Distal Intersection Syndrome
Other Names
- Distal Intersection Syndrome (DIS)
- Distal Intersection Tenosynovitis
Background
- This page refers to distal intersection syndrome (DIS), a pathologic interface between the 2nd and 3rd dorsal compartments of the wrist
- This should not be confused with the much more common Intersection Syndrome of the Forearm
History
- The term 'distal intersection syndrome' was first proposed by Parellada in 2007[1]
Epidemiology
- Unknown, limited to case reports/ case series
Introduction
General
- DIS is rare and not well described in the literature
- Defined as tenosynovitis between the 2nd and 3rd dorsal compartment
- Patients present with dorsal wrist pain and swelling
- Typically this is from overuse, although traumatic events have been cited
Pathophysiology
- Occurs where the EPL tendon traverses over the ECRB, ECRL tendons, just distal to Lister's tubercle[5]
- EPL's course around Lister's tubercle creates an anatomic pulley however it predisposes the tendon to injury
- Extensor retinaculum can constrict directly over the tendon course, further amplifying the effects[6]
- Overuse and excessive friction within and between these dorsal compartments results in tenosynovitis
Anatomy of the 2nd and 3rd dorsal compartments of the wrist
- Extensor Pollicis Longus (EPL) courses through 3rd dorsal compartment
- Extensor carpi radialis longus (ECRL), Extensor carpi radialis brevis (ECRB) courses through the second dorsal compartment
- As EPL moves distally to the thumb, it crosses superficially over the second dorsal compartment at Lister's tubercle
- Previous injury to Lister's tubercle such as a fracture can contribute to this syndrome
- The 2nd/3rd dorsal compartments can communicate with each other
- EPL has watershed supply here, making it vulnerable to ischemia
Associated Conditions
- Rupture of Extensor Pollicis Longus
- Pathogenesis in the setting of DIS not fully understood
- Hypothesis: effusion in confined space contributes to avascular necrosis of tendon[7]
Risk Factors
- Sports
- Occupation
- Pianist[10]
- Systemic
Differential Diagnosis
Differential Diagnosis Dorsal Wrist Pain
- Distal Intersection Syndrome
- Intersection Syndrome of the Forearm
- De Quervains Tenosynovitis
- Wartenbergs Syndrome
- Ganglion Cyst of the Wrist
- Muscle Strain
Differential Diagnosis Wrist Pain
- Fractures
- Dislocations
- Wrist Dislocation (Radiocarpal and/or Ulnocarpal)
- Carpometacarpal Joint Dislocation
- Distal Radioulnar Joint Dislocation
- Lunate Dislocation
- Perilunate Dislocation
- Instability & Degenerative
- Tendinopathies & Ligaments
- Neuropathies
- Pediatric Considerations
- Distal Radial Epiphysitis (Gymnast's Wrist)
- Torus Fracture
- Arthropathies
- Cartilage
- Vascular
- Other
Clinical Features
History
- Dorsoradial distal wrist pain
- Patients will endorse swelling, tenderness
- Patient may endorse parasthesia
Physical Exam
- Tenderness over Lister's tubercle, 2nd or 3rd dorsal compartment
- Variable presence of edema, mass
Special Tests
- Needs to be updated
Evaluation
Radiographs
- Standard Radiographs Wrist
- Findings: typically normal
MRI
- Findings
- Peritendinous edema
- Fluid and distention of the tendon compartments of the EPL, ECRB and ECRL
- Location: at their point of intersection
- Associated findings
- Tendinosis with thickening and/or increased signal in the involved tendons
- Partial tendon tears
- Reactive marrow edema in adjacent osseous structures such as Lister’s tubercle
Ultrasound
- Findings
- Excessive fluid within the tendon sheaths
- Increased with of the peritendinous hypoechoic rim
- Hyperemia
Classification
- Not applicable
Management
Nonoperative
- First line therapy
- Relative rest
- Activity modification
- Discontinue offending activities
- Ice
- NSAIDS
- Immobilization
- Cock Up Wrist Splint
- Consider kinesiology tape, which has shown some benefit[13]
- Physical Therapy
- Distal Intersection Syndrome Injection
Operative
- Indications
- Extensor Pollicis Longus tendon rupture
- Failure of conservative management
- Technique
- Irrigation, debridement
- Synovectomy
- EPL reconstruction or graft
Rehab and Return to Play
Rehabilitation
- Needs to be updated
Return to Play/ Work
- Needs to be updated
Prognosis and Complications
Prognosis
- Most cases are mild, respond to conservative treatment
Complications
- Complete tear of the extensor pollicis longus
See Also
References
- ↑ Parellada AJ, Gopez AG, Morrison WB, et al. Distal intersection tenosynovitis of the wrist: a lesser-known extensor tendinopathy with characteristic MR imaging features. Skeletal Radiol. 2007;36(3):203–8.
- ↑ Image courtesy of teachmeanatomy.info, "The Extensor Tendon Compartments of the Wrist"
- ↑ Image courtesy of radsource.us, "tendon intersection syndromes"
- ↑ Li, Tony Y. "Unique sonographic presentation of distal intersection syndrome." Journal of Diagnostic Medical Sonography 33.5 (2017): 428-432.
- ↑ Distal intersection syndrome progressing to extensor pollicis longus tendon rupture: a case report with sonographic findings. Mattox R, Battaglia PJ, Scali F, Ottolini K, Kettner NW. J Ultrasound. 2017;20:237–241
- ↑ Distal intersection tenosynovitis of the wrist: a lesser-known extensor tendinopathy with characteristic MR imaging features. Parellada AJ, Gopez AG, Morrison WB, Sweet S, Leinberry CF, Reiter SB, Kohn M. Skeletal Radiol. 2007;36:203–208.
- ↑ Rupture of the extensor pollicis longus tendon after fracture of the lower end of the radius--a clinical and microangiographic study. Engkvist O, Lundborg G. Hand. 1979;11:76–86.
- ↑ 8.0 8.1 Alter, Todd H., et al. "Distal Intersection Syndrome Between Second and Third Dorsal Compartments of the Wrist." Cureus 15.3 (2023).
- ↑ Distal intersection syndrome combined with partial attritional changes of the extensor carpi radialis brevis in tennis players. Sunagawa T, Dohi D, Shinomiya R. J Hand Surg Glob Online. 2021;3:224–227.
- ↑ 10.0 10.1 Distal intersection syndrome of the wrist: three cases report. Nam SO, Shin DJ, Kim TE, Kim SW, Cho HS.
- ↑ Image courtesy of ultrasoundcases.info, "Distal Intersection Syndrome"
- ↑ Case courtesy of Bahman Rasuli, Radiopaedia.org, rID: 61904
- ↑ Kaneko S, Takasaki H. Forearm pain, diagnosed as intersection syndrome, managed by taping: a case series. J Orthop Sports Phys Ther. 2011 Jul;41(7):514-9. Epub 2011 Apr 6.