eMedicine Specialties > Orthopedic Surgery > Hand & Upper Extremity

Scapholunate Advanced Collapse: Treatment

Author: Dimitrios Danikas, MD, Attending Plastic Surgeon, Bayhealth Medical Center
Coauthor(s): Steve Lee, MD, Physician in Plastic, Reconstructive, and Hand Surgery, Plastic Surgery, PLLC; Michael Neumeister, MD, FRCSC, Professor & Chairman - FACS - Director Hand/Microsurgery Fellowship - Division of Plastic Surgery, Southern Illinois University School of Medicine; Richard Brown, MD, FACS, Clinical Professor, Department of Surgery, Division of Plastic and Reconstructive Surgery, Southern Illinois University School of Medicine
Contributor Information and Disclosures

Updated: Sep 2, 2008

Treatment

Medical Therapy

It is not uncommon to encounter a patient with an asymptomatic scapholunate advanced collapse (SLAC) wrist.10 The patient should be informed of the problem but may not require any treatment. If symptomatic, the patient should be given the various options for treatment.

Mild symptomatic SLAC can often be managed nonoperatively with periodic steroid injections, splinting, and NSAIDs. If the grip strength registers more than 80% that of the uninvolved wrist and the condition is not significantly impairing, then living with the condition is a valid option.11

Surgical Therapy

Limited wrist fusion (SLAC reconstruction)

A scapholunate advanced collapse (SLAC) reconstruction involves scaphoid excision and arthrodesis of the capitate, lunate, hamate, and triquetrum.12 Two parallel dorsal transverse incisions, a lazy S, or a central longitudinal incision over the distal radiocarpal joint and styloid process is made. The extensor retinaculum is incised through the third dorsal compartment. The terminal branch of the posterior interosseous nerve in the floor of the fourth extensor compartment can be sacrificed as an adjunctive pain relief measure. The wrist capsule is opened over the capitolunate joint. The scaphoid is resected in piecemeal fashion. Articular cartilage and subchondral bone are removed from the capitate, lunate, hamate, and triquetrum. Care should be taken to maintain the anatomic relationship of the intercarpal intervals. Cancellous bone is harvested from the distal radius, the proximal ulna or, from the iliac crest.

Lunate dorsal intercalated segment instability (DISI) should be corrected, and 5 percutaneous Kirschner wires (K-wires) are used. Two wires are placed through the capitate into the lunate, one each through the hamate and triquetrum into the lunate, and a fifth wire through the triquetrum into capitate. Cancellous bone graft is packed between the interstices of the 4 bones.

A long arm splint is placed after the procedure. After a week, the splint is replaced with a long arm cast, which is maintained for 3 weeks. Then, a short arm cast is placed and maintained for an additional 2-4 weeks. The cast and wires are removed when fusion is evident on radiographs.

Some newer fixation methods of this 4-quadrant fusion include the use of intercalary screws and a dorsal carpal plate marketed especially for this fusion. It remains to be seen whether the increased cost of such devices results in improved outcomes. More solid fixation does allow the use of a short arm cast and an earlier initiation of wrist ROM therapy.13

Patients with radiolunate changes are not candidates for SLAC reconstruction. A wrist arthrodesis should be performed.

Proximal row carpectomy

Proximal row carpectomy (PRC) requires resection of the proximal row of wrist bones to allow articulation of the capitate within the lunate fossa.14  15   For a successful procedure, both the proximal capitate articular surface and the lunate fossa should ideally be free of pathology. The procedure is usually effective only when the disease is restricted to the radioscaphoid joint. PRC provides the best motion (average arc 71°) but may be associated with painful narrowing of radiocapitate joint. It is not indicated for stage 2 SLAC wrist. It may serve as a salvage procedure for stages 1A and 1B when limited wrist fusion is not indicated. Failure of PRC requires conversion to wrist arthrodesis.

A dorsal longitudinal or transverse incision is used. The extensor tendons are retracted. A longitudinal capsulotomy is extended radially and ulnarly. The capitate is identified, and its articular surface is inspected. In the presence of capitate degenerative changes, the procedure should not be performed. If both proximal capitate articular surface and lunate fossa are free of pathology, the scaphoid, lunate, and triquetrum are excised. Both radioscaphocapitate and long radiolunate ligaments are preserved. Wrist collapse follows, with placement of the capitate head in the lunate fossa along with radial deviation of the wrist. If impingement between the radial styloid and the trapezium is present, a limited radial styloidectomy is performed. The capsulotomy incision is closed snugly.

