptoms. Pain radiating from the fingers to the elbow was noted in June 2022 and the applicant was again referred for ultrasound guided injection to the wrist and ganglion aspiration in September 2022. 17. In January 2023, Dr Albadran noted pain from the elbow to the fingers and numbness in the fingers and wrist. The applicant was commenced on Lyrica and was noted to be taking Panadeine Forte for his symptoms. 18. Further investigations of the elbow, wrist and hand were performed in the first half of 2023 with a clinical history of constant left elbow pain radiating to the left hand with limited arm movement and numbness of the middle and ring fingers. 19. Contrary to Dr Courtenay's assertion that there was a latency of at least three years before any symptoms other than those at the fingertips was reported, the treating evidence records regular reports of symptoms of pain and numbness at the fingers, progressing to the wrist, forearm and up to the elbow throughout the period between the incident on 15 October 2018 and the first consultation with A/Prof Smith. 20. I accept the applicant's submission that the inconsistencies between the histories recorded by Dr Courtenay and the other evidence, with regard to the mechanism of injury, the treatment of the finger fractures, and the ongoing reporting of symptoms beyond the tips of the fingers, diminishes the reliability of Dr Courtenay's opinions on causation. Dr Courtenay concluded that any condition at the relevant body parts was constitutional and not related to the work injury. 21. I note in this regard that there is no suggestion anywhere in the evidence that the applicant experienced any symptoms at his wrist, forearm or elbow prior to the traumatic event on

15 October 2018. The evidence suggests that other than a brief return to work, the applicant's use of his upper limbs for work or activities of daily living has been severely curtailed. There is no suggestion of any intervening event or other discrete cause of the reported symptoms. 22. It does, however, remain, the applicant's onus to demonstrate a causal relationship between his symptoms and the incident on 15 October 2018. 23. Reaching a diagnosis for the applicant's symptoms has clearly proven challenging for the applicant's treating doctors and the medicolegal experts. 24. Despite numerous radiological investigations and the employment of a range of treatment modalities, Dr Albadran was unable to achieve a definitive diagnosis or resolve the reported symptoms. 25. I accept that A/Prof Smith has taken a cautious approach. A/Prof Smith's treating reports demonstrate that he took care to obtain a clear history as to the mechanism of injury. After reviewing the available radiological investigations, A/Prof Smith recommended a corticosteroid injection, which provided partial relief for about a week. The applicant was referred for further investigations, including a nerve conduction study and further MRI after some clarity issues were noted with the previous investigation. After all of this, A/Prof Smith, doing the best he could, diagnosed a multifactorial problem which included left ulnar neuropathy at the elbow and probable left carpal tunnel syndrome.The endoscopic carpal tunnel release and ulnar nerve decompression procedures were recommended as an initial step before any more extensive interventions. 26. In his reports for the applicant's solicitors, A/Prof Smith noted that there was a clear injury and ongoing, diffuse symptoms. A/Prof Smith said he had spent a fair amount of effort trying to localise the source of the symptoms and he acknowledged that it was not completely watertight. A/Prof Smith said that, to the best of his ability, a probable carpal tunnel syndrome and ulnar neuropathy were the two problems at the top of the list. The basis for this conclusion was explained, including the improvement of symptoms following the guided corticosteroid injection, positive clinical findings, the nerve conduction studies and the radiological investigations. 27. In his report, dated 21 February 2025, A/Prof Smith said that a correlation between the carpal tunnel and ulnar nerve problems and the injury on 15 October 2018 was "highly likely". A/Prof Smith noted that the injury in October 2018 was "significantly forceful" and said that a carpal tunnel syndrome and ulnar neuropathy could have developed "secondary to this". 28. A/Prof Smith also posited other explanations, including the applicant elevating the injured fingers with his elbow in a fixed position or overuse while recovering from the difficult right shoulder problem. 29. Dr Gehr also found positive clinical signs suggesting involvement of the ulnar nerve and equivocal signs over the carpal tunnel of the left hand at the time of his second examination. The applicant reported tingling in the median and ulnar nerve distributions in the left-hand. The nerve conduction studies were observed to be consistent with a left sided ulnar nerve dysfunction at the level of the elbow. The nerve conduction studies were said to be consistent with Dr Gehr's own physical examination. Dr Gehr said the MRI of the left wrist identified findings that were likely to correlate with carpal tunnel syndrome. Dr Gehr said it was "not unreasonable" that the injury could have caused a left carpal tunnel syndrome and left cubital tunnel syndrome with a later presentation. Dr Gehr supported the proposal for surgery. 30. Consistently with A/Prof Smith's and Dr Gehr's opinions, Dr Hanna agreed that the initial finger fracture had caused dysfunction within the entire left upper limb. Dr Hanna said this was common in chronic limb injuries due to the need to rely on neighbouring body parts. Dr Hanna said it was not uncommon to see a chronic injury in the hand create consequential injuries to the wrist including neural dysfunction. Dr Hanna also supported the proposal for surgery. 31. The respondent has criticised the lack of conviction or certainty in the applicant's doctors' opinions. In this regard, I note the principles stated by Herron CJ, with whom Asprey and Holmes JJA agreed (at 245), in EMI (Aust) Ltd v Bes:[11]

