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Introduction

Intersection syndrome is a repetitive motion injury of the wrist that occurs from overuse and subsequent inflammation, or peritenosynovitis, at the intersection of the muscles of the first and second dorsal compartments. The muscles involved in this syndrome are the abductor pollicis longus (APL) and the extensor pollicis brevis (EPB) of the first dorsal compartment and the extensor carpi radialis brevis (ECRB) and extensor carpi radialis longus (ECRL), or radial wrist extensors, of the second dorsal compartment. Fluid collection in the tendon sheaths of these muscles along with swelling and pain are indications of this syndrome. Intersection syndrome is fairly uncommon and is usually a result of recurring flexion and extension of the wrist.

Pathophysiology

Repetitive flexion and extension of the wrist, often associated with resistance, is the major cause of intersection syndrome. It commonly occurs in rowers, weightlifters, gymnasts, and athletes participating in sports that require swinging a racquet, stick, or bat (eg, tennis, field hockey, or baseball). Additionally, manual laborers who undergo extensive and repetitive flexing and extending motions with high resistance and compression forces can develop intersection syndrome (eg, landscapers). 

Related Anatomy

Dorsal compartments 1 and 2 are involved in intersection syndrome; there are six dorsal compartments involved in wrist movement.

Incidence and Related Conditions

  • Occurs in 0.2–0.4% of the general population
  • Possibly a greater incidence occurs among athletes, but this has yet to be studied
  • Intersection syndrome can be mistaken for other syndromes, and there is controversy regarding the exact location of the tendons causing the condition (compartment 2 or both 1 and 2)

Differential Diagnosis

  • Blunt trauma
  • de Quervain’s tenosynovitis (dorsal compartment 1)
  • Ganglion cysts
  • Muscle strains
  • Tenosynovitis (dorsal compartments 2 or 3)
  • Wartenberg’s syndrome
  • Wrist ligament strains
ICD-10 Codes
  • INTERSECTION SYNDROME

    Diagnostic Guide Name

    INTERSECTION SYNDROME

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    INTERSECTION SYNDROME M65.842M65.841 

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Clinical Presentation Photos and Related Diagrams
  • Intersection Syndrome is caused by inflammation in the area (arrow) between the radial wrist extensors (ECRB&ECRL) and the thumb abductor and extensor (APL & EPB)
    Intersection Syndrome is caused by inflammation in the area (arrow) between the radial wrist extensors (ECRB&ECRL) and the thumb abductor and extensor (APL & EPB)
Symptoms
Crepitus in dorsal radial distal forearm
Erythema in dorsal radial distal forearm
Fluid in the tendon sheaths in dorsal radial distal forearm
Positive Tests, Exams or Signs
Work-up Options
Images (X-Ray, MRI, etc.)
  • Normal X-ray of distal forearm and wrist (Typical of Intersection Syndrome)
    Normal X-ray of distal forearm and wrist (Typical of Intersection Syndrome)
  • MRI showing fluid (arrow) in intersection of AbPL and ECRL&B
    MRI showing fluid (arrow) in intersection of AbPL and ECRL&B
Treatment Options
Conservative
  • Rest, splinting, NSAIDs
  • Properly immobilized patients should heal within 12 days
  • Steroid-anesthetic combination injections for patients with no improvement after 2–3 weeks of splinting
Operative
  • Surgical decompression of dorsal compartment 2 and release of tendon sheath (no procedure directed to structures proximal to sheath)
  • Highly effective in almost all patients; only provided as an option to patients that do not respond to conservative treatments
Complications
  • Splinting and NSAIDs: incorrect splinting can lengthen recovery time
  • Corticosteroid injections: ecchymosis, tendon rupture, ≤6% of patients experience adverse events
  • Surgery: nerve injury, incomplete decompression of tendons, instability of tendons, adhesion, surgical scar hypertrophy, wound dehiscence
Outcomes
  • Proper splinting and rest in patients with intersection syndrome can promote healing within 12 days
  • Success rate for surgery is almost 100%
Video
Intersection Syndrome Examination
Key Educational Points
  • Intersection syndrome is a repetitive motion injury of the intersection of the muscles/tendons of the first and second dorsal compartments
  • Intersection syndrome is very rare and surgical treatment is rarely needed.
References

New Articles

  1. Kaneko S, Takasaki H. Forearm pain, diagnosed as intersection syndrome, managed by taping: a case series. J Orthoped Sports Physical Ther 2011;41:514-519. PMID: 21471652
  2. Lee H-J, Kim P-T, Aminata IW, et al. Surgical release of the first extensor compartment for refractory de Quervain’s tenosynovitis: surgical findings and functional evaluation using DASH scores. Clin Orthoped Surg 2014;6:405-409. PMID: 25436064
  3. Yonnet G.  Intersection syndrome in a handcyclist: Case report and literature review. Top Spinal Cord Inj Rehabil 2013;19(3):236-43. PMID: 23960708

Review

  1. Montechiarello S, Miozzi F, D’Ambrosio I, Giovagnorio F. The intersection syndrome: Ultrasound findings and their diagnostic value. J Ultrasound 2010;13(2):70-3. PMID 23396515

Chapter

  1. Smithers JD. Tendinopathy. In: Micheli LJ, ed. Encyclopedia of Sports Medicine, Vol 4.  Thousand Oaks, CA: Sage Publications, Inc; 2011.

Case Report

  1. Browne J, Helms CA. Clinical Images: Intersection syndrome of the forearm. Arthritis Rheum 2006;54:2038. PMID: 16736508

Classics

  1. Grundberg A, Reagan D. Pathologic anatomy of the forearm: Intersection syndrome. J Hand Surg Am 1985;10(2):299-302. PMID: 3980951
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