High Yield Topics

Intersection Syndrome

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Ovid: 5-Minute Sports Medicine Consult, The


Intersection Syndrome
Jennifer Scott Koontz
Basics
Description
  • Intersection syndrome is an inflammatory condition located in the distal radial forearm where the tendons of the 1st extensor compartment cross over the tendons of the 2nd compartment.
  • Patient usually presents with pain, crepitus, and squeaky sensation in the dorsal distal forearm. May have localized swelling.
  • Pain usually occurs about 4 cm (range of 4–8 cm) proximal to the radial styloid.
  • Synonym(s): Oarsman's wrist; Crossover syndrome; Squeaker's wrist; Peritendinitis crepitans
Epidemiology
  • Most common in rowers and weight lifters
  • Skiers, other athletes, or workers that do repetitive forceful wrist flexion and extension activities are also at risk.
Risk Factors
Sports with increased risk include:
  • Rowing (1)
  • Weightlifting
  • Skiing
  • Racquetball
  • Tennis
  • Any activity with repetitive forceful flexion and extension of the wrist
Etiology
  • The abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons comprise the 1st compartment.
  • The extensor carpi radialis longus (ECRL) and brevis (ECRB) tendons comprise the 2nd compartment.
  • Friction occurs at the intersection where the APL and EPB of the 1st compartment cross over the tendon sheath of the ECRL and ECRB in the 2nd compartment.
  • This results in a tenosynovitis of the 2nd compartment.
Diagnosis
History
  • Commonly misdiagnosed as de Quervain's tenosynovitis
  • History of increase in activity that requires repetitive wrist flexion/extension
  • Athletes will report pain in the distal forearm or radial side of wrist, typically 4 cm (range of 4–8 cm) proximal to the radial styloid. May complain of localized swelling and a squeaking sensation.
Physical Exam
  • Localized swelling 4–8 cm proximal to the radial styloid may be present.
  • Crepitus on palpation is classic for intersection syndrome.
  • Pain exacerbated by ulnar deviation of the hand
  • Movement of wrist typically causes more pain than movement of thumb, as seen in de Quervain's
  • Bony palpation is typically nontender, and neurovascular status should be intact.
Diagnostic Tests & Interpretation
Imaging
  • Radiographs should be taken to rule out any underlying abnormalities. Anteroposterior, lateral, and oblique views of the wrist and distal forearm should be obtained.
  • If US is available, this could be helpful for differentiating intersection syndrome from other disorders (2)[C].
  • MRI would not be indicated in the initial evaluation of this syndrome. If diagnosis is not clear or pain is persistent, MRI could be considered to evaluate for soft tissue masses or bony abnormalities. The MRI may need to be extended to include the forearm in addition to the wrist (3)[B].
Differential Diagnosis
  • De Quervain's tenosynovitis
  • Extensor pollicis longus tendinitis (drummer boy palsy)
  • Wartenberg's syndrome (neuritis of superficial radial nerve)
  • Degenerative joint disease of carpometacarpal joint
  • Radial styloid fracture
  • Scaphoid fracture

P.337


Treatment
Initial treatment (for 2–3 wks):
  • Rest
  • Ice
  • NSAIDs
  • Thumb spica splint in 15–20 degrees of extension
Additional Treatment
  • All treatment requires subsequent activity modification to prevent recurrence.
  • Occupational therapy may be helpful for stretching program, local swelling reduction, and to help with activity modification.
  • If no relief with NSAIDs, a short course of oral prednisone may be given.
  • Injection is usually reserved after no improvement with 2–3 wks of splinting and activity modification.
  • 2–3 mL of a local anesthetic and steroid combination may be injected into the area of maximal swelling.
Surgery/Other Procedures
  • Surgery is reserved for recalcitrant cases.
  • Surgery may include tenosynovectomy or bursectomy.
Ongoing Care
Follow-Up Recommendations
  • If no improvement after adequate course of conservative therapy, surgical referral is warranted.
  • Surgery may be needed if fibrosis of the tendon sheath has occurred (4).
Prognosis
  • Recovery is usually achieved after initial treatment of activity modification, splinting, and NSAIDs for 2–3 wks. A 60% recovery response to conservative therapy has been reported (5).
  • If surgery is necessary, postoperative rehabilitation typically lasts 4–6 wks.
  • Return to play may occur once symptoms have resolved.
References
1. Rumball JS, Lebrun CM, Di Ciacca SR, et al. Rowing injuries. Sports Med. 2005;35:537–555.
2. De Maeseneer M, Marcelis S, Jager T, et al. Spectrum of normal and pathologic findings in the region of the first extensor compartment of the wrist: sonographic findings and correlations with dissections. J Ultrasound Med. 2009;28:779–786.
3. Lee RP, Hatem SF, Recht MP. Extended MRI findings of intersection syndrome. Skeletal Radiol. 2008.
4. Fulcher SM, Kiefhaber TR, Stern PJ. Upper-extremity tendinitis and overuse syndromes in the athlete. Clin Sports Med. 1998;17:433–448.
5. Grundberg AB, Reagan DS. Pathologic anatomy of the forearm: intersection syndrome. J Hand Surg [Am]. 1985;10:299–302.
Additional Reading
Rettig AC. Wrist and hand overuse syndromes. Clin Sports Med. 2001;20:591–611.
Codes
ICD9
726.4 Enthesopathy of wrist and carpus
Clinical Pearls
  • Intersection syndrome is an overuse syndrome.
  • Pain is located 4–8 cm proximal to radial styloid.
  • Athletes will often report a squeaking sensation in their wrist.
  • Be able to consider both intersection syndrome and de Quervain's tenosynovitis in the differential of distal forearm pain.
  • The mainstay of treatment is conservative, utilizing activity modification and a short course of NSAIDs and thumb-spica splinting.


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