Reginald, a 73-year-old man, presents to your Emergency Department with neck pain. He tells you that last night he was straining to lift a heavy box. He heard and felt a snap in his neck. This morning, he awoke with neck pain, dizziness, and mild confusion. You examine Reginald and find that he has pain with neck rotation, flexion, and extension. He also has exquisite, sharp tenderness on palpation over the C6 vertebrae.
Initial Impression and Investigations
While on history you had suspected a cervical sprain or strain, due to his midline tenderness over C6 and age you decide to obtain a x-ray of his cervical spine. Uh-oh, what happened to Reginald?
Image courtesy of: Dr Chris O’Donnell (https://radiopaedia.org/cases/barbell-injury-to-cervical-spine-c6-clay-shoveler-fracture-1)
Clay Shoveler’s Fracture
Definition and Mechanism
The Clay Shoveler’s fracture is an avulsion fracture of a vertebral spinous process, most commonly C6 or C7. Clay Shoveler’s fractures are relatively rare and can easily be confused with cervical spine sprain or strain. This injury is believed to be caused by strain on the cervical muscles and resultant snapping of the paraspinous ligamentous complex against the spinous process1. It is named for its occurrence in Australian clay miners during the 1930’s, who sometimes sustained these fractures when the heavy clay that they tossed over their shoulder was stuck to their long-handled shovel causing a sudden flexion force on the neck and back muscles2.
Exam and Investigations
Patients with this injury present with sharp pain between the shoulder blades that is worsened with palpation. They may also have pain with neck movement and unilateral upper back pain3.
The Clay Shoveler fracture can usually be seen on plain film lateral radiograph. CT can be performed if clinical suspicion is high and X-ray findings are negative2. CT can also identify additional fragments of fractured bone. A close look at the radiograph is warranted, as the avulsed fragment may be small and posteriorly displaced, making it difficult to identify.
Treatment and Prognosis
The Clay Shoveler fracture is stable, and treatment is usually conservative. If pain doesn’t resolve with supportive care, referral to a spine surgeon for removal of fragments is indicated. Most people return to normal activities 3 weeks to 4 months after the initial injury3.
The Basics
| Definition
| Vertebral spinous process fracture, usually C6 or C7 |
| Mechanism
| Pull of ligamentous complex on bone, can occur during strenuous lifting |
| Presents like…
| Cervical strain or sprain |
| Diagnosis
| Hx, PEx, X-ray, CT |
| Treatment
| Pain control, activity modification, immobilization, surgery, all as required |
Conclusion
You diagnose Reginald with a Clay Shoveler fracture and discharge him home with appropriate analgesia and instructions to return if he develops any neurological symptoms. You arrange appropriate follow up and Reginald leaves your ED, relieved to hear that he is likely to recover within the coming weeks.
This post was copyedited by Dr. Sarah Luckett-Gatopoulos and uploaded by Evan Formosa.
References
Reviewing with the Staff
This is an excellent overview of a relatively uncommon fracture. Beyond the traditional ‘clay shoveling’ mechanism, sudden muscle contraction from other causes, motor vehicle accidents, and direct blows to the spine can be associated with this presentation. As it does affect the patients prognosis, it should be kept in mind when assessing patients with cervical spine pain.
Andrei Smarandache
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