Updated: 6/23/2021

Clay-shoveler Fracture (Cervical Spinous Process Fractures)

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  • 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
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