Imaging Studies

Plain wrist radiographs (posteroanterior [PA], lateral, and oblique) are usually sufficient to make the diagnosis of scapholunate advanced collapse (SLAC) and permit staging.^[14](See the images below.) They can reveal joint narrowing, sclerosis, osteophytes, cysts, scapholunate dislocation, and carpal collapse.

Stage 2 scapholunate advanced collapse (SLAC) wrist.

View Media Gallery

Scapholunate advanced collapse (SLAC) wrist from Kienböck disease.

View Media Gallery

Early changes at the radioscaphoid articulation can appear as an elongated radial styloid process. The scaphoid may assume a vertical position with a cortical ring sign. In SLAC secondary to scapholunate dissociation, increased distance between the scaphoid and lunate, as well as lunate ulnar translocation, will be obvious. A lateral view can show an increase in the scapholunate angle with a dorsiflexion of the lunate (dorsal intercalated segment instability [DISI] deformity).

As the disease progresses, the whole radioscaphoid joint becomes narrowed. In subtle cases, PA and lateral wrist computed tomography (CT) can reveal these joint changes.

For imaging of the skeletal morphology or occult fracture, CT (particularly multidetector CT [MDCT]) is most useful.^[14]CT arthrography can help identify ligament tears.

Magnetic resonance imaging (MRI) and MR arthrography provide excellent imaging of osseous and soft tissues.^[14]If avascularity is a concern, then MRI is the best imaging modality.

Arthroscopy

Nagle recommended staging wrist arthroscopy for articular surface evaluation on the grounds that lunate fossa changes may be present in advanced cases of SLAC wrist but may not be appreciated on plain radiography.^[15]Because scaphoid resection and ulnar column fusion are contraindicated in the presence of lunate fossa degenerative changes, accurate assessment of the radiolunate joint is critical for correct surgical planning. When necessary, staging arthroscopy is performed as part of the definitive procedure.

