Updated: 1/23/2019

Clay-shoveler Fracture (Cervical Spinous Process Fractures)

Review Topic
  • Avulsion-type spinous process fracture in the lower cervical or upper thoracic spine
  • Epidemiology
    • incidence
      • rare
    • demographics
      • direct trauma to posterior spinous process
      • indirect trauma 
        • sudden muscular/ligamentous pull in flexion or extension
    • body location
      • most commonly C7, but can affect C6 to T3
      • usually occurs midway between the spinous tip and lamina
    • risk factors
      • labourers
      • racket or contact sports
      • motor vehicle accidents
  • Associated conditions
    • usually occurs in isolation
      • other orthopaedic injuries to consider
        • lamina fracture
        • facet dislocations
  • Prognosis
    • stable injury in isolation
    • very rarely assoicated with neurological injury
    • high union rate
  • Symptoms
    • sudden onset of pain between the shoulder blades or base of neck
    • reduced head/neck ROM
  • Physical exam
    • inspection
      • localized swelling and tenderness
      • crepitus
    • motion
      • document flexion-extension of cervical spine
    • neurovascular examination
  • Radiographs 
    • recommended views  
      • cervical +/- throacic xrays that should always be obtained on evaluation
    • alternative views
      • flexion and extension views 
    • findings
      • lateral view  
        • fracture line is usually obliquely oriented with the fragment displaced posteroinferior
      • AP view   
        • double spinous process shadow is suggestive of displaced fracture
  • CT 
    • indications  
      • method of choice
      • 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 isolcation
  • Nonoperative
    • NSAIDS, rest, immobilization in 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 clincal outcomes
  • Operative
    • surgical excision
      • indications
        • persistent pain or non-union 
        • failed conservative treatment
  • Chronic pain
  • Neck stiffness

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