summary Clay-shoveler Fractures are an avulsion-type spinous process fracture in the lower cervical or upper thoracic spine. Diagnosis is made with lateral radiographs of the cervical spine. Treatment is usually rest and pain control as the injuries are mechanically stable. Epidemiology Incidence rare Demographics direct trauma to posterior spinous process indirect trauma sudden muscular/ligamentous pull in flexion or extension Anatomic 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 Etiology Associated conditions usually occurs in isolation other orthopaedic injuries to consider lamina fracture facet dislocations Presentation 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 Imaging 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 Treatment 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 Complications Chronic pain Neck stiffness Prognosis Stable injury in isolation Very rarely associated with neurological injury High union rate