Treatment & Management

Lane R, Tafti D, Varacallo M. Scapholunate Advanced Collapse (SLAC Wrist). Treasure Island, FL: StatPearls; 2021. [Full Text].
Watson HK, Ballet FL. The SLAC wrist: scapholunate advanced collapse pattern of degenerative arthritis. J Hand Surg Am. 1984 May. 9 (3):358-65. [QxMD MEDLINE Link].
Sauerbier M, Bickert B, Tränkle M, Kluge S, Pelzer M, Germann G. [Surgical treatment possibilities of advanced carpal collapse (SNAC/SLAC wrist)]. Unfallchirurg. 2000 Jul. 103 (7):564-71. [QxMD MEDLINE Link].
Schmitt R, Heinze A, Fellner F, Obletter N, Strühn R, Bautz W. Imaging and staging of avascular osteonecroses at the wrist and hand. Eur J Radiol. 1997 Sep. 25 (2):92-103. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Wolfe SW, Kakar S. Carpal instability. Wolfe SW, Pederson WC, Kozin SH, Cohen MS, eds. Green's Operative Hand Surgery. 8th ed. Philadelphia: Elsevier; 2022. Vol 1: 439-87.
Watson HK, Ryu J. Evolution of arthritis of the wrist. Clin Orthop Relat Res. 1986 Jan. (202):57-67. [QxMD MEDLINE Link].
Chen C, Chandnani VP, Kang HS, Resnick D, Sartoris DJ, Haller J. Scapholunate advanced collapse: a common wrist abnormality in calcium pyrophosphate dihydrate crystal deposition disease. Radiology. 1990 Nov. 177 (2):459-61. [QxMD MEDLINE Link].
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. 1997 Oct. 22 (5):659-61. [QxMD MEDLINE Link].
Murphy BD, Nagarajan M, Novak CB, Roy M, McCabe SJ. The Epidemiology of Scapholunate Advanced Collapse. Hand (N Y). 2020 Jan. 15 (1):23-26. [QxMD MEDLINE Link].
Traverso P, Wong A, Wollstein R, Carlson L, Ashmead D, Watson HK. Ten-Year Minimum Follow-Up of 4-Corner Fusion for SLAC and SNAC Wrist. Hand (N Y). 2017 Nov. 12 (6):568-572. [QxMD MEDLINE Link].
Rimokh J, Benazech B, Lebeau N, Haddad B, Moughabghab M, David E. Clinical and radiological outcomes of 40 cases of SLAC and SNAC wrist treated by four-corner arthrodesis with locking plate. Hand Surg Rehabil. 2020 Feb. 39 (1):36-40. [QxMD MEDLINE Link].
Andronic O, Nagy L, Burkhard MD, Casari FA, Karczewski D, Kriechling P, et al. Long-term outcomes of the four-corner fusion of the wrist: A systematic review. World J Orthop. 2022 Jan 18. 13 (1):112-121. [QxMD MEDLINE Link]. [Full Text].
Kompoliti E, Prodromou M, Karantanas AH. SLAC and SNAC Wrist: The Top Five Things That General Radiologists Need to Know. Tomography. 2021 Sep 23. 7 (4):488-503. [QxMD MEDLINE Link]. [Full Text].
Nagle DJ. Arthroscopy. Russell RC, ed. Hand Surgery. St Louis: Mosby; 2000. Vol 4:
Noback PC, Seetharaman M, Danoff JR, Birman M, Rosenwasser MP. Arthroscopic Wrist Debridement and Radial Styloidectomy for Advanced Scapholunate Advanced Collapse Wrist: Long-term Follow-up. Hand (N Y). 2018 Nov. 13 (6):659-665. [QxMD MEDLINE Link].
Fassler PR, Stern PJ, Kiefhaber TR. Asymptomatic SLAC wrist: does it exist?. J Hand Surg Am. 1993 Jul. 18 (4):682-6. [QxMD MEDLINE Link].
Pilný J, Kubes J, Hoza P, Sprláková A, Hart R. [Consequennce of nontreatment scapholunate instability of the wrist]. Rozhl Chir. 2006 Dec. 85 (12):637-40. [QxMD MEDLINE Link].
Kadji O, Duteille F, Dautel G, Merle M. [Four bone versus capito-lunate limited carpal fusion. Report of 40 cases]. Chir Main. 2002 Jan. 21 (1):5-12. [QxMD MEDLINE Link].
Garcia-López A, Perez-Ubeda MJ, Marco F, Molina M, López-Duran L. A modified technique of four-bone fusion for advanced carpal collapse (SLAC/SNAC wrist). J Hand Surg Br. 2001 Aug. 26 (4):352-4. [QxMD MEDLINE Link].
Tielemans A, Van Innis F, Troussel S, Detrembleur C, Libouton X, Lequint T. Effect of four-corner fusion with locking plate without bone graft on functional recovery of the wrist: New treatment guidelines. Hand Surg Rehabil. 2017 Jun. 36 (3):186-191. [QxMD MEDLINE Link].
Baur EM. Arthroscopic-Assisted Partial Wrist Arthrodesis. Hand Clin. 2017 Nov. 33 (4):735-753. [QxMD MEDLINE Link].
Vihanto A, Kotkansalo T, Pääkkönen M. The Learning Curve and Pitfalls of Arthroscopic Four-Corner Arthrodesis. J Wrist Surg. 2019 Jun. 8 (3):202-208. [QxMD MEDLINE Link].
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. 1994 Jan. 19 (1):134-42. [QxMD MEDLINE Link].
Welby F, Alnot JY. [Resection of the first row of carpal bones: post-traumatic wrist and Kienbock's disease]. Chir Main. 2003 Jun. 22 (3):148-53. [QxMD MEDLINE Link].
Laulan J, Marteau E, Bacle G. Wrist osteoarthritis. Orthop Traumatol Surg Res. 2015 Feb. 101 (1 Suppl):S1-9. [QxMD MEDLINE Link].
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. 2008 Apr. 33 (2):118-25. [QxMD MEDLINE Link].
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. 2008 Oct. 61 (10):1210-8. [QxMD MEDLINE Link].
van Riet RP, Bain GI. Three-corner wrist fusion using memory staples. Tech Hand Up Extrem Surg. 2006 Dec. 10 (4):259-64. [QxMD MEDLINE Link].
Ahmadi AR, Duraku LS, van der Oest MJW, Hundepool CA, Selles RW, Zuidam JM. The never-ending battle between proximal row carpectomy and four corner arthrodesis: A systematic review and meta-analysis for the final verdict. J Plast Reconstr Aesthet Surg. 2021 Oct 23. [QxMD MEDLINE Link]. [Full Text].
Sauerbier M, Kania NM, Kluge S, Bickert B, Germann G. [Initial results of treatment with the new AO wrist joint arthrodesis plate]. Handchir Mikrochir Plast Chir. 1999 Jul. 31 (4):260-5. [QxMD MEDLINE Link].
Kalb K, Ludwig A, Tauscher A, Landsleitner B, Wiemer P, Krimmer H. [Treatment outcome after surgical arthrodesis]. Handchir Mikrochir Plast Chir. 1999 Jul. 31 (4):253-9. [QxMD MEDLINE Link].
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. 2007 Feb. 48 (1):76-9. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Mosillo G, Basso MA, Balato G, Bernasconi A, Coviello A, Tamborini F, et al. Adaptive proximal scaphoid implant (APSI): a systematic review of the literature. Orthop Rev (Pavia). 2021 Dec 11. 14 (1):30721. [QxMD MEDLINE Link].
Watson HK, Weinzweig J. Intercarpal arthrodesis. Green DP, Hotchkiss RN, Pederson WC, eds. Green's Operative Hand Surgery. Philadelphia: Churchill Livingstone; 1999. Vol 1:
Brown RE, Erdmann D. Complications of 50 consecutive limited wrist fusions by a single surgeon. Ann Plast Surg. 1995 Jul. 35 (1):46-53. [QxMD MEDLINE Link].
Krakauer JD, Bishop AT, Cooney WP. Surgical treatment of scapholunate advanced collapse. J Hand Surg Am. 1994 Sep. 19 (5):751-9. [QxMD MEDLINE Link].
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. 1995 Nov. 20 (6):965-70. [QxMD MEDLINE Link].
Imbriglia JE, Broudy AS, Hagberg WC, McKernan D. Proximal row carpectomy: clinical evaluation. J Hand Surg Am. 1990 May. 15 (3):426-30. [QxMD MEDLINE Link].
Mantovani G, Mathoulin C, Fukushima WY, Cho AB, Aita MA, Argintar E. Four corner arthrodesis limited to the centre using a scaphoid one piece graft and a dorsal circular plate. J Hand Surg Eur Vol. 2010 Jan. 35 (1):38-42. [QxMD MEDLINE Link].
Mulford JS, Ceulemans LJ, Nam D, Axelrod TS. Proximal row carpectomy vs four corner fusion for scapholunate (Slac) or scaphoid nonunion advanced collapse (Snac) wrists: a systematic review of outcomes. J Hand Surg Eur Vol. 2009 Apr. 34 (2):256-63. [QxMD MEDLINE Link].
Gaston RG, Greenberg JA, Baltera RM, Mih A, Hastings H. Clinical outcomes of scaphoid and triquetral excision with capitolunate arthrodesis versus scaphoid excision and four-corner arthrodesis. J Hand Surg Am. 2009 Oct. 34 (8):1407-12. [QxMD MEDLINE Link].
Ferreres A, Garcia-Elias M, Plaza R. Long-term results of lunocapitate arthrodesis with scaphoid excision for SLAC and SNAC wrists. J Hand Surg Eur Vol. 2009 Oct. 34 (5):603-8. [QxMD MEDLINE Link].
Kiefhaber TR. Management of scapholunate advanced collapse pattern of degenerative arthritis of the wrist. J Hand Surg Am. 2009 Oct. 34 (8):1527-30. [QxMD MEDLINE Link].
Hastings H 2nd, Weiss AP, Quenzer D, Wiedeman GP, Hanington KR, Strickland JW. Arthrodesis of the wrist for post-traumatic disorders. J Bone Joint Surg Am. 1996 Jun. 78 (6):897-902. [QxMD MEDLINE Link].
Weiss AC, Wiedeman G Jr, Quenzer D, Hanington KR, Hastings H 2nd, Strickland JW. Upper extremity function after wrist arthrodesis. J Hand Surg Am. 1995 Sep. 20 (5):813-7. [QxMD MEDLINE Link].
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. 2006 Feb. 56 (2):139-44. [QxMD MEDLINE Link].