Following the procedure, the wrist is splinted for 4 weeks. Early active digital flexion and extension are recommended. ROM exercises start 4 weeks after the procedure. Strengthening exercises and heavy lifting may begin 3 months after the procedure.

Comparisons between PRC and other techniques can be found in Vanhove et al16 and Dacho et al.17   Van Riet and Bain present findings using memory staples in the three-corner wrist fusion technique.18


Total wrist arthrodesis

Total wrist fusion diminishes pain, but wrist function is sacrificed. Patients may have functional limitations interfering with lifestyle, and total fusion does not always result in complete pain relief.

Using a central, dorsal, longitudinal incision, the extensor retinaculum is incised. The incision is carried down to bone surface from middle finger metacarpal to distal radius, raising capsular and periosteal flaps. Articular cartilage and subchondral bone are resected from the radioscaphoid, radiolunate, lunocapitate, scaphocapitate, and middle finger carpometacarpal joints. The radioulnar joint should not be entered. The index finger carpometacarpal joint may also be opened for fusion. The radial metaphysis is generally used for the necessary cancellous bone graft and more distal harvest is not required.

Bone grafts are placed in the radiocarpal, midcarpal, and carpometacarpal fusion sites, and a wrist fusion plate is applied.19 The fusion plate is secured with screws at the middle finger metacarpal, the capitate, and the radius. Periosteal and capsular flaps are reapproximated. A short arm splint is applied until fusion can be seen on radiographs. Fusion is usually evident in 6-8 weeks.20,21

Total wrist arthroplasty

Total wrist arthroplasty is an alternative to diffuse arthrosis of the wrist, especially in rheumatoid arthritis and if bilateral disease is present.22 With bilateral disease, a combination of a total wrist arthroplasty and a contralateral total wrist fusion is an option. Numerous implants have been used; however, major complications of implant loosening and wear of the components are common.

Follow-up

For excellent patient education resources, visit eMedicine's Arthritis Center. Also, see eMedicine's patient education articles Carpal Tunnel Syndrome.

Complications

See Outcome and Prognosis.

More on Scapholunate Advanced Collapse

Overview: Scapholunate Advanced Collapse
Workup: Scapholunate Advanced Collapse
Treatment: Scapholunate Advanced Collapse
Follow-up: Scapholunate Advanced Collapse
Multimedia: Scapholunate Advanced Collapse
References
Further Reading
[ CLOSE WINDOW ]

References

  1. Watson HK, Ballet FL. The SLAC wrist: scapholunate advanced collapse pattern of degenerative arthritis. J Hand Surg [Am]. May 1984;9(3):358-65. [Medline].

  2. Sauerbier M, Bickert B, Trankle M, et al. [Surgical treatment possibilities of advanced carpal collapse (SNAC/SLAC wrist)]. Unfallchirurg. Jul 2000;103(7):564-71. [Medline].

  3. Schmitt R, Heinze A, Fellner F, et al. Imaging and staging of avascular osteonecroses at the wrist and hand. Eur J Radiol. Sep 1997;25(2):92-103. [Medline].

  4. Gong X, Lu LJ. What is the implication of scaphoid ring sign in advanced Kienböck's disease? Is it a sign of advanced carpal collapse or rotary scaphoid subluxation?. J Plast Reconstr Aesthet Surg. 2006;59(7):726-9. [Medline].

  5. Bednar MS, Light TR. Degenerative arthritis. In: Russell RC, ed. Hand Surgery. Vol 4. St Louis, Mo: Mosby; 2000.

  6. Watson HK, Ryu J. Evolution of arthritis of the wrist. Clin Orthop. Jan 1986;(202):57-67. [Medline].

  7. Chen C, Chandnani VP, Kang HS, et al. Scapholunate advanced collapse: a common wrist abnormality in calcium pyrophosphate dihydrate crystal deposition disease. Radiology. Nov 1990;177(2):459-61. [Medline].

  8. Taniguchi Y, Yoshida M, Tamaki T. X-ray characteristics of wrists in calcium pyrophosphate crystal deposition disease. Is pseudogout a major cause of scapholunate advanced collapse?. J Hand Surg [Br]. Oct 1997;22(5):659-61. [Medline].

