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P R E S E N T E D B Y :
D R . N . B E N T H U N G O T U N G O E
P . G , M S ( O R T H O P E D I C S )
C E N T R A L I N S ...
INTRODUCTION
 Scapholunate advanced collapse (SLAC) and
scaphoid nonunion advanced collapse (SNAC) are
the two most commo...
ETIOLOGY OF SLAC
 TRAUMATIC CAUSES:
 Scaphoid fracture non union,
 Scapholunate ligament dissosciation
 ATRAUMATIC CAU...
SCAPHO LUNATE LIGAMENTOUS COMPLEX
 The scapholunate ligament complex is a U-
shaped ligamentous complex joining thelunate...
 Dorsal component
 blends with joint capsule, scaphotriquetral and intercarpal
ligaments
 strongest portion of the comp...
 Intermediate/interosseous component
 located proximally and centrally and therefore may be
referred to as the central o...
RADIOGRAPHIC FEATURES
 The pattern is that of a progressive osteoarthritis
affecting initially the articulation between t...
SCAPHOLUNATE DISSOSCIATION(TERRY
THOMAS SIGN)
SLAC
Watson staging (often used by hand surgeons)
 I: osteoarthritis of the articulation between the radial styloid
and the sc...
SURGICAL TREATMENT
 Surgical treatment for SLAC wrist includes
 four-corner arthrodesis,
 capitolunate arthrodesis,
 c...
SNAC(scaphoid non union advcance collapse)
 In a SNAC wrist, the proximal scaphoid fragment
usually remains attached to t...
Jupiter et al classification of non union
based on the extent of arthosis:
1. nonunions without arthrosis,
2. nonunions wi...
Radiographic findings of SNAC
 radioscaphoid narrowing,
 capitolunate narrowing,
 cyst formation,
 pronounced dorsal i...
Effect of SLAC & SNAC ON JOINT
KINEMATICS:
 Both of these processes lead to abnormal joint
kinematics, since the lunate i...
DISI(dorsal intercalated segment instability )
CAUSES:
1. wrist trauma +/- fracture
 Scaphoid fracture: bony DISI
 dista...
Radiographic features
 On an AP view the normal trapezoidal configuration
of the scaphoid may be lost and it may appear
t...
DIFFERENTIAL DIAGNOSIS
 CARPAL TUNNEL SYNDROME
 TRIGGER FINGER
 DE QUERVANS TENOSYNOVITIS
 FCR TENDONITIS
NON OPERATIVE MANAGEMENT
 WRIST IMMOBILIZATION WITH SPLINTS
 NSAIDS
 CORTICO STEROIDS INJECTIONS
OPERATIVE MANAGEMENT
 RADIAL STYLOIDECTOMY
 WRIST DENERVATION
 SCAPHOID EXCISION
 PROXIMAL ROW CARPECTOMY
 ARTHODESIS...
Four corner arthodesis
THANK YOU
SLAC & SNAC WRIST
SLAC & SNAC WRIST
SLAC & SNAC WRIST
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SLAC & SNAC WRIST