Media Gallery

Stage 2 scapholunate advanced collapse (SLAC) wrist.
Scapholunate advanced collapse (SLAC) wrist from Kienböck disease.
Scapholunate advanced collapse (SLAC) wrist from nonunion of the scaphoid. The patient underwent 4-bone fusion.
Scapholunate advanced collapse (SLAC) wrist from nonunion of the scaphoid. The patient underwent 4-bone fusion.
Scapholunate advanced collapse (SLAC) wrist treated with total wrist fusion.
Scapholunate advanced collapse (SLAC) wrist treated with total wrist fusion.
Stage 2 scapholunate advanced collapse (SLAC) wrist treated with 4-bone fusion.
Stage 2 scapholunate advanced collapse (SLAC) wrist treated with 4-bone fusion.

of 8

Author

Dimitrios Danikas, MD, FACS Attending Plastic Surgeon, Pikeville Medical Center

Dimitrios Danikas, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society for Aesthetic Plastic Surgery, American Society of Plastic Surgeons, American Academy of Anti-Aging Medicine, Northeastern 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, American Society of Plastic Surgeons

Disclosure: Nothing to disclose.

Michael Neumeister, MD, FRCSC, FACS Chairman, Professor, Division of Plastic Surgery, Director of Hand/Microsurgery Fellowship Program, Chief of Microsurgery and Research, Institute of Plastic and Reconstructive Surgery, Southern Illinois University School of Medicine

Michael Neumeister, MD, FRCSC, FACS is a member of the following medical societies: American Association for Hand Surgery, American Burn Association, American College of Surgeons, American Medical Association, American Society for Surgery of the Hand, American Society of Plastic Surgeons, American Society for Reconstructive Microsurgery, 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, Society of University Surgeons, American Council of Academic Plastic 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.

Sotirios Papafragkou, MD Chair, Department of Surgery, Hand and Microvascular Surgery, Northern Maine Medical Center

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

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, Leonard M Miller School of Medicine; Clinical Professor of Surgery, Nova Southeastern 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, Arkansas Medical Society, Florida Medical Association, Florida Orthopaedic Society

Disclosure: Nothing to disclose.

Additional Contributors

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.

Acknowledgements

The authors and editors gratefully acknowledge the contributions to this topic made by Mark F. Hendrickson, MD.

Sections Scapholunate Advanced Collapse (SLAC)
Overview
Presentation
DDx
Workup
Treatment
Media Gallery
References

Scapholunate Advanced Collapse (SLAC) Workup

Imaging Studies

Arthroscopy

References

Tables

Contributor Information and Disclosures

What would you like to print?