Pectoralis Major Tear/Rupture
August 30, 2017
Persistent Post-Concussion Symptoms
September 12, 2017

Intersection Syndrome

Intersection Syndrome (Also known as crossover syndrome; Oarsman’s wrist)

Description:
Intersection syndrome is a chronic, overuse injury in the distal radial forearm where the tendons of the 1st extensor compartment and the 2nd extensor compartment cross over, resulting in bursitis or tenosynovitis of either or both tendon sheaths. This condition is easily confused with and misdiagnosed with de Quervain’s tenosynovitis!

Epidemiology:

Often found in rowers, weight lifters, and skiers. Prolonged activities that involve repetitive wrist extension and flexion increases the risk of this injury.

Anatomy:
Figure 1 – Extensor Compartments of Wrist

(From Right to Left 1-6 – 1. Abductor Pollicis Longus (APL) and Extensor Pollicis Brevis (EPB) 2. Extensor Carpi Radialis Longus and Brevis (ECRL & ECRB) 3. Extensor Pollicis Longus (EPL) 4. Extensor Digitorum (ED) 5. Extensor Digiti Minimi (EDM) 6. Extensor Carpi Ulnaris (ECU)

Figure 2 – Anatomy of Intersection Syndrome


(image source http://iop.net.au/wp-content/uploads/2015/07/cotw_july3.jpg)

Figure 3 – Surface Anatomy of Intersection Syndrome


Figure 4 – Illustration of Intersection area of pain

 

Presentation:

Patient will often present with gradual development and worsening of pain in the distal radial forearm.

Pain is proximal to the wrist, within 4-8cm to Lister’s tubercle of the radius

Pain worsens with activities that involve repetitive forceful wrist flexion and extension

Pain is typically worse with movements of the wrist than movements of the thumb

Pain subsides with rest from such activities

Pain may be associated with localized swelling or crepitus (squeaking sensation) with active or resisted wrist or thumb extension (1)

 

Investigations:

Diagnosis of intersection syndrome is based on clinical findings

Imaging is often not required for diagnosis; however, imaging may help to confirm the diagnosis and/or to rule out other conditions

X-ray of the wrist and forearm: non-specific, to rule out other abnormalities not helpful in the diagnosis. Only indicated to rule out other pathology

Ultrasound of the forearm, esp. area of tenderness: may reveal tenosynovitis of tendon sheaths between the first two extensor compartments. An adventitial bursa between the two compartments at the level of intersection may also be seen (2)

MRI is indicated if there is persistent pain despite treatment or if the diagnosis is unclear after X-rays and ultrasound

Management:

Initial treatment:

  • Rest from aggravating activities, including any repetitive forceful wrist motions
  • Ice as needed
  • A short course of anti-inflammatory medication, e.g. naproxen 500mg PO bid x2wks
  • A short period of immobilization, for example, a thumb spica splint in 20 degrees of wrist extension may be used
  • Referral to physiotherapy to work on stretching, ROM exercises, and strengthening of the extensor muscle groups
  • Activity modification when returning to the aggravating sport/activity to minimize repetitive micro trauma. Consider change in techniques or oar size in rowers
  • If there is insufficient improvement in pain and functional after 2-3 weeks of the above measures, consider a corticosteroid injection (mixed with local anesthetic) into the bursa or tendon sheaths as appropriate

Surgical Treatment:

If the initial treatment fails after 3-4 weeks, a referral to surgery is indicated surgery is very rarely indicated. Consider only after failed prolonged conservative management

Surgical options include:

  • release of the second dorsal compartment
  • exploration and debridement of the intersection zone and excision of adventitial bursal tissue

release of the fascial sheaths of the tendons in the first dorsal compartment (doesn’t appear to be typically done)Postoperatively, the wrist is splinted for 7–10 days followed by a stretching and strengthening program, and return to sport is allowed when the patient is symptom free (3)

Author Dr. Hao Liu (July 24, 2017, PR KA)

References:

  1. Bracker, Mark. (2011) The 5-minute Sports Medicine Consult. Second Edition. Philadelphia : Wolters Kluwer Health/Lippincott Williams & Wilkins.
  2. Robinson, Philip. (2010) Essential Radiology for Sports Medicine. London: Springer.
  3. O’Connor, Francis. (2012) ACSM’s Sports Medicine: A Comprehensive Review. Wolters Kluwer Health/Lippincott Williams & Wilkins.