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SLAC & SNAC WRIST

  1. 1. P R E S E N T E D B Y : D R . N . B E N T H U N G O T U N G O E P . G , M S ( O R T H O P E D I C S ) C E N T R A L I N S T I T U T E O F O R T H O P E D I C S V M M C & S A F D A R J U N G H O S P I T A L N E W D E L H I SNAC & SLAC WRIST
  2. 2. INTRODUCTION  Scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) are the two most common patterns of post-traumatic wrist arthritis.
  3. 3. ETIOLOGY OF SLAC  TRAUMATIC CAUSES:  Scaphoid fracture non union,  Scapholunate ligament dissosciation  ATRAUMATIC CAUSES:  CPPD(calcium pyro phosphate dehydrate) diseases  Rheumatoid arthritis  Neuropathic diseases  Beta 2 microglobulin assosciated amyloid deposition disease
  4. 4. SCAPHO LUNATE LIGAMENTOUS COMPLEX  The scapholunate ligament complex is a U- shaped ligamentous complex joining thelunate and the scaphoid.  It is divided into dorsal, volar and intermediate components with surrounding secondary stabilisers.
  5. 5.  Dorsal component  blends with joint capsule, scaphotriquetral and intercarpal ligaments  strongest portion of the complex  controls flexion/extension  Volar component  oblique collagen fibres  blends with extrinsic volar radioscapholunate ligament  controls rotational motion  major proprioceptive role
  6. 6.  Intermediate/interosseous component  located proximally and centrally and therefore may be referred to as the central or proximal component  fibrocartilage  weakest portion of the complex  extends a few millimeters into the joint, akin to a meniscus  Secondary stabilisers  scapho-trapezial-trapezoidal ligament  radio-scapho-capitiate ligament
  7. 7. RADIOGRAPHIC FEATURES  The pattern is that of a progressive osteoarthritis affecting initially the articulation between the radial styloid and the scaphoid. In later stages of the disease, osteoarthritis affects the whole radioscaphoid articulation, then the articulation between lunate and capitate. Finally it may involve other intercarpal joints. In addition there is widening of the space between scaphoid and lunate as well as proximal migration of the scaphoid and the capitate  CT FINDINGS: angulations of the scaphoid and lunate bones (increased scapholunate angle and dorsal or volar intercalated segment instability deformity), radioscaphoid incongruity, cartilage loss, and subchondral bone degenerative changes.
  8. 8. SCAPHOLUNATE DISSOSCIATION(TERRY THOMAS SIGN)
  9. 9. SLAC
  10. 10. Watson staging (often used by hand surgeons)  I: osteoarthritis of the articulation between the radial styloid and the scaphoid  II: osteoarthritis involving the whole radioscaphoid articulation  III: osteoarthritis of the radioscaphoid and capitolunate articulations  IV: osteoarthritis of the radiocarpal and intercarpal articulations +/- distal radioulnar joint (DRUJ)  NOTE: Note that the radiolunate joint is almost preserved until very last stages of the disease. It is also worth noting that the scaphoid fossa in the radius may be deep / preserved in cases of CPPD in contrast to post-traumatic SLAC wris
  11. 11. SURGICAL TREATMENT  Surgical treatment for SLAC wrist includes  four-corner arthrodesis,  capitolunate arthrodesis,  complete wrist arthrodesis, scaphoidectomy,  proximal row carpectomy (PRC),  denervation,  radial styloidectomy
  12. 12. SNAC(scaphoid non union advcance collapse)  In a SNAC wrist, the proximal scaphoid fragment usually remains attached to the lunate (which rotate together during extension), while the distal scaphoid fragment rotates into flexion. This results in abnormal contact in the radioscaphoid compartment, characterised by early styloid osteoarthritis between the distal scaphoid fragment and the radial styloid process
  13. 13. Jupiter et al classification of non union based on the extent of arthosis: 1. nonunions without arthrosis, 2. nonunions with radiocarpal arthrosis, 3. nonunions with advanced radiocarpal and intercarpal arthrosis
  14. 14. Radiographic findings of SNAC  radioscaphoid narrowing,  capitolunate narrowing,  cyst formation,  pronounced dorsal intercalated segment instability(DISI)  Note: The radiolunate joint usually is spared in early stages but may show degenerative changes as the arthritis becomes more diffuse.
  15. 15. Effect of SLAC & SNAC ON JOINT KINEMATICS:  Both of these processes lead to abnormal joint kinematics, since the lunate is unrestrained by the distal scaphoid and, therefore, assumes an extended posture.  Over time, this may result in a dorsal intercalated segment instability (DISI) deformity, which invariably progresses to degenerative arthritis at the radioscaphoid articulation, followed by carpal collapse and midcarpal arthritis
  16. 16. DISI(dorsal intercalated segment instability ) CAUSES: 1. wrist trauma +/- fracture  Scaphoid fracture: bony DISI  distal radius fracture: compensatory DISI  radius malunion: adaptive DISI 2.Scapholunate ligament sissosciation: ligamentous DISI
  17. 17. Radiographic features  On an AP view the normal trapezoidal configuration of the scaphoid may be lost and it may appear triangular.  On lateral plain film typically shows a dorsal tilt of the lunate:  scapholunate angle > 60º: sign of scapholunate ligament dissociation  capitolunate angle > 30º: the capitate is displaced posteriorly compared to the distal radius
  18. 18. DIFFERENTIAL DIAGNOSIS  CARPAL TUNNEL SYNDROME  TRIGGER FINGER  DE QUERVANS TENOSYNOVITIS  FCR TENDONITIS
  19. 19. NON OPERATIVE MANAGEMENT  WRIST IMMOBILIZATION WITH SPLINTS  NSAIDS  CORTICO STEROIDS INJECTIONS
  20. 20. OPERATIVE MANAGEMENT  RADIAL STYLOIDECTOMY  WRIST DENERVATION  SCAPHOID EXCISION  PROXIMAL ROW CARPECTOMY  ARTHODESIS  Four corner arthodesis  Capito-lunate arthodesis  Wrist arthodesis
  21. 21. Four corner arthodesis
  22. 22. THANK YOU

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