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Intersection Syndrome: Difference between revisions

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{{Authors}}
Ā 
{{Condition
Intersection syndrome is a tenosynovitis of the second dorsal compartment tendons caused by the "crossover" of the muscle bellies of the first dorsal compartment of the wrist, occurring approximately 2-4 cm proximal to the radial tubercle.{{condition
|image=De-Quervain-tenosynovitis-vs-intersection-syndrome.jpg
|image=
|caption=Regions of pain in De Quervain tenosynovitis and intersection syndrome.<ref name=":2" />
|name=
|synonym=peritendinitis crepitans, crossover syndrome, adventitial bursitis, subcutaneous perimyositis with abductor pollicis longus syndrome and bugaboo forearm.
|synonym=peritendinitis crepitans, crossover syndrome, adventitial bursitis, subcutaneous perimyositis with abductor pollicis longus syndrome and bugaboo forearm.
|definition=
|epidemiology=Rare
|epidemiology=
|classification=Proximal and distal forms.
|causes=
|riskfactors=Sports and occupational
|pathophysiology=
|ddx=[[De Quervain Tendinopathy]]
|classification=
|treatment=Rest, activity modification, wrist splinting, injection
|primaryprevention=
|prognosis=Good
|secondaryprevention=
|riskfactors=
|history=
|examination=
|diagnosis=
|tests=
|ddx=
|treatment=
|prognosis=
}}
}}
Ā 
{{Partial}}
Intersection syndrome is an uncommon overuse disorder of the forearm.
==Aetiopathophysiology==
==Aetiopathophysiology==
[[File:Intersection syndrome sites.jpg|left|thumb|400x400px|The anatomy of the proximal and distal intersection syndromes.]]
Intersection syndrome is an overuse injury caused by repetitive wrist extension. There are two forms - the more common proximal form, and less common distal form.
Intersection syndrome is an overuse injury caused by repetitive wrist extension. There are two forms - the more common proximal form, and less common distal form.


The most commonly affected site is where the musculotendinous junctions of the first compartment containing abductor pollicis longus (APL) and extensor pollicis brevis (EPB) cross over the tendons of the second compartment containing extensor carpi radialis longus (ECRL) and extensor carpi radialis brevis (ECRB). These two compartments intersect at an angle of approximately 60 degrees. One theory is that the syndrome is caused by frictions between the muscle bellies of first compartment cross over the tendons of the second compartment. Ā 
'''Proximal Intersection Syndrome'''
Ā 
In the proximal form the affected location is where the musculotendinous junctions of the first compartment containing abductor pollicis longus (APL) and extensor pollicis brevis (EPB) cross over the tendons of the second compartment containing extensor carpi radialis longus (ECRL) and extensor carpi radialis brevis (ECRB). These two compartments intersect at an angle of approximately 60 degrees located 4-8cm proximal to Lister's tubercle.
Ā 
One theory is that the syndrome is caused by frictions between the muscle bellies of first compartment cross over the tendons of the second compartment. A second theory is that there is entrapment of muscles in the second compartment secondary to stenosis - a "stenosing tenosynovitis". Ā 


A second theory is that there is entrapment of muscles in the second compartment secondary to stenosis - a "stenosing tenosynovitis".
'''Distal Intersection Syndrome'''


There is a rarer distal intersection site - where the third extensor compartment tendon intersects the second extensor compartment tendons.
There is a rarer distal intersection site that has been much more recently described than the proximal form. In the distal form the affected site is where the third extensor compartment tendon intersects with the second extensor compartment tendons. It is hypothesised that this form is related to the "biomechanical pulley effect" that Lister's tubercle has on the EPL tendon.<ref>{{Cite journal|last=Parellada|first=Antoni J.|last2=Gopez|first2=Angela G.|last3=Morrison|first3=William B.|last4=Sweet|first4=Stephanie|last5=Leinberry|first5=Charles F.|last6=Reiter|first6=Sean B.|last7=Kohn|first7=Mark|date=2007-01-26|title=Distal intersection tenosynovitis of the wrist: a lesser-known extensor tendinopathy with characteristic MR imaging features|url=http://link.springer.com/10.1007/s00256-006-0238-6|journal=Skeletal Radiology|language=en|volume=36|issue=3|pages=203ā€“208|doi=10.1007/s00256-006-0238-6|issn=0364-2348}}</ref>


