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WRIST OSTEOARTHRITIS (Scaphoid Nonunion Advanced Collapse)

Introduction

Scaphoid nonunion advanced collapse (SNAC) causes progressive degenerative arthritic changes in the wrist.  It is caused by trauma leading to scaphoid fracture and subsequent nonunion which results in abnormal joint kinematics.2 Degenerative changes in SNAC wrist are similar to those in scapholunate advanced collapse (SLAC).3 Arthritic changes initially involve the interface between the radius and the fractured scaphoid.  These changes are followed by changes in the interface between the lunate and the capitate. The radiolunate joint, lunotriquetral joint and the spherical proximal scaphoid fragment are often spared from arthritic changes.4

Pathophysiology

  • Rotary subluxation of the fractured scaphoid is the prominent etiology for the degenerative changes associated with SNAC wrist.
  • Watson stages3
    • Stage I: OA between scaphoid and radial styloid
    • Stage II: OA between scaphoid and capitate
    • Stage III: OA between capitate and lunate

Related Anatomy

  • Distal scaphoid
  • Radial styloid
  • Capitate
  • Lunate
  • Capitolunate joint

Incidence and Related Conditions

  • SNAC is often accompanied by dorsal intercalated segmental instability (DISI)
  • Nearly 10% of scaphoid fractures progress to nonunion5

Differential Diagnosis6

  • Scapholunate advanced Collapse
  • Distal radius fracture
  • de Quervain’s disease
  • Kienböck’s disease
  • Basilar joint thumb arthritis
ICD-10 Codes

  • WRIST OSTEOARTHRITIS (SNAC)

    Diagnostic Guide Name

    WRIST OSTEOARTHRITIS (SNAC)

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    SCAPHOID/NAVICULAR FRACTURE, NONUNION    
    - DISTAL POLE OF SCAPHOID    
     - DISPLACED S62.012_S62.011_ 
     - NONDISPLACED S62.015_S62.014_ 
    - MIDDLE THIRD OF SCAPHOID    
     - DISPLACED S62.022_S62.021_ 
     - NONDISPLACED S62.025_S62.024_ 
    - PROXIMAL THIRD OF SCAPHOID    
     - DISPLACED S62.032_S62.031_ 
     - NONDISPLACED S62.035_S62.034_ 

    Instructions (ICD 10 CM 2020, U.S. Version)

    THE APPROPRIATE SEVENTH CHARACTER IS TO BE ADDED TO EACH CODE FROM CATEGORY S62
     Closed FracturesOpen Type I or II or OtherOpen Type IIIA, IIIB, or IIIC
    Initial EncounterABC
    Subsequent Routine HealingDEF
    Subsequent Delayed HealingGHJ
    Subsequent NonunionKMN
    Subsequent MalunionPQR
    SequelaSSS

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Symptoms
Pain localized to scapholunate interval
Wrist clicking or clunking
Wrist stiffness with or without radial wrist swelling
Progressive weakness in affected hand
Difficulty bearing weight across affected wrist
Typical History

Patients with SNAC will present with long-standing and progressive wrist pain with difficulty in grasping and reaching for objects. Often patients will report an untreated injury in the affected wrist. As the problem progrsses the patient may develop dorsal radial swelling secondary to localized synovitis.  Many patients use NSAIDs for pain relief which may temporarily control their symptoms.

Positive Tests, Exams or Signs
Work-up Options
Images (X-Ray, MRI, etc.)
  • SNAC Wrist with arthritic radioscaphoid joint (1) and S-L gap (2)
    SNAC Wrist with arthritic radioscaphoid joint (1) and S-L gap (2)
  • SNAC Wrist with arthritic radioscaphoid joint (1) ; scaphoid nonunion (2) ; (3) AVN ; (4) S-L gap
    SNAC Wrist with arthritic radioscaphoid joint (1) ; scaphoid nonunion (2) ; (3) AVN ; (4) S-L gap
  • SNAC Wrist with early arthritic radioscaphoid joint and proximal pole scaphoid nonunion with no stress applied to the wrist joint.
    SNAC Wrist with early arthritic radioscaphoid joint and proximal pole scaphoid nonunion with no stress applied to the wrist joint.
  • SNAC Wrist with early arthritic radioscaphoid joint and proximal pole scaphoid nonunion with ulnar deviating STRESS applied to the wrist joint.
    SNAC Wrist with early arthritic radioscaphoid joint and proximal pole scaphoid nonunion with ulnar deviating STRESS applied to the wrist joint.
Treatment Options
Treatment Goals
  • Control wrist pain
  • Improve wrist function by decreasing pain while maintaining or improving wrist range of motion
  • Maintain or improve grip strength
Conservative

