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The Ending of Two Injuries This Site Has Already Warned You About
SLAC wrist (scapholunate advanced collapse) and SNAC wrist (scaphoid nonunion advanced collapse) are patterns of wrist arthritis that follow an old injury: a torn scapholunate ligament, or a scaphoid fracture that never healed. Both wear the wrist out in a predictable order over years.
Treatment starts with a splint for heavy tasks, changing how you load the wrist, and injections for flares. When those stop working, every operation trades some movement for less pain.
Most wrist arthritis isn’t the wear-and-tear kind that arrives with age. It’s the consequence of an injury, often one that happened decades earlier and was never treated properly.
Two injuries account for the majority of it, and both have their own articles here because both are catchable.
- A torn scapholunate ligament that was called a sprain.
- A scaphoid fracture that never healed because the first X-ray looked clean.
Both let the carpal bones move in ways they were never designed to, and both wear the wrist out along a route that hand and even orthopedic surgeons can predict years in advance.
If you’re reading this because you had a fall last month and the X-ray was normal, read those two articles instead. This one is what those two turn into.
And if you’re already here…the mistake I see most is waiting for the X-ray to “get bad enough” before having the surgical conversation. Every stage the wear moves through closes off one of the better operations. Waiting doesn’t keep your options open. It spends them.
What is SLAC wrist?
When the scaphoid and lunate come apart, the load stops passing through the wrist evenly.
Instead of a broad surface carrying weight across a wide area, contact narrows onto an edge. Cartilage designed for spread-out pressure gets a concentrated load in one spot, and it wears through there first.
From that corner it spreads across the wrist in a known sequence over years.
One joint survives longest: the one between the radius and the lunate, because the lunate keeps sitting square under the radius even while everything around it degrades.
That detail isn’t trivia.
It’s the entire reason the salvage operations work, because they’re built around a joint that’s still healthy.
What is SNAC wrist?
SNAC is the same story with a different starting point. The scaphoid broke, never joined, and now moves as two separate pieces.
The lower piece moves with the hand. The upper piece stays with the lunate. The bone that was supposed to link the two rows of the wrist has become a hinge in the wrong place.
- Wear starts where the tip of the radius rubs on the loose lower piece of the scaphoid.
- Then spreads to the joint between the scaphoid and the capitate, the bone in the center of the wrist.
- Then reaches the joint between the capitate and the lunate.
As in SLAC, the radius-lunate joint usually holds up until late. That’s why the surgical options for SLAC and SNAC are almost the same list.
This is one of the few conditions in medicine where someone can look at a 25-year-old’s X-ray and describe, roughly, what their wrist will look like at 45.
What are the stages of SLAC and SNAC wrist?
Both are staged 1 to 3 by where the wear has reached. In Closing Window terms, the window here isn’t about saving the joint. It’s about which operations are still on the menu.
- Stage 1 (window OPEN, widest choice). Wear only at the tip of the radius against the scaphoid. Non-surgical care often works well for years. In SNAC, if the joints are still healthy, the surgeon may try to get the scaphoid to heal with a bone graft. See scaphoid fixation surgery recovery.
- Stage 2 (CLOSING). SLAC: the whole joint between the radius and the scaphoid is worn. SNAC: the scaphoid-capitate joint is worn too. Most of the salvage operations are still available.
- Stage 3 (SHUT for some options). The wear has reached the capitate-lunate joint in the middle of the wrist. Removing the first row of carpal bones usually stops being a good option here, cos that operation needs a healthy head of the capitate to work. The menu narrows to fusions.
- Late, whole-wrist arthritis. If the radius-lunate joint finally wears too, total fusion or replacement is what’s left.
What does wrist arthritis after an old injury feel like?
- Aching with load rather than at rest, at least early on. Pressing up out of a chair, push-ups, carrying, opening jars.
- Grip strength dropping, often quite noticeably compared with the other side.
- Loss of movement, especially bending the wrist backward.
- Swelling or a firm fullness on the back of the wrist, on the thumb side.
- Clunking or grinding with certain movements.
- Somewhere in the history, a fall in their twenties that was “just a sprain”.
How is SLAC or SNAC wrist diagnosed?
- Examination. Tenderness on the thumb side of the back of the wrist, reduced range compared with the other side, and grip measured. Pressing on the scaphoid while the wrist moves side to side can produce a painful clunk when the ligament has gone.
- X-ray. Usually enough to make the diagnosis and stage it. In SLAC there’s a widened gap between the scaphoid and lunate. (Radiologists named it after the gap-toothed comedian Terry-Thomas. Medicine has its moments.) In SNAC the X-ray shows the scaphoid still in two pieces.
- CT scan. Shows the scaphoid nonunion and the bone quality in detail, which matters if a repair is being considered.
- MRI or arthroscopy. Sometimes used to check the cartilage directly before choosing an operation, especially the capitate and lunate surfaces.
Can wrist arthritis be treated without surgery?
Yes, and you should start here, because the non-surgical options buy real time:
- A supportive wrist splint for heavy tasks. A wrist cock-up splint worn for lifting, gripping and manual work, not all day. Worn 24/7, the wrist stiffens and the forearm muscles weaken, and you’ve made the next stage harder.
- Changing how you load the wrist. Carry with the forearm, not the fingertips. Push up from a chair on your fists or knuckles, wrist straight, instead of on a bent-back flat palm.
- Tool and technique adaptation. Thicker handles, power tools instead of manual twisting, jar openers. Boring…and effective.
- A steroid injection into the joint for flares. Useful for a bad patch, not a long-term plan. See how many steroid injections is too many.
Plenty of people manage well for years like this.