==Epidemiology and Risk Factors==
==Epidemiology and Risk Factors==
The condition is considered to be rare. For example in a study of 1,131 patients referred for wrist ultrasound, intersection syndrome was only identified in 21 cases (1.9%).<ref>{{Cite journal|last=Draghi|first=Ferdinando|last2=Bortolotto|first2=Chandra|date=2014-03|title=Intersection syndrome: ultrasound imaging|url=http://link.springer.com/10.1007/s00256-013-1786-1|journal=Skeletal Radiology|language=en|volume=43|issue=3|pages=283ā€“287|doi=10.1007/s00256-013-1786-1|issn=0364-2348}}</ref>
The condition is considered to be rare. For example in a study of 1,131 patients referred for wrist ultrasound, intersection syndrome was only identified in 21 cases (1.9%).<ref name=":0">{{Cite journal|last=Draghi|first=Ferdinando|last2=Bortolotto|first2=Chandra|date=2014-03|title=Intersection syndrome: ultrasound imaging|url=http://link.springer.com/10.1007/s00256-013-1786-1|journal=Skeletal Radiology|language=en|volume=43|issue=3|pages=283ā€“287|doi=10.1007/s00256-013-1786-1|issn=0364-2348}}</ref> In another study of 1,815 MRI examinations of the wrist and forearm, intersection syndrome was only identified in 3 cases (0.2%).<ref name=":1">{{Cite journal|last=Costa|first=C. Rosalia|last2=Morrison|first2=William B.|last3=Carrino|first3=John A.|date=2003-11|title=MRI features of intersection syndrome of the forearm|url=https://pubmed.ncbi.nlm.nih.gov/14573413|journal=AJR. American journal of roentgenology|volume=181|issue=5|pages=1245ā€“1249|doi=10.2214/ajr.181.5.1811245|issn=0361-803X|pmid=14573413}}</ref>


In sport-people common culprits are heavy lifting, rowing, and racket sports. The highest risk is when beginning a new sport. The dominant hand is more commonly affected. It can also occur occupationally for example in typists and carpenters.
In sport-people common culprits are heavy lifting, rowing, skiing, and racket sports. The highest risk is when beginning a new sport. The dominant hand is more commonly affected. It can also occur occupationally for example in typists and carpenters.


==Clinical Features==
==Clinical Features==


===History===
===History===
The pain is located radially but is slightly more proximal and dorsal than [[De Quervain Tendinopathy|de quervains]]. They will typically also report a "squeaking" sensation with wrist and thumb movement.
The pain is located radially but is slightly more proximal and dorsal than [[De Quervain Tendinopathy|de Quervains]]. They will typically also report a "squeaking" sensation with wrist and thumb movement.


===Examination===
===Examination===
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==Investigations==
==Investigations==
Ultrasound and/or MRI
Ultrasound and/or MRI can confirm the diagnosis.
Ā 
In proximal intersection syndrome there is an effusion within the second extensor compartment tendon sheath and occasionally also within the first osseofibrous tunnel sheath. Less frequently there is oedema or a bursitis between the two tendon groups. In distal intersection syndrome common findings are tenosynovitis, soft tissue oedema, and bursitis.<ref name=":0" /> MRI shows peritendinous oedema.<ref name=":1" />


==Diagnosis==
==Diagnosis==
The diagnosis is made on clinical features, however imaging can be supportive.
The diagnosis is made on clinical features, however imaging can be supportive. Some clinicians prefer confirmation on imaging due to the low prevalence.<ref name=":0" />


==Differential Diagnosis==
==Differential Diagnosis==
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* Stretching
* Stretching
* NSAIDs
* NSAIDs
* Corticosteroid injection into the tendon sheath of the second compartment at the area of maximal tenderness.
* Injections - Corticosteroid injection into the tendon sheath of the second compartment at the area of maximal tenderness. Prolotherapy has also been described.<ref name=":2">{{Cite journal|last=Schmidt|first=Eric|last2=Kobayashi|first2=Yuka|last3=Gottschalk|first3=Andrew W.|date=2021|title=It's Not De Quervain Tenosynovitis - A Diagnosis to Consider in Persistent Wrist Pain|url=https://pubmed.ncbi.nlm.nih.gov/34239368|journal=Ochsner Journal|volume=21|issue=2|pages=120ā€“122|doi=10.31486/toj.21.0005|issn=1524-5012|pmc=8238112|pmid=34239368}}</ref>
* Surgery. This involves release of the second extensor compartment.
* Surgery. This involves release of the second extensor compartment.


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==References==
==References==
<references />
<references />
{{Reliable sources}}
Ā 
[[Category:Tendinopathies]]
[[Category:Tendinopathies]]
[[Category:Hand and Wrist Conditions]]
[[Category:Hand and Wrist Conditions]]
{{References}}
{{Reliable sources}}

Revision as of 22:47, 11 May 2024


De-Quervain-tenosynovitis-vs-intersection-syndrome.jpg
Regions of pain in De Quervain tenosynovitis and intersection syndrome.[1]
Intersection Syndrome
Synonym peritendinitis crepitans, crossover syndrome, adventitial bursitis, subcutaneous perimyositis with abductor pollicis longus syndrome and bugaboo forearm.
Epidemiology Rare
Classification Proximal and distal forms.
Risk Factors Sports and occupational
DDX De Quervain Tendinopathy
Treatment Rest, activity modification, wrist splinting, injection
Prognosis Good
This article is still missing information.

Intersection syndrome is an uncommon overuse disorder of the forearm.

Aetiopathophysiology

The anatomy of the proximal and distal intersection syndromes.

Intersection syndrome is an overuse injury caused by repetitive wrist extension. There are two forms - the more common proximal form, and less common distal form.

