Updated: 11/16/2022

Scaphoid Lunate Advanced Collapse (SLAC)

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  • Summary
    • Scaphoid Lunate Advanced Collapse (SLAC) describes the specific pattern of degenerative arthritis seen in chronic dissociation between the scaphoid and lunate.
    • Diagnosis is made clinically with progressive wrist pain and wrist instability with radiographs showing advanced arthritis of the radiocarpal and midcarpal joints (radiolunate joint spared).
    • Treatment involves observation, NSAIDs and splinting in early stages of disease. A variety of operative procedures may be indicated depending on severity of disease and patient's symptoms.
  • Etiology
    • Pathoanatomy
      • chronic SL ligament injury creates a DISI deformity
        • scaphoid is flexed and lunate is extended as scapholunate ligament no longer restrains this articulation
          • scapholunate angle > 70 degrees
          • lunate extended > 10 degrees past neutral
      • resultant scaphoid flexion and lunate extension creates
        • abnormal distribution of forces across midcarpal and radiocarpal joints
        • malalignment of concentric joint surfaces
      • initially affects the radioscaphoid joint and progresses to capitolunate joint
        • notably the radiolunate joint is spared
  • Classification
    • Watson classification
      • describes predictable progression of degenerative changes from the radial styloid to the entire scaphoid facet and finally to the unstable capitolunate joint, as the capitate subluxates dorsally on the lunate
      • key finding is that the radiolunate joint is spared, unlike other forms of wrist arthritis, since there remains a concentric articulation between the lunate and the spheroid lunate fossa of the distal radius
        • Watson Classification
        • Stage I
        • Arthritis between scaphoid and radial styloid
        • Stage II
        • Arthritis between scaphoid and entire scaphoid facet of the radius
        • Stage III
        • Arthritis between capitate and lunate
        • note: radiolunate joint spared
    • While original Watson classification describes preservation of radiolunate joint in all stages of SLAC wrist, subsequent description by other surgeons of "stage IV" pancarpal arthritis observed in rare cases where radiolunate joint is affected
      • validity of "stage IV" changes in SLAC wrist remains controversial and presence pancarpal arthritis should alert the clinician of a different etiology of wrist arthritis
  • Presentation
    • Symptoms
      • difficulty bearing weight across wrist
      • patients localize pain in region of scapholunate interval
      • progressive weakness of affected hand
      • wrist stiffness
    • Physical exam
      • tenderness directly over scapholunate ligament dorsally
      • decreased wrist ROM
      • weakness of grip strength
      • Watson scaphoid shift test
        • patients may have positive Watson scaphoid shift test early in the process,
        • will not be positive in more advanced cases as arthritic changes stabilize the scaphoid
        • technique
          • with firm pressure over the palmar tuberosity of the scaphoid, wrist is moved from ulnar to radial deviation
          • positive test seen in patients with scapholunate ligament injury or patients with ligamentous laxity, where the scaphoid is no longer constrained proximally and subluxates out of the scaphoid fossa resulting in pain
          • when pressure removed from the scaphoid, the scaphoid relocates back into the scaphoid fossa, and typical snapping or clicking occurs
          • must compare to contralateral side
  • Imaging
    • Radiographs
      • obtain standard PA and lateral radiographs
        • PA radiograph will reveal greater than 3mm diastasis between the scaphoid and lunate
          • Stage I SLAC wrist
            • PA radiograph shows radial styloid beaking, sclerosis and joint space narrowing between scaphoid and radial styloid
          • Stage II SLAC wrist
            • PA radiograph shows sclerosis and joint space narrowing between scaphoid and the entire scaphoid fossa of distal radius
          • Stage III SLAC wrist
            • PA radiograph shows sclerosis and joint space narrowing between the lunate and capitate, and the capitate will eventually migrate proximally into the space created by the scapholunate dissociation
        • lateral radiograph
          • will reveal DISI deformity and subluxation of capitate dorsally onto lunate
      • stress radiographs unnecessary
    • MRI
      • unnecessary for staging, but will show
        • thinning of articular surfaces of the proximal scaphoid
        • scaphoid facet of distal radius and capitatolunate joint with synovitis in radiocarpal and midcarpal joints
  • Differential
    • SNAC wrist 
  • Treatment
    • Nonoperative
      • NSAIDs, wrist splinting, and possible corticosteroid injections
        • indications
          • mild disease
    • Operative
      • radial styloidectomy
        • indications
          • Stage I SLAC
        • technique
          • removes symptomatic impingement between proximal scaphoid and radial styloid
          • may be performed open or arthroscopically via 1,2 portal for instrumentation
      • PIN and AIN denervation
        • indications
          • Stage I SLAC
        • technique
          • since posterior and anterior interosseous nerve only provide proprioception and sensation to wrist capsule at their most distal branches, they can be safely dennervated to provide pain relief
          • can be used in combination with below procedures for Stage II or III
      • proximal row carpectomy
        • indications
          • Stage II SLAC
        • contraindications
          • contraindicated with caputolunate arthritis (Stage III SLAC) because capitate articulates with lunate fossa of the distal radius
          • contraindicated if there is an incompetent radioscaphocapitate ligament
        • technique
          • excising entire proximal row of carpal bones (scaphoid, lunate and triquetrum) while preserving radioscaphocapitate ligament (to prevent ulnar subluxation after proximal row carpectomy)
        • outcomes
          • provides relative preservation of strength and motion
      • scaphoid excision and four corner fusion
        • indications
          • Stage II or III SLAC
        • technique
          • also provides relative preservation of strength and motion
          • wrist motion occurs through the preserved articulation between lunate and distal radius (lunate fossa)
        • outcomes
          • similar long term clinical results between scaphoid excision/ four corner fusion and proximal row carpectomy
      • wrist fusion
        • indications
          • Stage III SLAC
          • any form of pancarpal arthritis
        • outcomes
          • wrist fusion gives best pain relief and good grip strength at the cost of wrist motion