"... it is not incumbent upon the applicant, upon whom the onus rests, to produce evidence from medical witnesses which proves to demonstration that the applicant's contention is correct. Medical science may say in individual cases that there is no possible connexion between the events and the death, in which case, of course, if the facts stand outside an area in which common experience can be the touchstone, then the judge cannot act as if there were a connexion. But if medical science is prepared to say that it is a possible view, then, in my opinion, the judge after examining the lay evidence may decide that it is probable."

1. In Woolworths Limited v Christopher-Coates,[12] Keating P, referring to the decision in Tubemakers of Australia Ltd v Fernandez[13] stated at [176] that:

"Fernandez was cited with approval in Commonwealth v McLean [1996] NSWSC 657; (1996) 41 NSWLR 389 (McLean), where Handley and Beazley JJA said this at 410: 'A tribunal of fact is entitled to find causation as a matter of commonsense from the sequence of events, although medical science does not support an affirmative answer, provided it does not exclude such a finding: see Adelaide Stevedoring Co Ltd v Forst [1940] HCA 45; (1940) 64 CLR 538 at 563-564, 569 and Tubemakers of Australia Ltd v Fernandez (1976) 50 ALJR 720.'"

1. As the cases I have referred to above establish, in order to demonstrate a consequential condition, the applicant is not required to identify specific pathology. It is sufficient if the evidence establishes, on the balance of probabilities, that symptoms or restrictions have resulted from the "injury".
2. After my own careful review of the totality of the evidence, I am satisfied, on the balance of probabilities, that the applicant has experienced symptoms at his left arm, particularly at his wrist and elbow, which have "resulted from" the injury on 15 October 2018.
3. While the precise causal mechanism and pathology remain somewhat obscure, and may in fact be multifactorial, there is a consistency of opinion between A/Prof Smith, Dr Gehr and

Dr Hanna that the significantly forceful impact of the metal hook on the applicant's fingers has resulted in a probable carpal tunnel syndrome and left ulnar neuropathy. 4. In making my finding, I have not accepted that there was an 'overuse' of the left limb following the right shoulder condition. It is also not necessary to express a concluded view as to whether elevation or the splinting of the fingers contributed the condition at the elbow. I accept A/Prof Smith's primary view that the conditions at the left wrist and elbow were "secondary" to the significantly forceful injury to the hand on 15 October 2018. 5. For the reasons given above, Dr Courtenay's reports do not persuade me that this opinion should not be accepted. 6. I am satisfied that the applicant has discharged his onus of establishing consequential conditions at his left wrist and elbow which have resulted from the injury on 15 October 2018.

Is the surgery proposed by A/Prof Nicholas Smith reasonably necessary as a result of the injury?

1. Section 60 of the 1987 Act relevantly provides:

"(1) If, as a result of an injury received by a worker, it is reasonably necessary that:

(a) any medical or related treatment (other than domestic assistance) be given, or

(d) any workplace rehabilitation service be provided,

the worker's employer is liable to pay, in addition to any other compensation under this Act, the cost of that treatment or service and the related travel expenses specified in subsection (2)."

1. What constitutes reasonably necessary treatment was considered in the context of s 10 of the Workers Compensation Act 1926 in Rose v Health Commission (NSW)[14] where Burke CCJ stated:

"Treatment, in the medical or therapeutic context, relates to the management of disease, illness or injury by the provision of medication, surgery or other medical service designed to arrest or abate the progress of the condition or to alleviate, cure or remedy the condition. It is the provision of such services for the purpose of limiting the deleterious effects of a condition and restoring health. If the particular 'treatment' cannot, in reason, be found to have that purpose or be competent to achieve that purpose, then it is certainly not reasonable treatment of the condition and is really not treatment at all. In that sense, an employer can only be liable for the cost of reasonable treatment."

1. In Diab v NRMA Ltd,[15] Roche DP provided a summary of the relevant principles as follows:

"In the context of s 60, the relevant matters, according to the criteria of reasonableness, include, but are not necessarily limited to, the matters noted by Burke CCJ at point (5) in Rose (see [76] above), namely:

(a) the appropriateness of the particular treatment;

(b) the availability of alternative treatment, and its potential effectiveness;

(c) the cost of the treatment;

(d) the actual or potential effectiveness of the treatment, and

(e) the acceptance by medical experts of the treatment as being appropriate and likely to be effective.

With respect to point (d), it should be noted that while the effectiveness of the treatment is relevant to whether the treatment was reasonably necessary, it is certainly not determinative. The evidence may show that the same outcome could be achieved by a different treatment, but at a much lower cost. Similarly, bearing in mind that all treatment, especially surgery, carries a risk of a less than ideal result, a poor outcome does not necessarily mean that the treatment was not reasonably necessary. As always, each case will depend on its facts.