Exercises for wrist arthritis
The goal is to keep the movement you have and make the muscles around the wrist do more of the work. Stay in the comfortable range. Pain up to about 3 out of 10 that settles within an hour is acceptable. Pain that’s worse the next morning means you did too much.
- Active wrist range. Forearm on a table, bend the wrist up and down slowly within the pain-free arc. 10 reps, 2 to 3 times a day.
- Forearm rotation. Elbow tucked at your side, turn the palm up, then down. 10 reps, 2 to 3 times a day.
- Isometric wrist holds. Wrist straight, press the back of the hand up into your other hand without moving. Hold 10 seconds, 5 reps. Repeat pressing the palm down. Once a day.
- Soft grip work. Squeeze a soft ball or light putty, wrist straight. 10 reps, once or twice a day. Build gradually.
- Skip: forcing the wrist into a bent-back stretch under bodyweight. Flat-palm push-ups and planks can switch to handles or fists.
Which surgery for SLAC or SNAC wrist?
When the non-surgical options stop working, every surgical option involves the same trade in different proportions: you give up movement to get rid of pain.
The question is how much of each.
- Wrist denervation. Small nerve branches carrying pain signals from the joint are cut. Movement is fully preserved and the arthritis is untouched, so this reduces pain without changing the underlying problem. A reasonable option for someone who needs their range.
- Proximal row carpectomy. The whole first row of carpal bones is removed and the hand articulates directly on the radius. Keeps a useful amount of movement, gives up some grip strength, and is a smaller operation than it sounds. Needs a healthy capitate, so it’s usually a stage 1 or 2 option.
- Partial fusion. The worn-out scaphoid is removed and the remaining bones fused into one block, often called a four-corner fusion. Keeps roughly half your range and generally more strength than the option above. Works in stage 3 because it relies on the radius-lunate joint, not the capitate.
- Total wrist fusion. The wrist is fused solid in one functional position. Reliable pain relief, strong, and no movement at all. For heavy manual workers this is sometimes the right answer rather than the last resort.
- Wrist replacement. Keeps movement, doesn’t tolerate heavy load, and is generally reserved for lower-demand hands.
There is no universally best choice here, and that’s the honest answer.
It depends on what your hand has to do. A plumber and a pianist with identical X-rays should probably have different operations.
If fusion is the one on the table, go in understanding what you’re signing. It is PERMANENT. Fusion trades movement, for good, for a joint that stops hurting, and the movement doesn’t come back later if you change your mind about the deal. That article covers what the months after look like, including how long it takes to stop reaching for a wrist that no longer bends.
How long is recovery after wrist arthritis surgery?
Conservative ranges. Your surgeon may give you different dates. Use theirs.
- Denervation: quick. A few weeks, then normal use.
- Proximal row carpectomy: splint or cast for about 2 to 4 weeks, then guided movement. Strengthening from around 8 to 12 weeks. Final result at 6 to 12 months.
- Partial fusion: protected in a cast or splint until the bones have joined on X-ray, often 8 to 12 weeks. Then movement, then strengthening. Final result closer to 12 months.
- Total fusion: protected until fused, often 8 to 12 weeks or more. Then a few months of relearning tasks with a wrist that doesn’t bend.
The bone operations take longer to feel like your own hand, and adapting to a wrist that doesn’t bend takes a few months of relearning tasks rather than a few weeks.
Grip strength usually improves substantially after any of these, because pain has been limiting it as much as anything mechanical.
Can I work, drive and lift with SLAC or SNAC wrist?
- Desk work: usually fine before surgery. After a bone operation, often 2 to 4 weeks if you can work one-handed.
- Heavy manual work: before surgery, a splint for heavy tasks and adapted tools. After a carpectomy or fusion, commonly 3 to 6 months before full heavy duties.
- Driving: once you could control the car in an emergency, which after bone surgery means out of the cast and able to grip the wheel firmly. Check with your surgeon and your insurer.
- Gym and lifting: push-ups and presses on handles or dumbbells keep the wrist straight. After a fusion, some lifts change for good. After a carpectomy, expect a few months before loading through the wrist.
Wrist arthritis in someone under 60 usually has an old injury behind it. If that’s you, the useful conversation is about which trade suits your hand, not whether surgery is needed yet. And if the X-ray says something different from what you expected, Kienböck’s disease is the other condition that ends in the same set of operations.
Get it checked today if
- After surgery or in a cast: fingers cold, pale, numb, or the cast feels too tight even with the hand raised.
- After surgery: increasing redness, warmth and throbbing, discharge from the wound, or a fever.
- A new fall on the wrist with sudden severe pain, a visible deformity, or new numbness in the fingers.
Get it checked if
- A recent wrist “sprain” is still painful or swollen on the thumb side after 2 weeks. That’s the stage where none of this has happened yet. See wrist sprain or something worse.
- A new clunk in the wrist, or grip strength dropping quickly.
- Pain that used to come with load now comes at rest or at night.
- Tingling or numbness in the thumb, index and middle fingers. Swelling from an arthritic wrist can crowd the carpal tunnel.
- Injections that used to last months now last weeks. That’s usually the signal to have the surgical conversation, before the next stage takes an option away.
The arthritis was decided years ago. The trade you make for it is still yours to choose.
Written by Nigel Chua, hand occupational therapist in practice since 2005. Thousands of hands, wrists and elbows assessed and treated. My credentials are here. Every article on this site is written using the Closing Window Method: name the window your condition runs on, find where you are in it, and act while it’s still open. This article explains; it doesn’t examine. Surgical choices here should be made with a hand surgeon who knows what your hand does all day.
Part of: Recovery after hand, wrist and elbow surgery: every week-by-week guide