Proximal intersection syndrome is an overuse tenosynovitis that occurs around the intersection of the first extensor compartment (abductor pollicis longus and extensor pollicis brevis) and second extensor compartment (extensor carpi radialis longus and extensor carpi radialis brevis) within the forearm. It occurs proximal to the location of the more common condition De Quervain tenosynovitis.
The condition goes by an excessive array other names including peritendinitis crepitans, oarsman's wrist, crossover syndrome, subcutaneous perimyositis, squeaker's wrist, bugaboo forearm, adventitial bursitis, and APL syndrome 1.
There is usually a history of overuse through repetitive wrist flexion and extension, or, less commonly, direct trauma. Weightlifters, rowers, racket sport players, horseback riders, and skiers are particularly prone 1,2. Patients complain of radial wrist or forearm pain exacerbated by flexion and extension. Swelling and tenderness at the area of intersection may be present 2.
The musculotendinous junctions of the first extensor compartment tendons (abductor pollicis longus and extensor pollicis brevis) intersect the second extensor compartment tendons (extensor carpi radialis longus and extensor carpi radialis brevis tendons) at an angle of approximately 60° at a location approximately 4 cm proximal to Lister's tubercle. In intersection syndrome there is tenosynovitis particularly of the second extensor compartment possibly caused by friction from the overlying first compartment tendons 2.
The diagnosis is often made clinically but may be found when wrist and forearm pain is investigated with ultrasound and MRI.
Ultrasound often reveals fluid within the tendon sheaths and peritendinous edema. There is interruption of the hyperechoic plane that divides two tendon groups. Subcutaneous edema and ganglion cysts can be present.
The main finding is peritendinous edema concentrically surrounding the second and first extensor compartments centered around the point of crossover ~4 cm proximal to the Lister tubercle. Sometimes the edema may extend as far distally as the radiocarpal joint. There may or may not be tendon sheath fluid or fluid found in the interval between the tendon sheaths at the intersection point. Increased intrasubstance tendon signal may be seen indicating tendinosis 1,3.
Treatment and prognosis
Conservative management with immobilization, activity modification and anti-inflammatory medications is usually sufficient to control the symptoms. Local injection of corticosteroid can also be effective. Surgical treatment exists for recalcitrant cases 2.
History and etymology
The term "intersection syndrome" was proposed by Dobyns et al. in 1978. It refers to the intersection (at an angle of around 60°) of the musculotendinous junctions of the first and second extensor compartment tendons.
On imaging consider:
- 1. Lee RP, Hatem SF, Recht MP. Extended MRI findings of intersection syndrome. Skeletal Radiol. 2009;38 (2): 157-63. doi:10.1007/s00256-008-0587-4 - Pubmed citation
- 2. Intersection Syndrome by David R Steinberg from emedicine.com. Intersection Syndrome
- 3. Costa CR, Morrison WB, Carrino JA. MRI features of intersection syndrome of the forearm. AJR Am J Roentgenol. 2003;181 (5): 1245-9. AJR Am J Roentgenol (full text) - Pubmed citation
- 4. Montechiarello S, Miozzi F, D'Ambrosio I et-al. The intersection syndrome: Ultrasound findings and their diagnostic value. J Ultrasound. 2010;13 (2): 70-3. doi:10.1016/j.jus.2010.07.009 - Free text at pubmed - Pubmed citation
- 5. McAuliffe JA. Tendon disorders of the hand and wrist. (2010) The Journal of hand surgery. 35 (5): 846-53; quiz 853. doi:10.1016/j.jhsa.2010.03.001 - Pubmed
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