eMedicine Specialties > Orthopedic Surgery > Hand & Upper Extremity

Intersection Syndrome: Treatment

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

Treatment

Medical Therapy

Conservative treatment of intersection syndrome includes immobilization, activity modification, and pharmacologic intervention. The radial wrist extensors can be immobilized with a cock-up wrist splint (20 º of extension). Because of secondary irritation by the abductor pollicis longus (APL) and extensor pollicis brevis (EPB), a thumb spica splint (allowing thumb interphalangeal [IP] motion) is frequently required. Three weeks of relatively constant immobilization, followed by gradual splint weaning, usually is recommended. Activity modification at home or work is also critical.

Oral nonsteroidal anti-inflammatory drugs (NSAIDs) may decrease inflammation. A 2-mL injection of 1% lidocaine/betamethasone directly into the area of swelling may be effective in recalcitrant cases. A short course of oral steroids may be needed.

Once the most severe symptoms are under control, a program of supervised hand or occupational therapy leads to long-term recovery. This may include tendon stretching, ultrasound, and thermal modalities, followed by secondary strengthening and activities of daily living (ADL) modification or essential job task retraining.

Surgical Therapy

Surgery can be effective in cases of intersection syndrome that do not respond to conservative measures.10

Intraoperative Details

The second extensor compartment is approached through a dorsal longitudinal incision, beginning over the area of swelling and continuing distally 3-4 cm. Bluntly dissect down to the dorsal forearm fascia and divide longitudinally. Protect major veins and, particularly, branches of the radial sensory nerve that are located in this region. Completely mobilize the extensor carpi radialis longus (ECRL) and extensor carpi radialis brevis (ECRB) tendons by longitudinally incising the extensor retinaculum over the second compartment. A bursa also may form between the overlying APL and EPB tendons. When present, this bursa should be resected. Perform a thorough tenosynovectomy while elevating and protecting the tendons. This also may require mobilization of the EPB and APL, which then are retracted proximally and distally to provide complete access to the second compartment. The extensor retinaculum is not repaired. Skin is closed in routine fashion.

Postoperative Details

Immobilize the area in a compressive dressing and well-padded volar thumb spica splint, maintaining the wrist at 20 º of extension for 7-10 days.

Follow-up

At the first postoperative visit, place the patient in a removable splint and encourage early wrist range-of-motion (ROM) exercises. Some patients require postoperative therapy similar to that used prior to surgery.

Occupational therapy generally is initiated early for patients with labor-intensive occupations. The goals of therapy are strengthening, full ROM, and modification of equipment. The rehabilitation period may last 4-6 weeks.

Complications

Cortisone injections near the skin may cause depigmentation in patients who are dark skinned. These injections also may lead to subcutaneous fat atrophy or necrosis, infection, and tendon rupture, although, fortunately, these complications are rare.

Theoretically, surgical release of the extensor retinaculum could lead to bowstringing of the tendons in extreme wrist extension. However, this potential problem has not been reported.

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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