Proximal Intersection Syndrome

In the proximal form the affected location is where the musculotendinous junctions of the first compartment containing abductor pollicis longus (APL) and extensor pollicis brevis (EPB) cross over the tendons of the second compartment containing extensor carpi radialis longus (ECRL) and extensor carpi radialis brevis (ECRB). These two compartments intersect at an angle of approximately 60 degrees located 4-8cm proximal to Lister's tubercle.

One theory is that the syndrome is caused by frictions between the muscle bellies of first compartment cross over the tendons of the second compartment. A second theory is that there is entrapment of muscles in the second compartment secondary to stenosis - a "stenosing tenosynovitis".

Distal Intersection Syndrome

There is a rarer distal intersection site that has been much more recently described than the proximal form. In the distal form the affected site is where the third extensor compartment tendon intersects with the second extensor compartment tendons. It is hypothesised that this form is related to the "biomechanical pulley effect" that Lister's tubercle has on the EPL tendon.[2]

Epidemiology and Risk Factors

The condition is considered to be rare. For example in a study of 1,131 patients referred for wrist ultrasound, intersection syndrome was only identified in 21 cases (1.9%).[3] In another study of 1,815 MRI examinations of the wrist and forearm, intersection syndrome was only identified in 3 cases (0.2%).[4]

In sport-people common culprits are heavy lifting, rowing, skiing, and racket sports. The highest risk is when beginning a new sport. The dominant hand is more commonly affected. It can also occur occupationally for example in typists and carpenters.

Clinical Features

History

The pain is located radially but is slightly more proximal and dorsal than de Quervains. They will typically also report a "squeaking" sensation with wrist and thumb movement.

Examination

Swelling and redness may be noted compared to the contralateral side. Pay careful attention to the location of tenderness to avoid misdiagnosis as de quervains - they should not be tender over the radial styloid. More prominent movement of the thumb is required to reproduce the pain in comparison to de quervains. Wrist extension and radial deviation may reproduce pain. Squeaking or crepitus may be noted at the site. Auscultation can be performed over the area of pain while the patient flexes and extends their wrist.

Investigations

Ultrasound and/or MRI can confirm the diagnosis.

In proximal intersection syndrome there is an effusion within the second extensor compartment tendon sheath and occasionally also within the first osseofibrous tunnel sheath. Less frequently there is oedema or a bursitis between the two tendon groups. In distal intersection syndrome common findings are tenosynovitis, soft tissue oedema, and bursitis.[3] MRI shows peritendinous oedema.[4]

Diagnosis

The diagnosis is made on clinical features, however imaging can be supportive. Some clinicians prefer confirmation on imaging due to the low prevalence.[3]

Differential Diagnosis

Differential Diagnosis
  • De Quervain Syndrome
  • Scaphoid fracture
  • Osteoarthritis of the first metacarpal joint
  • Ganglion cyst
  • Wartenderg syndrome
  • Sprain

Treatment

  • Rest - The condition is commonly self-limited.
  • Activity modification
  • Bracing (wrist splint in neutral extension)
  • Stretching
  • NSAIDs
  • Injections - Corticosteroid injection into the tendon sheath of the second compartment at the area of maximal tenderness. Prolotherapy has also been described.[1]
  • Surgery. This involves release of the second extensor compartment.

Follow Up and Prognosis

The prognosis is generally good.

Summary

References

  1. ā†‘ 1.0 1.1 Schmidt, Eric; Kobayashi, Yuka; Gottschalk, Andrew W. (2021). "It's Not De Quervain Tenosynovitis - A Diagnosis to Consider in Persistent Wrist Pain". Ochsner Journal. 21 (2): 120ā€“122. doi:10.31486/toj.21.0005. ISSN 1524-5012. PMC 8238112. PMID 34239368.
  2. ā†‘ Parellada, Antoni J.; Gopez, Angela G.; Morrison, William B.; Sweet, Stephanie; Leinberry, Charles F.; Reiter, Sean B.; Kohn, Mark (2007-01-26). "Distal intersection tenosynovitis of the wrist: a lesser-known extensor tendinopathy with characteristic MR imaging features". Skeletal Radiology (in English). 36 (3): 203ā€“208. doi:10.1007/s00256-006-0238-6. ISSN 0364-2348.
  3. ā†‘ 3.0 3.1 3.2 Draghi, Ferdinando; Bortolotto, Chandra (2014-03). "Intersection syndrome: ultrasound imaging". Skeletal Radiology (in English). 43 (3): 283ā€“287. doi:10.1007/s00256-013-1786-1. ISSN 0364-2348. Check date values in: |date= (help)
  4. ā†‘ 4.0 4.1 Costa, C. Rosalia; Morrison, William B.; Carrino, John A. (2003-11). "MRI features of intersection syndrome of the forearm". AJR. American journal of roentgenology. 181 (5): 1245ā€“1249. doi:10.2214/ajr.181.5.1811245. ISSN 0361-803X. PMID 14573413. Check date values in: |date= (help)

Literature Review

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