summary Clay-shoveler fractures are avulsion-type spinous process fractures in the lower cervical or upper thoracic spine Diagnosis is made using lateral radiographs of the cervical spine Treatment usually consists of rest and pain control, as the injuries are mechanically stable Epidemiology Incidence rare Demographics direct trauma to the posterior spinous process indirect trauma sudden muscular or ligamentous pull during flexion or extension Anatomic location most commonly C7, but can affect C6-T3 usually occurs midway between the spinous process tip and the lamina Risk factors laborers racket or contact sports motor vehicle accidents Etiology Associated conditions usually occurs in isolation other orthopaedic injuries to consider: lamina fracture facet dislocation Presentation Symptoms sudden onset of pain between the shoulder blades or at the base of the neck reduced head/neck ROM Physical exam inspection localized swelling tenderness crepitus motion document flexion-extension of cervical spine neurovascular examination Imaging Radiographs recommended views cervical +/- thoracic x-rays should always be obtained on initial evaluation alternative views flexion and extension views findings lateral view fracture line is usually obliquely oriented with the fragment displaced posteroinferiorly AP view double spinous process shadow is suggestive of displaced fracture CT indications routine CT imaging in high-energy trauma patients clinical criteria altered consciousness midline spinal pain or tenderness impaired CCJ motion lower cranial nerve paresis motor paresis views fracture is best seen on lateral view MRI indications not required in isolation Treatment Nonoperative NSAIDs, rest, and immobilization in a hard collar for comfort indications most common treatment for pain control modalities short-term treatment with hard collar outcomes usually high union rates and excellent clinical outcomes Operative surgical excision indications persistent pain or nonunion failed conservative treatment Complications Chronic pain Neck stiffness Prognosis Stable injury in isolation Very rarely associated with neurologic injury High union rate