eMedicine Specialties > Orthopedic Surgery > Hand & Upper Extremity

Intersection Syndrome

Author: David R Steinberg, MD, Director of Hand Fellowship, Associate Professor, Department of Orthopedic Surgery, University of Pennsylvania Health System
Contributor Information and Disclosures

Updated: Oct 22, 2008

Introduction

Multiple conditions can cause radial-sided wrist and forearm pain; the most common are de Quervain tenosynovitis and thumb carpometacarpal (CMC) arthritis. Intersection syndrome (tenosynovitis of the radial wrist extensors) can also cause radial-sided wrist and forearm pain.

Problem

Intersection syndrome is tenosynovitis of the radial wrist extensors, extensor carpi radialis longus (ECRL), and extensor carpi radialis brevis (ECRB). The condition also affects the extensor pollicis brevis (EPB) and the abductor pollicis longus (APL), causing pain and swelling of these muscle bellies. Intersection syndrome is characterized by pain and swelling in the distal dorsoradial forearm.1,2

Frequency

Intersection syndrome is much less common than de Quervain tenosynovitis, the syndrome with which it is most easily confused.

Etiology

Intersection syndrome can be caused by direct trauma to the second extensor compartment. It is more commonly brought on by activities that require repetitive wrist flexion and extension.3 Weightlifters, rowers, and other athletes are particularly prone to this condition.4,5

Pathophysiology

While this condition occurs at the intersection of the first and second extensor compartments, many contend that the condition is a tenosynovitis of the extensor carpi radialis longus (ECRL) and extensor carpi radialis brevis (ECRB) tendons. However, the condition has long been held to be caused by friction from the overlying extensor pollicis brevis (EPB) and abductor pollicis longus (APL) tendons.6 Tensile and shearing stresses in the tendons and peritendinous tissues may lead to thickening, adhesions, and cellular proliferation. Subsequent swelling and proliferation of tenosynovium may cause pain, as these tissues are compressed within the unyielding second extensor compartment.

Presentation

Patients with intersection syndrome complain of radial wrist or forearm pain. Symptoms may be exacerbated by repetitive wrist flexion and extension.

On examination, discrete swelling at this area of intersection often is present. Active or passive wrist motion produces a characteristic "wet leather" crepitus. The examiner must exclude other causes of radial forearm pain, such as de Quervain tenosynovitis, thumb CMC arthritis, radial sensory nerve irritation (Wartenberg syndrome), and extensor pollicis longus (EPL) tendinitis.

Indications

Surgery is only rarely required, when symptoms persist despite an adequate course of conservative treatment (including activity modification).

Relevant Anatomy

The dorsal wrist and dorsal distal forearm are divided into 6 extensor compartments. Intersection syndrome involves the first 2 compartments. The tendons of the first compartment, the abductor pollicis longus (APL) and extensor pollicis brevis (EPB), pass obliquely over (dorsal to) the extensor carpi radialis longus (ECRL) and extensor carpi radialis brevis (ECRB) in the second compartment, approximately at their musculotendinous junction. This intersection occurs dorsoradially at the junction of the middle and distal thirds of the forearm, just proximal to the extensor retinaculum. The radial wrist extensors continue distally through the second compartment, the boundaries of which are the distal radius, 2 vertical septal walls, and the overlying extensor retinaculum. The ECRL and ECRB pass over the dorsal wrist capsule before inserting into the base of the index and long finger metacarpals, respectively.

Contraindications

Surgery is contraindicated in patients with vague nonspecific complaints or in those patients who have not received or been compliant with recommended nonoperative measures.

More on Intersection Syndrome

Overview: Intersection Syndrome
Workup: Intersection Syndrome
Treatment: Intersection Syndrome
Follow-up: Intersection Syndrome
References
Further Reading
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References

  1. Thorson E, Szabo RM. Common tendinitis problems in the hand and forearm. Orthop Clin North Am. Jan 1992;23(1):65-74. [Medline].

