Standard radiographs show a nonunited scaphoid waist fracture . Changes consistent with stage I SNAC wrist were present with beaking of the radial styloid and degenerative change and loss of joint space within the styloid–scaphoid articulation. The lateral radiograph revealed a classic dorsal intercalated segmental instability (DISI) pattern with a scapholunate angle of 85° (Fig. 23.1a, 23.1b). Radial styloid–scaphoid impingement was visualized with a clenched fist PA radiograph (Fig. 23.1c) .

Stage I Scaphoid Nonunion Advanced Collapse (SNAC) with radial styloid–scaphoid arthritis.

We often find patients with early SNAC wrist to be relatively asymptomatic and as such may be treated with simple observation. Additional nonoperative measures include short-term immobilization as well as corticosteroid injections and other modalities.

Operative treatment includes radial styloidectomy , either open or arthroscopic. Denervation may also be an option. Bone grafting and open reduction of the scaphoid may also be performed with early SNAC wrists. In cases with more advanced radial scaphoid or scaphocapitate arthritis, a partial wrist fusion may be necessary .

The patient underwent standard wrist arthroscopy, which showed a chronic scaphoid waist nonunion. Degenerative changes were noted about the distal aspect of the scaphoid and the radial styloid (Fig. 23.2). The remaining weight-bearing portion of the scaphoid and lunate facets of the radius did not show significant arthritic changes. The scaphocapitate and capitolunate joints were free of degenerative change as well .

In this case, with isolated radial styloid–scaphoid arthritis , an arthroscopic radial styloidectomy was performed. A standard wrist arthroscopic setup was used. The wrist was placed in 10 pounds of traction using finger traps and a traction tower. The customary 3–4 portal was employed for visualization, and a 1–2 portal was the working portal. Using the 2.7- or 2.3-mm arthroscope, a thorough diagnostic evaluation was done. Additional pathology may be addressed at this time prior to performing the styloidectomy, which may produce bleeding and debris that can impede visualization. In this case, no other concomitant pathology was noted. A small joint 3.5- or 2.9-mm burr was then used through the 1–2 portal to complete the resection with care taken to protect the radial extrinsic ligaments. Direct visualization and fluoroscopy was and should be used to ensure adequate amount of resection, approximately 3–4 mm. In addition, the diameter of the burr can be used as a reference to help guide resection .

After completion of the styloidectomy, the patient was placed in a short-arm volar splint for 7–10 days until initial postoperative follow-up. Gentle motion is begun at this visit, with limited activity for 6 weeks, followed by a gradual return to normal use. At 6 weeks postoperatively, the patient was released to increase his activities as tolerated and a strengthening program was begun .

The patient noted early improvement of his radially sided wrist pain. Pain relief was most notable with push-off and power grip. At 3-year follow-up, the patient was pain free. He had returned to his normal job as well as normal sporting activities. Range of motion had improved in all directions. There was also dramatic improvement of his grip strength (Table 23.2). X-rays showed a persistent nonunion but a stable wrist with improvement in his DISI deformity (Figs. 23.3a, 23.3b) .