  9. Nagle DJ. Artroscopy. In: Russell RC, ed. Hand Surgery. Vol 4. St Louis, Mo: Mosby; 2000.

  10. Fassler PR, Stern PJ, Kiefhaber TR. Asymptomatic SLAC wrist: does it exist?. J Hand Surg [Am]. Jul 1993;18(4):682-6. [Medline].

  11. Pilný J, Kubes J, Hoza P, Sprláková A, Hart R. [Consequennce of nontreatment scapholunate instability of the wrist]. Rozhl Chir. Dec 2006;85(12):637-40. [Medline].

  12. Kadji O, Duteille F, Dautel G, Merle M. [Four bone versus capito-lunate limited carpal fusion. Report of 40 cases]. Chir Main. Jan 2002;21(1):5-12. [Medline].

  13. Garcia-Lopez A, Perez-Ubeda MJ, Marco F, et al. A modified technique of four-bone fusion for advanced carpal collapse (SLAC/SNAC wrist). J Hand Surg [Br]. Aug 2001;26(4):352-4. [Medline].

  14. Tomaino MM, Miller RJ, Cole I, Burton RI. Scapholunate advanced collapse wrist: proximal row carpectomy or limited wrist arthrodesis with scaphoid excision?. J Hand Surg [Am]. Jan 1994;19(1):134-42. [Medline].

  15. Welby F, Alnot JY. [Resection of the first row of carpal bones: post-traumatic wrist and Kienbock''s disease]. Chir Main. Jun 2003;22(3):148-53. [Medline].

  16. Vanhove W, De Vil J, Van Seymortier P, Boone B, Verdonk R. Proximal row carpectomy versus four-corner arthrodesis as a treatment for SLAC (scapholunate advanced collapse) wrist. J Hand Surg Eur Vol. Apr 2008;33(2):118-25. [Medline].

  17. Dacho AK, Baumeister S, Germann G, Sauerbier M. Comparison of proximal row carpectomy and midcarpal arthrodesis for the treatment of scaphoid nonunion advanced collapse (SNAC-wrist) and scapholunate advanced collapse (SLAC-wrist) in stage II. J Plast Reconstr Aesthet Surg. Oct 19 2007;[Medline].

  18. van Riet RP, Bain GI. Three-corner wrist fusion using memory staples. Tech Hand Up Extrem Surg. Dec 2006;10(4):259-64. [Medline].

  19. Sauerbier M, Kania NM, Kluge S, et al. [Initial results of treatment with the new AO wrist joint arthrodesis plate]. Handchir Mikrochir Plast Chir. Jul 1999;31(4):260-5. [Medline].

  20. Kalb K, Ludwig A, Tauscher A, et al. [Treatment outcome after surgical arthrodesis]. Handchir Mikrochir Plast Chir. Jul 1999;31(4):253-9. [Medline].

  21. Ekelund L, Hagberg L, Hörberg L, Jörgsholm P, Gunnarsson M. Imaging of four-corner fusion (SLAC arthrodesis) of the wrist with 64-slice computed tomography. Acta Radiol. Feb 2007;48(1):76-9. [Medline].

  22. Masmejean E, Dutour O, Touam C, Oberlin C. [Bilateral SLAC (scapholunate advanced collapse) wrist: an unusual entity. Apropos of a 7000-year-old prehistoric case]. Ann Chir Main Memb Super. 1997;16(3):207-14. [Medline].

  23. Watson HK, Weinzweig J. Intercarpal arthrodesis. In: Green DP, Hotchkiss RN, Pederson WC, eds. Green's Operative Hand Surgery. Vol 1. Philadelphia, Pa: Churchill Livingstone; 1999.

  24. Brown RE, Erdmann D. Complications of 50 consecutive limited wrist fusions by a single surgeon. Ann Plast Surg. Jul 1995;35(1):46-53. [Medline].

  25. Krakauer JD, Bishop AT, Cooney WP. Surgical treatment of scapholunate advanced collapse. J Hand Surg [Am]. Sep 1994;19(5):751-9. [Medline].

  26. Wyrick JD, Stern PJ, Kiefhaber TR. Motion-preserving procedures in the treatment of scapholunate advanced collapse wrist: proximal row carpectomy versus four-corner arthrodesis. J Hand Surg [Am]. Nov 1995;20(6):965-70. [Medline].

