Distal Intersection Syndrome

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Distal Intersection Syndrome

Authors, Editors, Case Information Author: David Robinson, MD Affiliation: Mayo Clinic Co Author(s): Jeffrey Payne, MD Ike Hasley, MD Senior Editor: Raul Rosario-Concepcion, MD Editor: Laura Mattson, DO Clinical Vignette: A 70-year-old right hand dominant female presented with dorsal radial wrist pain, distal to the radiocarpal joint. Symptoms started after a distal radius fracture and worsened with wrist extension and thumb movements such as texting. Type of Probe Used: 2-14Hz Linear Array Transducer Unlabeled Short Axis View of the 2nd Dorsal Compartment Unlabeled Short Axis View of the 2nd Dorsal Compartment with oblique view of the 3rd extensor compartment (EPL) crossing superficially. Labeled Short Axis View of the 2nd Dorsal Compartment Labeled Short Axis View of the 2nd Dorsal Compartment with oblique view of the 3rd extensor compartment (EPL) crossing superficially, with hypoechoic fluid collection located within the extensor carpi radialis brevis and extensor policis longus tendon sheaths. #3 - Video View Video Short-axis video of the 2nd dorsal extensor compartment, starting at Lister's tubercle and scanning distally to the intersection of the 2nd and 3rd extensor compartments (3rd crossed over the 2nd). ECRL is left and ECRB is right. EPL crosses from right to left. A fluid collection is seen predominantly around the ECRB with normal appearance of the ECRB/ECRL tendons themselves. #4 - Video View Video Asymptomatic contralateral wrist comparison scan (short-axis to 2nd dorsal extensor compartment). ECRB is left and ECRL is right. EPL crosses from left to right. #5 - Video View Video Short-axis video of the 3rd dorsal extensor compartment as it crosses over the 2nd extensor compartment. There was also a smaller, but present fluid collection within the 3rd dorsal extensor compartment surrounding the EPL tendon with a normal appearing tendon. #6 - Video View Video Long-axis video of the EPL crossing over the ECRB with both tendon sheaths having fluid collections present. Interpretation Image Interpretation: Sonographic findings consistent with 2nd and 3rd dorsal extensor compartment tenosynovitis located at the intersection of the EPL crossing over the 2nd dorsal extensor compartment (ECRL and ECRB) with most of the fluid collection noted around the extensor carpi radialis brevis and extensor pollicis longus. This can be seen in distal intersection syndrome. No sonographic evidence of significant tendinosis or a partial or full-thickness tear of the EPL, ECRB, or ECRL. Teaching Pearl: When scanning the third extensor compartment, remember that the extensor pollicis longus has an oblique course from the ulnar side, near Lister's tubercle, to the radial side as it inserts on the thumb. Make sure you angle the transducer to remain perpendicular to the tendon and avoid anisotropy. Distal intersection syndrome occurs where the EPL (3rd dorsal compartment) crosses the ERCL and ECRB (2nd dorsal compartment) and may show tenosynovitis, tendon thickening, crepitus with dynamic movement, and Doppler hyperemia. This distinction can help separate distal intersection syndrome from alternative etiologies such as De Quervain tenosynovitis or a dorsal ganglion. References: 1. Li TY. Unique sonographic presentation of distal intersection syndrome. J Diagn Med Sonogr. 2017;33(5):428-432. doi:10.1177/8756479317721664 2. Mattox R, Battaglia PJ, Scali F, Ottolini K, Kettner NW. Distal intersection syndrome progressing to extensor pollicis longus tendon rupture: a case report with sonographic findings. J Ultrasound. 2017;20(3):237-241. doi:10.1007/s40477-016-0223-4 3. Parellada AJ, Gopez AG, Morrison WB, Sweet S, Leinberry CF, Reiter SB, Kohn M. Distal intersection tenosynovitis of the wrist: a lesser-known extensor tendinopathy with characteristic MR imaging features. Skeletal Radiol. 2007;36(3):203-208. doi:10.1007/s00256-006-0238-6
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Authors, Editors, Case Information

Unlabeled Short Axis View of the 2nd Dorsal Compartment

Labeled Short Axis View of the 2nd Dorsal Compartment

#3 - Video

#4 - Video

#5 - Video

#6 - Video

Interpretation

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