http://upload.orthobullets.com/topic/6032/images/Illustration - hand university_moved.jpg
http://upload.orthobullets.com/topic/6032/images/extensor compartments_moved.jpg
Introduction
  • Due to inflammation at crossing point of 1st dorsal compartment (APL and EPB ) and 2nd dorsal compartment (ECRL, ECRB)
  • Epidemiology
    • common in
      • rowers
      • weight lifters
  •  Pathophysiology
    • mechanism is repetitive wrist extension
Anatomy
  • Extensor tendon compartments  
    • Compartment 1 (De Quervain's Tenosynovitis )
      •  APL
      •  EPB 
    • Compartment 2 (Intersection syndrome)
      •  ECRL 
      •  ECRB 
    • Compartment 3
      •  EPL 
    • Compartment 4
      •  EIP 
      •  EDC 
    • Compartment 5 (Vaughn-Jackson Syndrome )
      •  EDM
    • Compartment 6 (Snapping ECU )
      •  ECU
Presentation
  • Symptoms
    • pain over dorsal forearm and wrist
  • Physical exam 
    • tenderness on dorsoradial forearm
      • approximately 5cm proximal to the wrist joint
    • provocative tests
      • crepitus over area with resisted wrist extension and thumb extension
Imaging
  • Radiographs
    • not required for the diagnosis or treatment of intersection syndrome
  • MRI  
    • indications
      • to confirm diagnosis when clinical findings unclear
    • views
      • fluid sensitive sequences (short tau inversion recovery, STIR; fat suppressed proton density, FS PD; T2-weighted)
    • findings
      • most characteristic is peritendinous edema or fluid surrounding the 1st and 2nd extensor compartments  
      • other findings - tendinosis, muscle edema, tendon thickening, loss of the normal comma shape of the tendon, and juxtacortical edema may also be seen
Treatment
  • Nonoperative
    • rest, wrist splinting, steroid injections
      • indications
        • first line of treatment
      • technique
        • injection aimed into 2nd dorsal compartment (ECRL, ECRB) q
  • Operative
    • surgical debridement and release
      • indications
        •  rarely indicated in recalcitrant cases
      • technique
        • release of the 2nd dorsal compartment approximately 6 cm proximal to radial styloid
 

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Questions (1)

(OBQ07.235) A collegiate rower complains of dorsal wrist pain for 6 weeks refractory to NSAIDs and bracing. Maximal tenderness is palpated on the dorsoradial forearm approximately 5 cm proximal to the wrist. Pain is exacerbated with resisted wrist extension. Radiographs are unremarkable. A steroid injection should be directed into the compartment containing which of the following structures? Review Topic

QID:896
1

APL and EPB tendons

11%

(183/1654)

2

ECRL and ECRB tendons

77%

(1272/1654)

3

EPL tendon

3%

(45/1654)

4

APL and ECRB tendons

8%

(130/1654)

5

Brachoradialis tendon

1%

(16/1654)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

The clinical scenario is consistent with intersection syndrome, a inflammatory response to overuse at the site of the second dorsal compartment crossing under the first dorsal compartment approximately 5 cm proximal to the wrist. An anatomical depiction is provided in illustration A. Injections of the second dorsal compartment, which includes ECRL and ECRB, may relieve symptoms and quell inflammation. Intersection must be differentiated from DeQuervain's syndrome, which is tenosynovitis of the first dorsal compartment. Injections of the first dorsal compartment, which includes APL and EPB, are part of the treatment algorithm for Dequervain's. Wood et al summarizes the evaluation and treatment of sports-related wrist injuries. Grundberg et al demonstrates the pathologic abnormality of intersection syndrome is stenosing tenosynovitis of the second compartment explaining the rationale behind steroid injections into the sheath.

ILLUSTRATIONS:

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