  27. Imbriglia JE, Broudy AS, Hagberg WC, McKernan D. Proximal row carpectomy: clinical evaluation. J Hand Surg [Am]. May 1990;15(3):426-30. [Medline].

  28. Hastings H 2nd, Weiss AP, Quenzer D, et al. Arthrodesis of the wrist for post-traumatic disorders. J Bone Joint Surg Am. Jun 1996;78(6):897-902. [Medline].

  29. Weiss AC, Wiedeman G Jr, Quenzer D, et al. Upper extremity function after wrist arthrodesis. J Hand Surg [Am]. Sep 1995;20(5):813-7. [Medline].

  30. Dacho A, Grundel J, Holle G, Germann G, Sauerbier M. Long-term results of midcarpal arthrodesis in the treatment of scaphoid nonunion advanced collapse (SNAC-Wrist) and scapholunate advanced collapse (SLAC-Wrist). Ann Plast Surg. Feb 2006;56(2):139-44. [Medline].

[ CLOSE WINDOW ]

Further Reading

Forearm, wrist, & hand (acute & chronic), not including carpal tunnel syndrome. Work Loss Data Institute.  2004 (revised 2007 May 16).  80 pages. [NGC Update Pending] NGC:005799
 
Chronic wrist pain.
American College of Radiology.  1998 (revised 2005).  7 pages.  NGC:004619
 
Acute hand and wrist trauma.
American College of Radiology - Medical Specialty Society.  1998 (revised 2005).  8 pages.  NGC:004607

[ CLOSE WINDOW ]

Keywords

scapholunate advanced collapse, SLAC wrist, degenerative arthritis, scaphoid injury, scapholunate collapse, scapholunate dissociation, wrist pain, carpal tunnel syndrome, carpal ligament instability,  scaphoid fracture, wrist arthritis, arthritis of the wrist, wrist arthrodesis, periscaphoid arthritis, scaphoid nonunion advanced collapse, SNAC, Terry Thomas sign, carpal bone, scaphoid, lunate, hand bone, os lunatum, os scaphoideum, perilunate fracture dislocations, perilunate injuries

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Dimitrios Danikas, MD, Attending Plastic Surgeon, Bayhealth Medical Center
Dimitrios Danikas, MD is a member of the following medical societies: American Academy of Anti-Aging Medicine, American College of Surgeons, and American Society of Plastic Surgeons
Disclosure: Nothing to disclose.

Coauthor(s)

Steve Lee, MD, Physician in Plastic, Reconstructive, and Hand Surgery, Plastic Surgery, PLLC
Steve Lee, MD is a member of the following medical societies: American College of Surgeons and American Society of Plastic Surgeons
Disclosure: Nothing to disclose.

Michael Neumeister, MD, FRCSC, Professor & Chairman - FACS - Director Hand/Microsurgery Fellowship - Division of Plastic Surgery, Southern Illinois University School of Medicine
Michael Neumeister, MD, FRCSC is a member of the following medical societies: American Association for Hand Surgery, American Association of Plastic Surgeons, American Burn Association, American College of Surgeons, American Medical Association, American Society for Reconstructive Microsurgery, American Society for Surgery of the Hand, American Society of Plastic Surgeons, Association of Academic Chairmen of Plastic Surgery, Canadian Society of Plastic Surgeons, Illinois State Medical Society, Illinois State Medical Society, Ontario Medical Association, Plastic Surgery Research Council, Royal College of Physicians and Surgeons of Canada, and Society of University Surgeons
Disclosure: Nothing to disclose.

Richard Brown, MD, FACS, Clinical Professor, Department of Surgery, Division of Plastic and Reconstructive Surgery, Southern Illinois University School of Medicine
Disclosure: Nothing to disclose.

Medical Editor

A Lee Osterman, MD, Director of Hand Surgery Fellowship, Director, Philadelphia Hand Center; Director, Professor, Department of Orthopedic Surgery, Division of Hand Surgery, University Hospital, Thomas Jefferson University
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Michael Yaszemski, MD, PhD, Associate Professor, Departments of Orthopedic Surgery and Bioengineering, Mayo Foundation, Mayo Medical School
Disclosure: Nothing to disclose.

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD, Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami School of Medicine
Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, and Arkansas Medical Society
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.