  2. Browne J, Helms CA. Intersection syndrome of the forearm. Arthritis Rheum. Jun 2006;54(6):2038. [Medline].

  3. Descatha A, Leproust H, Roure P, Ronan C, Roquelaure Y. Is the intersection syndrome an occupational disease?. Joint Bone Spine. May 2008;75(3):329-31. [Medline].

  4. Wood MB, Dobyns JH. Sports-related extraarticular wrist syndromes. Clin Orthop. Jan 1986;(202):93-102. [Medline].

  5. McNally E, Wilson D, Seiler S. Rowing injuries. Semin Musculoskelet Radiol. Dec 2005;9(4):379-96. [Medline].

  6. Wood MB, Linscheid RL. Abductor pollicis longus bursitis. Clin Orthop. Jun 1973;93:293-6. [Medline].

  7. de Lima JE, Kim HJ, Albertotti F, Resnick D. Intersection syndrome: MR imaging with anatomic comparison of the distal forearm. Skeletal Radiol. Nov 2004;33(11):627-31. [Medline].

  8. Lee RP, Hatem SF, Recht MP. Extended MRI findings of intersection syndrome. Skeletal Radiol. Sep 23 2008;[Medline].

  9. Costa CR, Morrison WB, Carrino JA. MRI features of intersection syndrome of the forearm. AJR Am J Roentgenol. Nov 2003;181(5):1245-9. [Medline].

  10. Williams JG. Surgical management of traumatic non-infective tenosynovitis of the wrist extensors. J Bone Joint Surg Br. Nov 1977;59-B(4):408-10. [Medline].

  11. Grundberg AB, Reagan DS. Pathologic anatomy of the forearm: intersection syndrome. J Hand Surg [Am]. Mar 1985;10(2):299-302. [Medline].

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Further Reading

Forearm, wrist, & hand (acute & chronic), not including carpal tunnel syndrome.
Work Loss Data Institute.  2004 (revised 2007 May 16).  80 pages. [NGC Update Pending] NGC:005799
 
Chronic wrist pain.
American College of Radiology.  1998 (revised 2005).  7 pages.  NGC:004619
 
Forearm, wrist and hand complaints.
American College of Occupational and Environmental Medicine.  1997 (revised 2004).  34 pages.  NGC:004754

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Keywords

intersection syndrome, tenosynovitis of the radial wrist extensors, tendinitis, de Quervain tenosynovitis, thumb carpometacarpal arthritis, thumb CMC arthritis, wrist pain, forearm pain

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Contributor Information and Disclosures

Author

David R Steinberg, MD, Director of Hand Fellowship, Associate Professor, Department of Orthopedic Surgery, University of Pennsylvania Health System
David R Steinberg, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons and American Society for Surgery of the Hand
Disclosure: Johnson & Jonhnson nothing received, but own stock in company from personal investment None

Medical Editor

Peter M Murray, MD, Associate Professor of Orthopedic Surgery, Mayo Clinic College of Medicine; Director of Education, Mayo Foundation for Medical Education and Research, Jacksonville; Consultant, Department of Orthopedic Surgery, Mayo Clinic, Jacksonville; Consulting Staff, Nemours Children's Clinic and Wolfson's Children's Hospital
Peter M Murray, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association for Hand Surgery, American Orthopaedic Association, American Society for Reconstructive Microsurgery, American Society for Surgery of the Hand, Florida Medical Association, Orthopaedic Research Society, and Society of Military Orthopaedic Surgeons
Disclosure: Small Bone Innovations Workshop Honoraria Speaking and teaching

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Thomas R Hunt III, MD, John D Sherrill Professor and Director of Orthopaedic Surgery, Surgeon in Chief of UAB Highlands Hospital, Director of Hand and Upper Extremity Fellowship, University of Alabama at Birmingham
Thomas R Hunt III, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association for Hand Surgery, American Orthopaedic Association, American Orthopaedic Society for Sports Medicine, American Society for Surgery of the Hand, AO Foundation, Mid-America Orthopaedic Association, and Southern Orthopaedic Association
Disclosure: Tornier Consulting fee Review panel membership; Tornier Royalty None; Tornier Ownership interest None

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD, Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami School of Medicine
Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, and Arkansas Medical Society
Disclosure: Nothing to disclose.

 
 
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