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Spinous Process Fracture

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Other Names

  • Clay Shoveler Fracture
  • Clay-shoveler fracture
  • Navvies’ disease (in British canal diggers)
  • Schipper’s disease (in German Autobahn laborers)
  • Land grader’s disease (in French land workers)
  • Thoracic spinous Proces Fracture
  • Schmitt’s disease (adolescent form)
  • Thoracic spinous process fracture
  • Lumbar spinous process fracture
  • Thoracolumbar spinous process fracture
  • SPF

Background

  • This page refers to stress or avulsion fractures of spinous process of the cervical, thoracic and lumbar spine
    • Classically and most commonly occur in the cervical spine
    • Can occur in thorax, lumbar segments as well

History

  • First described in 1875 (need citation)
  • Widely recognized in western Australia in the 1930s where they earned their common name 'clay shoveler's fracture'[1]

Pathophysiology

  • Historically, due to laborers shoveling heavy loads (i.e. clay)
  • Asymmetrical heavy loads are implicated specifically due to recruitment of upper back muscles along the intraspinal ligaments
  • Primarily considered an occupational disease
    • Much less common due to industrial revolution, automation and mechanized heavy labor
  • C7 and T1 spinous process most commonly involved
  • Other causes
    • Direct blow to spinous process
    • Avulsion of the spinous process after forced flexion of the cervical spine
    • Impaction fractures after forced hyperextension

Pathoanatomy

  • Spinous Process of vertebrae
  • Ligaments
    • Ligamentum Nuchae: extends along all cervical SP, acts as intermuscular septum
  • Muscles

Risk Factors

  • Occupational
    • Shoveling
    • Metal dipping
    • Land grading
    • Tree grubbing
    • Road construction
  • Sports
    • Contact sports
    • Racket sports
  • MVC

Differential Diagnosis

Differential Diagnosis Neck Pain

Differential Diagnosis Back Pain


Clinical Features

  • General: Physical Exam Neck, Physical Exam Back
  • History
    • Patient will complain of sudden, sharp upper back and neck pain or between the shoulder blades
    • Some patients may report a pop
    • Activity often not out of the ordinary for patient
    • Some my report a milder pain preceding the acute onset
  • Physical Exam
    • Antalgic posture, neck slightly flexed and scapula elevated
    • Pain with shoulder and cervical spine movement
    • Point tenderness on the spinous processes of the fracture
    • There may be crepitus
    • There should be no neurological deficits

Evaluation

Radiographs

  • Standard views of C-Spine, T-Spine, L-Spine
  • Usually sufficient to make diagnosis
  • AP: May see "double shadow" or "double spinous sign"
  • Lateral: fracture lines usually visible, extend of displacement
  • Fractures tend to run obliquely through the spinous process

CT

  • Indicated in the setting of high energy trauma
  • Indicated if diagnosis uncertain or other etiology suspected

MRI

  • Indicated if diagnosis uncertain or other etiology suspected

Classification

  • N/A

Management

Prognosis

  • Generally excellent
    • Most patients fully recover to preinjury activity levels

Nonoperative

  • Considered stable, thus conservative treatment is first line therapy
  • Rest
  • Activity modification for 4-6 weeks
  • Anaglesics including NSAIDS, Acetaminophen
  • Immobilization: Cervical Collar
    • Reduces fragment movement, pain
    • Average duration of immobilization is 4-6 weeks
  • Physical Therapy
    • Unclear if beneficial, one case report suggested aggravated symptoms[2]

Operative

  • Indications
    • Persistent pain refractory to conservative measures
  • Technique
    • Excision of fracture fragments

Rehab and Return to Play

Rehabilitation

  • Needs to be updated

Return to Play

  • Most individuals return to normal activities between 3 weeks and 4 months

Complications

  • Nonunion
  • Persistent Pain
  • Neck stiffness

See Also


References


  1. Hall, RD McKellar. "Clay-shoveler's fracture." JBJS 22.1 (1940): 63-75.
  2. . Kim SY, Chung SK, Kim DY. Multiple cervical spinous process fractures in a novice golf player. J Korean Neurosurg Soc 2012; 52:570–3.
Created by:
John Kiel on 4 July 2019 09:28:30
Authors:
Last edited:
17 November 2020 15:44:13
Categories: