MSK Case Conference - bonepit.combonepit.com › Cases › Scaphoid Nonunion Advanced...
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MSK Case Conference
August 21, 2015
Anthony Tadros, R3
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• 21 year old male presenting with wrist pain.
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November 2013
Acute scaphoid waist fracture
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November 2013 6 weeks later
No significant change
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December 2013
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Non-united scaphoid waist
fracture
Proximal pole sclerosis = ischemia
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August 2015
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Non-united scaphoid waist
fracture
Progressed sclerosis and cystic changes
= ischemia
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Humpback-like deformity
Dorsal intercalated
segment instability
Dorsal tilting of the lunate
Bodor. SLL Tear and DISI Deformity. Radsource MRI Web Clinic — June 2009
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August 2015
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Proximal pole ischemia
Cortical step off
Radial styloid osseous proliferation
Joint space arrowing and cartilage loss between radial styloid and distal pole of scaphoid
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Scaphoid Nonunion Advanced Collapse (SNAC)
• Failed union of scaphoid fracture • Three stages of progressive arthrosis • Dorsal intercalated segment instability (DISI)
Sauerbier et al. Intercarpal fusion for scaphoid nonunion. Atlas Hand Clin 8 (2003) 163–183
Stages 1 & 2 • Radioscaphoid joint
• Distal scaphoid
Spared • Proximal scaphoid • Distal radius
Stages 3 • Midcarpal joint
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SNAC versus SLAC Scaphoid nonunion advanced collapse (SNAC)
• Scaphoid fracture
• Abnormal joint
kinematics
• Lunate unrestrained by distal scaphoid
• DISI - Degenerative arthritis
• Radioscaphoid
• Midcarpal
• Scapholunate advanced collapse (SLAC)
• Scapholunate ligament injury
• CPPD, RA, neuropathic disease, amyloid
Crema et al. Scapholunate Advanced Collapse and Scaphoid Nonunion Advanced Collapse: MDCT Arthrography Features. AJR:199, August 2012 Shah et al. Scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) wrist arthritis. Curr Rev Musculoskelet Med (2013) 6:9–17
Only Difference • Sparing of proximal scaphoid-radius articulation
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Patterson. Scaphoid anatomy and mechanics: update and review. Operative Techniquesin Orthopaedics,Vol 13, No 1 (January),2003: pp 2-10 Shah et al. Scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) wrist arthritis. Curr Rev Musculoskelet Med (2013) 6:9–17
SNAC versus SLAC
Only Difference • Unloaded
proximal scaphoid pole
• Acts as extension of lunate through intact SL ligament
Scaphoid fracture
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SNAC Classification
• Two classifications – widespread use for treating SNAC • Watson & Ballet • Vender
• Evaluate intra and interobserver agreement between two classifications for SNAC
Penteado et al. Scaphoid Nonunion Advanced Collapse Classifications: A Reliability Study J Hand Microsurg (January–June 2012) 4(1):12–15 Watson HK, Ballet FL (1984) The SLAC wrist: scapholunate advanced collapse pattern of degenerative arthritis. J Hand Surg Am 9(3):358–365 Vender MI, Watson HK, Wiener BD, Black DM (1987) Degenerative change in symptomatic scaphoid nonunion. J Hand Surg Am 12 (4):514–519
Watson & Ballet (1984)
• 1 - Radial styloid – scaphoid
• 2 - Radioscaphoid fossa
• 3 - Midcarpal
Vender (1987) • 1 – Radioscaphoid fossa – distal scaphoid • 2 – Proximal scaphoid fragment – capitate • 3 – Midcarpal
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SNAC Classifications
• Forty-eight PA wrist XRs • Scaphoid nonunion
• Five observers • Hand surgeons/residents • Ortho surgeons/residents
• Unsatisfactory agreement: • Cohen’s Kappa < 0.5
Conclusions
• Unsatisfactory agreement for both classifications
• No clear correlation between expertise and kappa values
Treatment relevant
• Isolated radiocarpal
• Radiocarpal and midcarpal
Fatal Flaw
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Sauerbier et al. Intercarpal fusion for scaphoid nonunion. Atlas Hand Clin 8 (2003) 163–183 I.A. Trail, A.N.M. Fleming (eds.), Disorders of the Hand: Volume 2: Hand Reconstruction and Nerve Compression, DOI 10.1007/978-1-4471-6560-6_6 del Pinal F, Early experience with (dry) arthroscopic 4-corner arthrodesis: from a 4-hour operation to a tourniquet time. J Hand Surg Am. 2012;37:2389–2399.
SNAC Management
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Scaphoid Nonunion Postoperative MRI
Diffuse enhancement • Normal healing
Normal marrow crossing union sites
Low signal intensity graft
Karantanas The role of MR imaging in scaphoid disorders. Eur Radiol (2007) 17: 2860–2871