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(SBQ17SE.76) A 54-year-old Bavarian baker presents to your clinic 5 years after undergoing a Radio-Scapho-Lunate (RSL) fusion for post-traumatic osteoarthritis of the wrist. He has persistent pain and significantly decreased range of motion about the wrist, particularly after a long day in the bakery or when applying his lederhosen. On exam, he has noticeably weaker grip strength and poor motion, particularly in radial deviation, compared to his contralateral wrist. A current radiograph of the affected wrist is seen in Figure A. What additional surgical step, performed at the time of the index RSL fusion, may have prevented this outcome?

QID: 211941
FIGURES:

Excision of the distal pole of the scaphoid

53%

(605/1150)

Excision of the proximal pole of the scaphoid

21%

(236/1150)

Excision of the proximal pole of the capitate

7%

(76/1150)

Excision of the scaphoid, lunate, and triquetrum

12%

(140/1150)

No additional surgical adjuvant may have prevented this complication

8%

(88/1150)

L 5 A

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(SBQ17SE.71) A 45 year old dairy farmer from rural Michigan returns to a local hand surgeon with wrist pain, loss of motion, and loss of strength despite previously receiving an injection for this condition. His radiographs are shown in Figure 1. Surgical options are discussed with the farmer. Degeneration of which joint is a contraindication to a proximal row carpectomy?

QID: 211886
FIGURES:

Scaphoid - radial styloid

2%

(25/1108)

Scaphoid - radius

5%

(54/1108)

Scaphoid - capitate

15%

(171/1108)

Scaphoid - lunate

3%

(36/1108)

Capitate - lunate

74%

(817/1108)

L 2 A

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(SBQ17SE.65) A 35-year-old female presents after a fall on an outstretched hand with the injury shown in figures A & B. What articulation is expected to develop osteoarthritis in the third stage of scapholunate advanced collapse (SLAC)?

QID: 211820
FIGURES:

Radiolunate

10%

(159/1647)

Capitolunate

71%

(1166/1647)

Radial styloid and scaphoid

5%

(83/1647)

Entire radioscaphoid

8%

(128/1647)

Lunotriquetral

6%

(103/1647)

N/A A

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(SBQ17SE.12) A 52-year-old farmer’s periodic wrist pain has been managed with non-operative modalities to include two injections in the last 8 months. A recent imaging study is seen in Figure A. The patient now reports increasing pain and inability to use his wrist. The next best step in management would be:

QID: 211237
FIGURES:

Scapho-capitate fusion

4%

(68/1933)

Distal pole scaphoid excision

6%

(111/1933)

Total wrist arthroplasty

2%

(35/1933)

Scaphoid excision and four-corner fusion

65%

(1250/1933)

Proximal row carpectomy

23%

(454/1933)

L 3 A

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(OBQ12.163) A 65-year-old man fell and injured his right wrist. Radiographs taken in the emergency room are seen in Figure A. He was treated as a sprain and no further follow-up was planned. He sustained 2 minor falls over the next 6 years and his wrist pain recurred. Recent radiographs are seen in Figure B. Surgical treatment that will best address his symptoms and preserve wrist motion consists of

QID: 4523
FIGURES:

Anterior and posterior interosseous neurectomy

3%

(203/6534)

Scaphotrapezialtrapezoidal (STT) fusion

9%

(609/6534)

Complete wrist arthrodesis

1%

(96/6534)

Proximal row carpectomy

32%

(2095/6534)

Four-corner fusion with scaphoidectomy

54%

(3499/6534)

L 4 C

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(OBQ04.38) A 45-year-old male sustained a fall onto his right wrist 2 weeks ago. A radiograph is shown in figure A. What joint is first affected if left untreated with subsequent development of a SLAC (scapholunate advanced collapse) wrist?

QID: 99
FIGURES:

Capitolunate joint

5%

(202/4454)

Radioscaphoid

83%

(3713/4454)

Radioulnar

1%

(24/4454)

Radiolunate

8%

(352/4454)

STT (scaphotrapezotrapezoidal)

3%

(141/4454)

L 1 C

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