SLAC wrist — scapholunate advanced collapse — is the most common pattern of wrist arthritis, and it is treatable at every stage. Many patients do well with conservative care. When surgery becomes necessary, the right operation depends on where the arthritis is — not a single approach applied to everyone.
SLAC arthritis can develop silently over years before becoming symptomatic. Some patients are diagnosed when wrist pain from another cause prompts imaging.
Understanding the Condition
SLAC stands for scapholunate advanced collapse — a pattern of progressive wrist arthritis that develops after the scapholunate ligament fails. When that ligament is torn and not repaired, the scaphoid and lunate lose their coordinated motion. The scaphoid rotates into flexion while the lunate extends, and the wrist begins to load abnormally through joint surfaces that were never designed to bear that force.
Cartilage wears in a predictable sequence. The radial styloid goes first — the area where the flexed scaphoid repetitively contacts the tip of the styloid. From there the damage spreads to the entire radioscaphoid joint. In later stages, the midcarpal joint between the capitate and lunate is involved. The pattern is so consistent that the stage of arthritis can often be read from a plain X-ray.
SLAC is the end stage of an untreated or undiagnosed scapholunate ligament tear. Once significant cartilage loss has occurred, the opportunity for ligament repair or reconstruction has passed — the focus shifts to managing arthritis and deciding which operation best matches the patient's pattern of joint damage and functional goals.
SNAC (scaphoid nonunion advanced collapse) produces the same pattern of wrist arthritis from a different starting point: an untreated scaphoid fracture that fails to heal. The ununited scaphoid fragment gradually collapses, driving the same sequence of cartilage wear as SLAC. The treatment options and decision framework are essentially identical — the operation is chosen based on where the arthritis is, not what caused it.
SLAC arthritis follows a predictable sequence — radial styloid first, then the full radioscaphoid joint, then the midcarpal (capitolunate) joint. Importantly, the radiolunate joint is typically spared until late, which is what makes motion-preserving operations possible.
The preserved radiolunate joint is the key to both PRC and capitolunate fusion — both operations depend on that articulation remaining healthy enough to function after the damaged surfaces are removed or bypassed.
Non-Surgical Management
Many patients with SLAC wrist arthritis — particularly those with mild to moderate symptoms — manage well without surgery. The goal is pain control and maintaining function while the arthritis is not yet limiting daily life in an unacceptable way.
A custom or off-the-shelf wrist brace worn during aggravating activities reduces loading on the arthritic joint surfaces and can significantly reduce pain. Many patients use a brace for heavy work or sport and go without it for lighter activities.
Identifying and reducing activities that most reliably provoke symptoms — heavy lifting, impact loading, extreme wrist positions — often provides meaningful relief without restricting function overall. This doesn't mean stopping activity; it means managing load.
Anti-inflammatory medications reduce the synovitis that contributes to pain even in the presence of established cartilage loss. Used consistently and appropriately, they can extend the period of acceptable conservative management substantially.
A steroid injection into the radiocarpal or midcarpal joint — depending on where symptoms localize — reduces inflammation and provides a period of meaningful relief. The duration varies by patient. Injections can be repeated, and are particularly useful for patients who are not yet ready for surgery or have medical reasons to delay it.
Surgical Treatment
SLAC wrist does not have one surgical treatment. The operation is selected based on which joint surfaces are damaged, which are preserved, and what level of motion the patient wants to maintain.
PRC removes the three bones of the proximal carpal row — the scaphoid, lunate, and triquetrum — entirely. The capitate, the large bone at the head of the distal row, then settles into the cup of the radius and becomes the new articulation. The result is a functional wrist with meaningful preserved motion and reliable pain relief.
The simplicity of PRC is its strength. There is no hardware, no fusion to wait for, and recovery is faster than after a fusion procedure. The tradeoff is that the new capitate-on-radius joint is not as precise as the native wrist, and some grip strength and motion are reduced compared to a healthy wrist — though most patients find the functional result very acceptable.
This procedure removes the scaphoid — the arthritic troublemaker — and fuses the capitate and lunate together. The fused capitolunate unit then moves as one against the preserved radiolunate joint, which SLAC arthritis typically spares until late. The result is motion through a healthy articulation, with the arthritic surfaces eliminated.
Dr. Graham performs capitolunate fusion specifically — rather than a traditional four-corner fusion — because it achieves the same mechanical goals with a simpler construct. Capitolunate fusion is generally appropriate for patients with more advanced radioscaphoid disease where PRC is no longer reliable, or where a more durable result is the priority.
When arthritis has involved the capitolunate joint — ruling out both PRC and capitolunate fusion — wrist arthroplasty replaces the wrist joint with a prosthesis, preserving motion while eliminating the painful arthritic surfaces. Dr. Graham performs wrist arthroplasty across a range of patients and activity demands; it is not reserved only for sedentary or low-demand patients.
Arthroplasty requires careful patient selection, respect for activity restrictions to protect implant longevity, and a surgeon experienced with the procedure and its revision. Dr. Graham performs wrist arthroplasty regularly and accepts revision cases.
Total wrist fusion eliminates all wrist motion by fusing the entire radiocarpal and midcarpal joint complex into a single solid unit. It provides the most reliable and durable pain relief of any wrist arthritis operation — but at the cost of all wrist motion. Forearm rotation is preserved, and most patients adapt well to the functional limitation with the help of occupational therapy.
Dr. Graham performs total wrist fusion for patients whose primary goal is definitive pain control and who are prepared to accept the loss of wrist motion. It is used less commonly than wrist arthroplasty in his practice, but it remains the most dependable option when pain relief is the overriding priority.
"Roy said if there were 10 stars available he would give Dr. Graham 10. The outcome exceeded every expectation."
Roy Williams · Complex Upper Extremity Surgery · Verified Google Review ★ 5/5
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