While the above matters are 'useful heads for consideration', the 'essential question remains whether the treatment was reasonably necessary' (Margaroff v Cordon Bleu Cookware Pty Ltd [1997] NSWCC 13; (1997) 15 NSWCCR 204 at 208C). Thus, it is not simply a matter of asking, as was suggested in Bartolo, is it better that the worker have the treatment or not. As noted by French CJ and Gummow J at [58] in Spencer v Commonwealth of Australia [2010] HCA 28, when dealing with how the expression 'no reasonable prospect' should be understood, '[n]o paraphrase of the expression can be adopted as a sufficient explanation of its operation, let alone definition of its content'."[16]

1. Findings have been made as to the causal relationship between the injury on

15 October 2018 and the conditions at the applicant's left wrist and elbow above. While I accept that there is some uncertainty as to the diagnosis or pathology at the applicant's left wrist and elbow, a carpal tunnel syndrome and ulnar neuropathy at the elbow have been identified by A/Prof Smith as the most likely causes of the applicant's symptoms. 2. The applicant reported broadly the same symptoms to Dr Courtenay as were reported to his treating doctors and Dr Gehr. Dr Courtenay recorded slightly reduced measurements at the left forearm compared with the right limb. Although Dr Courtenay said this was not due to wasting but was consistent with the applicant being right hand dominant, it is unclear whether he took into account the evidence of a significant right shoulder condition and the reduced use of the right limb. Dr Courtenay acknowledged that the nerve conduction studies showed some ulnar neuritis and acknowledged the findings relating to the median nerve in the MRIs. 3. Despite this evidence, Dr Courtenay was not persuaded that there was any causal relationship to the injury on 15 October 2018 or any indication for surgical intervention. As I have noted above, Dr Courtenay's opinions in this regard appear to have been influenced by his assumptions as to the mechanism of injury and a three-year latency in the reporting of symptoms. Dr Courtenay placed weight on the lack of evidence of median carpal tunnel issues seen on the nerve conduction studies and the lack of MRI evidence of ulnar nerve involvement. Dr Courtenay explained the finger numbness by reference to there having been a "crush" injury, being a mechanism I have not accepted. 4. Dr Courtenay's opinion is contrary to the weight of evidence. 5. A/Prof Smith considered Dr Courtenay's reports and said he had considered for himself the relative sensitivity and specificity of all the tests and investigations that had been used. A/Prof Smith said it was not uncommon for people to have median nerve compression at the wrist level and yet have negative nerve conduction studies. The fact that the guided corticosteroid injection was helpful suggested that the carpal tunnel diagnosis was correct. With regard to the ulnar neuropathy, A/Prof Smith that noted the positive physical findings on examination as well as positive nerve conduction studies. 6. The reasons for the surgical intervention being proposed have been explained. Both Dr Gehr and Dr Hanna have expressed agreement with the proposal for surgical intervention. 7. The considerations set out in Rose and Diab have also been addressed. I am satisfied that the proposed surgery is an appropriate and a potentially effective treatment for the applicant's symptoms. The cost of the surgery is relatively modest. I am satisfied that it is an accepted or conventional treatment option for the applicant's conditions. The applicant has undergone multiple treatment modalities including physiotherapy, medication and injections without lasting benefit. No other alternative treatments have been suggested. 8. For all of these reasons, I am satisfied that the surgery proposed by A/Prof Smith is reasonably necessary as a result of the injury on 15 October 2018. There will be an order for the respondent to pay the costs of and incidental to the proposed surgery in accordance with s 60 of the 1987 Act.

1. The Application to Resolve a Dispute also includes a claim for incurred treatment expenses related to the consequential conditions at the applicant's wrist and elbow. In view of the findings above, I am satisfied that it is appropriate that a general order be made for the respondent to pay the applicant's reasonably necessary expenses relating to those conditions upon production of accounts, receipts and/or valid Medicare Notice of Charge in accordance with s 60 of the 1987 Act.

[1] The report of Dr Murray Hyde Page was relied on for the purposes of the history recorded only having regard to cl 44 of the Workers Compensation Regulation 2016.

[2] (1976) 50 ALJR 720.

[3] [1970] 2 NSWLR 238.

[4] [2009] NSWWCCPD 134.

[5] [2013] NSWWCCPD 4.

[6] [2016] NSWWCCPD 23.

[7] [2009] NSWWCCPD 134.

[8] [2012] NSWWCCPD 8.

[9] (1994) 10 NSWCCR 796 at [810].

[10] [2008] NSWCA 246.

[11] [1970] 2 NSWLR 238.

[12] [2014] NSWWCCPD 14.

[13] (1976) 50 ALJR 720.

[14] [1986] NSWCC 2; (1986) 2 NSWCCR 32 (Rose).

[15] [2014] NSWWCCPD 72.