Carpal

Instability
and Scaphoid fracture :
fracture acute
non-union
SNAC

Scapholunate
Dissociation :
Occult/Dynamic/Static
SLAC
Outline
 Scapholunate dissociation (SLD)
 Occult/Dynamic/Static
 Scapholunate advanced collapse(SLAC)

 Scaphoid fracture
 Acute scaphoid fracture
 Scaphoid non-union
 Scaphoid non-union advanced collapse(SNAC)

 Dorsal intercalated segment instability (DISI)

 Volar intercalated segment instability (VISI)
 Mayo classification
Scaphoid fracture

Unstable
• >1 mm of fracture displacement
• Lateral intrascaphoid angle of >35 deg.
• Bone loss / comminution
• Proximal pole fractures
• Perilunate fracture-dislocation
• DISI deformity
scapholunate angle > 60 degrees
capitolunate angle > 15 degrees
Scaphoid fracture
Acute scaphoid fracture, treatment options

Green
Scaphoid fracture
Scaphoid non-union, treatment options

Green
Scaphoid fracture
Scaphoid non-union, treatment options

Non-Vascularized bone graft

• Matti Technique (Cancellous)
• Russe Technique (Cortical)
• Matti-Russe Technique (Cancellous + Cortical)
• Hybrid Russe Procedure (Cancellous + Cortical + Screw)

when to use vascularized bone grafting

Vascularized bone graft is controversial
“many authors discuss using it for AVN when
there is lack of punctate bleeding intra-op”

• 1,2 intercompartmental supraretinacular artery (ICSRA) pedicle(Zaidemberg)

• Pedicled on the volar carpal artery (Mathoulin)
• Dorsal capsular pedicle (Sotereanos)
• Free medial femoral condyle graft (Doi, Bishop and Shin,Higgins)

Green
Scaphoid non-union
Scaphoid non-union advanced collapse(SNAC)

 the proximal scaphoid fragment usually remains

attached to the lunate (which rotate together
during extension)
 the distal scaphoid fragment rotates into flexion.

 Results in
 abnormal contact in the radioscaphoid compartment
 early osteoarthritis of distal scaphoid fragment and the
radial styloid process
SNAC vs SLAC

 The only difference between SNAC and SLAC wrist

arthritis

 SNAC wrists : Preservation of the articulation between

the proximal pole of the scaphoid and the radius
 Proximal pole of the scaphoid appears to be unloaded
and acts as an extension of the lunate through the
intact scapholunate ligament

Shah CM, Stern PJ. Scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) wrist arthritis.
Curr Rev Musculoskelet Med. 2013;6(1):9-17. doi:10.1007/s12178-012-9149-4
 Scapholunate dissociation
Pre-dynamic • Conservative : FCR re-education
• Normal X-ray Stage 1
• Scapholunate K-wire fixation
• scope/MRI diag. / Occult Partial tear • Thermal ablation

Stage 2
Complete tear • Scapholunate K-wire fixation

Dynamic
Widening in clench fist • Capsulodesis (Repair)
• Normal AP X-ray Repairable
• SL widening in clench fist Stage 3
Complete tear
Widening in clench fist
Irreparable • FCR Tendinosis
(3 Ligaments tendinosis)
Stage 4
Complete tear
Reducible scaphoid
Stable radiolunate
Stage 5
Complete tear • Spiral Tendinosis
(Anti-pronation tendinosis)
Static

Reducible scaphoid
• SL widening in AP X-ray Unstable radiolunate
• SL widening in clench fist
Stage 6
Complete tear, no OA • Limited fusion
Irreducible scaphoid (ex. RSL fus.+distal scaphoidec.)
Unstable radiolunate
Stage 7 (SLAC) • Proximal row carpectomy (No capitolunate OA)
Complete tear, OA • Four corners fusion
Irreducible scaphoid • Radial styloidectomy (SLAC 1)
Unstable radiolunate
Green
Scapholunate dissociation
Scapholunate advanced collapse(SLAC)

 The scaphoid assumes an abnormally flexed position

 The lunate pathologically deviates into extension.
 The scapholunate angle increases to greater than 70
degrees while the lunate is extended to greater than
10 degrees beyond neutral (DISI)

 Results in
 Abnormal distribution of forces across the midcarpal and
radiocarpal joints
 Eventually, cartilage degeneration occurs beginning with
the radioscaphoid joint (start at radial styloid)
Dorsal intercalated segment instability (DISI)

 Wrist trauma and fracture

 Scaphoid fracture : Bony DISI
 Scaphoid non-union : Bony DISI
 SNAC : Bony DISI

 Distal radius fracture : Compensatory DISI

 Radius malunion : Adaptive DISI

 Scapholunate dissociation : Ligamentous DISI

Brachial
Plexus
Injury Primary
Reconstruction:
nerve

Secondary
Reconstruction:
Tendon transfer
Free functioning muscle trans.
Bone/Soft tissue transfer
Brachial Plexus
Anatomy

Green
 Herbert and Fisher
Scaphoid fracture

Acute Chronic