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Intersection Syndrome

From WikiSM

Other Names

  • Tenosynovitis of first and second dorsal compartment
  • Tenosynovitis of first and second extensor compartment
  • Oarsmen's wrist
  • Crossover syndrome
  • Squeaker's wrist
  • Abductor pollicis longus bursitis
  • Abductor pollicis longus syndrome
  • Subcutaneous polymyositis
  • Peritendinitis crepitans
  • Bugaboo forearm
  • Intersection Syndrome of the Forearm
  • Proximal Intersection Syndrome

Background

History

  • First described in the literature by Alfred-Armand-Louis-Marie Velpeau, a French anatomist and surgeon, in 1841 (need citation)
  • Term 'intersection syndrome' first coined by James H. Dobyns in 1978 at the Mayo Clinic (need citation)

Epidemiology

  • Estimated to be less than 1 per 100,000 per year (need citation)
Illustration of the crossover of the first and second dorsal compartment demonstrating the intersection area.[1]
Anatomic structures involved in de Quervain's tenosynovitis and intersection syndrome.[2]

Introduction

General

  • Characterized by an inflammatory tenosynovitis at the intersection of the 1st and 2nd dorsal compartment
  • Pain is located over the dorsoradial forearm, made worse with resisted wrist extension and thumb extension
  • The term 'intersection syndrome' refers to intersection of the musculotendinous junctions of the 1st and 2nd dorsal compartment tendons[3]
  • Relatively uncommon, often misdiagnosed as De Quervains Tenosynovitis

Etiology

  • Result of repetitive extension and flexion activities
  • Friction injury at crossover of two junctions leads to inflammation and subsequent tenosynovitis

Anatomy of the 1st and 2nd Extensor Tendon Compartments

Risk Factors

  • Sports[4]
    • Rowing
    • Canoeing
    • Skiing
    • Racquet sports
    • Horseback riding
    • Weight lifters

Differential Diagnosis

Differential Diagnosis Intersection Syndrome

Differential Diagnosis Wrist Pain

Differential Diagnosis Forearm Pain

Clinical Features

Pain regions unique to intersection syndrome (IS) and de Quervain's tenosynovitis (DQT). IS typically presents with a pain region more proximal and dorsal than that presenting with DQT.[2]

History

  • Patients will endorse pain approximately 4-6 cm proximal and dorsal to listers tubercle

Physical Exam: Physical Exam Forearm

  • Tenderness over the dorsoradial forearm (5 cm proximal to listers tubercle)
  • Swelling and crepitus may be appreciated on exam
    • Worse with wrist and thumb extension
    • Crepitus is specific to intersection syndrome
  • Pronation is typically more painful than supination

Special Tests

  • Crepitus over area with resisted wrist extension, thumb extension
  • Finkelstein Test: may be positive, but requires more provocation than De Quervain's

Evaluation

T2-hyperintense inflammatory edema around the intersection of the APL and EPB tendons and the wrist extensor tendons, about 4 cm proximal to Lister's tubercle[5]
There is peritendinous soft tissue thickening at the intersection of 1st and 2nd extensor compartments. Tendons show mild thickening without a tear. There is mild tendon sheath effusion involving both compartments. Local hypervascularity is present.[6]
  • Primarily a clinical diagnosis based on history and physical exam

Radiographs

Ultrasound

  • Point of care ultrasound can aid in diagnosis
  • Findings
    • Hypoechoic area in between the two dorsal compartments
    • Thickening of the tendon sheaths
    • Subcutaneous edema
    • Ganglion cyst

CT

  • Not helpful in the diagnosis of intersection syndrome

MRI

  • Gold standard to confirm diagnosis
  • Findings
    • Demonstrates peritendinous edema around 1st and 2nd extensor compartments[7]
    • Chronic cases may show a stenosing tenosynovitis
    • Muscle edema
    • Tendon thickening
    • Loss of normal comma shape of the tendon
    • Juxtacortical edema

Classification

  • N/A

Management

Cock Up Wrist Splint

Nonoperative

Operative

  • Indications
    • Rarely necessary for recalcitrant cases
  • Technique
    • Surgical debridement and release

Rehab and Return to Play

Rehabilitation

  • Modification of offending/ sporting activities

Return to Play/ Work

  • Relative rest for athletes
  • Graded return to play as they progress through therapy

Prognosis and Complications

  • Chronic pain

See Also

Internal

External

References

  1. ↑ Image courtesy of Malanga, Gerard A., and Kenneth R. Mautner. "Atlas of ultrasound-guided musculoskeletal injections." (No Title) (2014).
  2. ↑ 2.0 2.1 Skinner, Thomas M. "Intersection syndrome: the subtle squeak of an overused wrist." The Journal of the American Board of Family Medicine 30.4 (2017): 547-551.
  3. ↑ Lee RP, Hatem SF, Recht MP. Extended MRI findings of intersection syndrome. Skeletal Radiol. 2009;38 (2): 157-63. doi:10.1007/s00256-008-0587-4
  4. ↑ Browne J, Helms CA. Intersection syndrome of the forearm. Arthritis Rheum. 2006 Jun;54(6):2038.
  5. ↑ Case courtesy of Roberto Schubert, Radiopaedia.org, rID: 24709
  6. ↑ Case courtesy of Maulik S Patel, Radiopaedia.org, rID: 66323
  7. ↑ Costa CR, Morrison WB, Carrino JA. MRI features of intersection syndrome of the forearm. AJR Am J Roentgenol. 2003 Nov;181(5):1245-9.
Created by:
John Kiel on 18 June 2019 23:15:09
Authors:
Last edited:
4 August 2024 23:40:58
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