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Scott Shreeve, MD

Hey there!

I'm the CEO of Crossover Health, a patient-centered, membership-based medical group that is redesigning the practice, delivery, and experience of health care. We offer urgent, primary, and online care to our members who can access our technology platform, practice model, and provider network from anywhere and anytime to optimize their health. Email Me



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Tales of a SLACer

Scapholunate Advanced Collapse (SLAC)

Refers to a specific pattern of osteoarthritis and subluxation which results from untreated chronic scapholunate dissociation or from chronic scaphoid non-union;
2. Degenerative changes occur most often in areas of abnormal loading; typically involves the radial-scaphoid joint initially, followed by degeneration in the unstable lunatocapitate joint, as capitate subluxates dorsally on lunate.

OK, I admit it, I am a SLACer.

After a 20 year career of serious hoops and football at the collegiate level, I was diagnosed with SLAC on my right wrist in November 2001. I had just finished competing in my first mini-triathlon and had noticed some increasing pain in my right wrist during training. I had noticed this pain on and off for several years, particularly after extended periods of intense weight training and occasionally after basketball. Usually, with a little time off I was able to return to my normal activity pain free. After the triathlon, the pain persisted despite rest and limited activity.

So one night, while working a shift the Northwest Medical Center Emergency Department in Tucson, I dropped by the radiology department to get a film of my wrist. I reviewed the image myself and did not see any obvious fracture or abnormal positioning of the bones. Later that night, I had to get an orthopedic consult for a fractured hip in an elderly patient and I curbsided the surgeon to look at the film. He casually glanced at it and said, “Dude, I feel sorry for this guy“. That wasn’t what I was hoping to hear from my physician colleague. Turns out he saw the subtle, but clearly present, dreaded widening at the scapho-lunate junction that is sin quo non for SLAC (the “Terry Thomas” sign).

Taken from Dr. K Orthopedic Case Study site.

In my case, it was most likely microtrauma of the scapho-lunate ligament over many years of competitive athletics. It was a slowly progressive condition, wherein the ligament ultimately gave way thereby creating an unstable joint. This instability, combined with ongoing high levels of activity, created a degenerative situation and the painful subluxation.
The problem with SLAC, and the reason for orthopedic surgeons comment, is there really are no good treatment options for this chronic condition. It can become particularly devastating to people who depend on the mobility in their wrist to perform their work (including intubating patients in the ED).

So, as an otherwise very healthy 31 year old physician, I was left with the decision about how to manage a potentially “career-ending injury”. I felt clueless about how to proceed, particularly given the ramifications, and so I did as nearly 20 million Americans last year by turning to the internet for health information. As a physician, I had access to additional resources, including primary clinical studies, orthopedic textbooks, and other advanced information sources to learn about SLAC and compare treatment options. After becoming familiar with the condition, I was able to back channel with my orthopedic surgeon friends to discuss treatment options. Even with all this inside information, I chose my physician solely on a personal recommendation without any clarity about outcomes, pricing, quality, or any other measurable indicator of rational healthcare decision making.

Fortunately, I chose a good friend and colleague to perform a four corner salvage procedure. While the surgical result was as expected (in terms of recovery, range of motion, and return of function) from a surgeon with an excellent reputation, the nature of the underlying condition has left me in chronic pain with intermittent paresthesias (fortunately I can still throw a near perfect 40 yard spiral and have been able to adjust my once deadly jumpshot to be respectable).

Fast forwarding six years, I knew I was in trouble when the familiar chronic discomfort began in my left wrist. Even without the X-ray (wherein I correctly diagnosed myself this time), I knew exactly what the problem was. So herein lies the SLACer tale that I will be spinning in this thread of blogs . . . what should I do?

How should I make a rational health care decision about how to manage this specific decision? What healthcare providers in my area are specialists in the treatment of SLAC? What are their outcomes in terms of recovery, range of motion, return of function, patient satisfaction, and overall outcome? What is the price of treatment over the full cycle of care? What hospital in my area, region, or nationally has the best orthopedic outcomes for this procedure? How much will the surgery cost? How much will the post surgery therapy cost? What will be my personal cost in downtime, wearing a cast, missing work to go to physical therapy, and dealing with the issues associated with recovery? Who will walk me through this process in order to help me make a rational healthcare choice?

This, my Health 2.0 doubters, is where I will show you the value of the new paradigm. I am going to use this blog, as a public educational forum, to show how the new school healthcare consumers can leverage the enabling technology of Web 2.0 coupled with the transparency catalyst of the current healthcare reform movement to redefine healthcare. Buzzword compliance aside, I want to test my theory that these new companies with their new technologies can help a new type of consumer maximize healthcare value (outcome/price).

I believe the Health 2.0 companies I have previously highlighted (Vimo, MedBillManager, Sermo, Subimo, Organized Wisdom, HealthGrades, HealthEquity, and even Blue Cross of CA) will rally to showcase their wares by helping me make a rational healthcare choice. I will be contacting the CEO’s or evangelists of each of these organizations to discuss this opportunity to demonstrate real value, and look forward to periodically reporting back on my progress. I have created a label called “SLAC” to allow you to track my condition and decision making over time. I am expecting that these companies will help me become an empowered consumer in principle, in practice, and in the practical – all right out here in the open on this blog. I hope you find this experience useful, and convincing, regarding the inevitability of Health 2.0.

No slackers in this showcase!

3 comments on “Tales of a SLACer

  1. Unity Stoakes says:

    Thanks for believing in the new paradigm. We all have a lot of work to do, but from our experience we are seeing a great deal of innovation, progress, and new ideas that I hope (and believe) will provide better service/information/resources/options for patients. This past year was just the beginning for us. We expect big changes and much progress over the coming months and years.

    Unity Stoakes,

  2. Came across your blog.

    We too are trying to integrate the web into our services. Still trying to figure out exactly how to do that but it is worth trying.

    As far as your wrist injury, that is a tough one. Good luck.

    1. Denver PT, I would be interested to talk with you as I am not so happy with the results and I have the same problem on my left wrist. Who could you refer me to to discuss therapeutic options?

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