Early-stage/mild disease: NSAIDs, wrist splinting, possible corticosteroid injections

Operative
  • Stage I
    • Reconstructive procedures for the scaphoid nonunion with or without styloidectomy
    • Wrist denervation by transecting the posterior interosseous nerve (PIN) and the anterior interosseous nerve (AIN)
  • Stage II and III
    • Proximal row carpectomy if the capitate head and lunate facet of the radius are not arthritic
    • Four corner arthrodesis with scaphoid excision when the radioscaphoid and capitolunate joints are arthritic but the lunoradial joint is intact
    • Excision of the distal ununited scaphoid fragment
Treatment Photos and Diagrams
  • SNAC Wrist after proximal row carpectomy (PRC) Note intact radiocapitate joint space (arrow)
    SNAC Wrist after proximal row carpectomy (PRC) Note intact radiocapitate joint space (arrow)
  • SNAC Wrist after proximal row carpectomy (PRC) Note intact radiocapitate joint space (arrow)
    SNAC Wrist after proximal row carpectomy (PRC) Note intact radiocapitate joint space (arrow)
  • SNAC Wrist with scaphoid (oval) to be excised; dotted line nonunion; R-L intact cartilage and (arrow) destroyed Lunate-capitate joint.
    SNAC Wrist with scaphoid (oval) to be excised; dotted line nonunion; R-L intact cartilage and (arrow) destroyed Lunate-capitate joint.
  • SNAC Wrist with scaphoid excised and intact L-C joint
    SNAC Wrist with scaphoid excised and intact L-C joint
  • SNAC Wrist with dotted line outlining area to be removed and grafted.
    SNAC Wrist with dotted line outlining area to be removed and grafted.
  • SNAC Wrist with arrow showing arthritic fragmented proximal scaphoid
    SNAC Wrist with arrow showing arthritic fragmented proximal scaphoid
  • SNAC Wrist showing capitate and hamate being prepared for arthrodesis
    SNAC Wrist showing capitate and hamate being prepared for arthrodesis
  • SNAC Wrist showing lunate and triquetrum being prepared for arthrodesis
    SNAC Wrist showing lunate and triquetrum being prepared for arthrodesis
  • SNAC Wrist showing 4-corner fusion area before grafting
    SNAC Wrist showing 4-corner fusion area before grafting
  • SNAC Wrist AP X-ray showing 4-corner fusion area after grafting and internal fixation with .62 K-wires.
    SNAC Wrist AP X-ray showing 4-corner fusion area after grafting and internal fixation with .62 K-wires.
  • SNAC Wrist Lateral X-ray showing 4-corner fusion area after grafting and internal fixation with .62 K-wires.
    SNAC Wrist Lateral X-ray showing 4-corner fusion area after grafting and internal fixation with .62 K-wires.
CPT Codes for Treatment Options

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Common Procedure Name
Proximal row carpectomy
CPT Description
Carpectomy all bones of proximal row
CPT Code Number
25215
Common Procedure Name
Radial styloidectomy
CPT Description
Radial styloidectomy (separate procedure)
CPT Code Number
25230
Common Procedure Name
Four corner arthrodesis with graft (partial wrist fusion) with excision scaphoid (25210)
CPT Description
Arthrodesis wrist, limited, with autograft (includes obtaining graft
CPT Code Number
25825
Common Procedure Name
Excision trapezium, pisiform, scaphoid or hook of hamate
CPT Description
Carpectomy; one bone
CPT Code Number
25210
CPT Code References

The American Medical Association (AMA) and Hand Surgery Resource, LLC have entered into a royalty free agreement which allows Hand Surgery Resource to provide our users with 75 commonly used hand surgery related CPT Codes for educational promises. For procedures associated with this Diagnostic Guide the CPT Codes are provided above. Reference materials for these codes is provided below. If the CPT Codes for the for the procedures associated with this Diagnostic Guide are not listed, then Hand Surgery Resource recommends using the references below to identify the proper CPT Codes.

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CPT 2021 Professional Edition: Spiralbound

Complications
  • Capitoradial joint arthritis after proximal row carpectomy
  • Nonunion of the 4 corner fusion
  • de Quervain’s disease
Outcomes
  • AIN/PIN wrist denervation: 59–70% of patients report improvements; minimal effects on ROM.6
  • Proximal row carpectomy: wrist ROM was 63% and grip strength was 83–91% of the contralateral side; objective findings did not correlate with patient satisfaction or wrist pain. 
  • Four-corner arthrodesis: postoperative ROM was 56% and grip strength was 76–80% of contralateral side; 92–95% had bony fusion and 12% required total arthrodesis.6
Video
SNAC Wrist with early arthritic radioscaphoid joint and proximal pole scaphoid nonunion with ulnar deviating STRESS applied to the wrist joint.
YouTube Video
Key Educational Points
  • Untreated small proximal pole scahoid nonunions can progress over time to develop the same arthritic changes seen in patients with SLAC wrist deformity.
  • Operative treat if the capitate lunate joint IS NOT arthritic is a Proximal Row Carpectomy (PRC).
  • Operative treat if the capitate lunate joint IS  arthritic is a 4-Corner fusion i.e. arthrodeses of the lunate, triquetrum, hamate and capitate with excision of the scaphoid.
References

Cited

  1. Vender MI, Watson HK, Wiener BD, Black DM. Degenerative change in symptomatic scaphoid nonunion. J Hand Surg 1987;12(4):514–9. PMID: 3611645
  2. Strauch RJ. Scapholunate advanced collapse and scaphoid nonunion advanced collapse arthritis--update on evaluation and treatment. J Hand Surg 2011;36(4):729–35. PMID: 21463735
  3. Watson HK, Ballet FL. The SLAC wrist: scapholunate advanced collapse pattern of degenerative arthritis. J Hand Surg 1984;9(3):358–65. PMID: 6725894
  4. Penteado FT, Dos Santos JBG, Caporrino FA, et al. Scaphoid nonunion advanced collapse classifications: a reliability study. J Hand Microsurg 2012;4(1):12–5. PMID: 23730082
  5. Pinder RM, Brkljac M, Rix L, et al. Treatment of Scaphoid Nonunion: A Systematic Review of the Existing Evidence. J Hand Surg 2015;40(9):1797–1805.e3. PMID: 26116095
  6. 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. PMID: 23325545

New articles

  1. Penteado FT, Dos Santos JBG, Caporrino FA, et al. Scaphoid nonunion advanced collapse classifications: a reliability study. J Hand Microsurg 2012;4(1):12–5. PMID: 23730082
  2. Malizos KN, Koutalos A, Papatheodorou L, et al. Vascularized bone grafting and distal radius osteotomy for scaphoid nonunion advanced collapse. J Hand Surg 2014;39(5):872–9. PMID: 24656393

Reviews

  1. Crema MD, et al. Scapholunate advanced collapse and scaphoid nonunion advanced collapse: MDCT arthrography features. Am J Roentgenol 2012;199(2):W202-7. PMID: 22826422
  2. Strauch RJ. Scapholunate advanced collapse and scaphoid nonunion advanced collapse arthritis--update on evaluation and treatment. J Hand Surg Am 2011;36(4):729-35. PMID: 21463735
  3. Pinder RM, Brkljac M, Rix L, Muir L, Brewster M. Treatment of Scaphoid Nonunion: A Systematic Review of the Existing Evidence. J Hand Surg 2015;40(9):1797–1805.e3. PMID: 26116095

Classics

  1. Vender MI, Watson HK, Wiener BD, Black DM. Degenerative change in symptomatic scaphoid nonunion. J Hand Surg 1987;12(4):514–9. PMID: 3611645
  2. Watson HK, Ballet FL. The SLAC wrist: scapholunate advanced collapse pattern of degenerative arthritis. J Hand Surg Am 1984;9(3):358-65. PMID: 6725894
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