A 14-year-old male player presented after an acute injury to his neck and upper thoracic region. This came on acutely after a collision with an opponent 10 days prior to his visit. He is not certain regarding the exact mechanism but reports running into another player at high speed. He had experienced immediate pain and was not able to continue. An x-ray taken on the day of injury was normal. He was noted to have a mild generalised restriction in neck movements, localised tenderness over the C7 spinous process and a normal neurological examination.
An x-ray series of the cervical spine is normal with no evidence of a bony injury, malalignment or soft tissue swelling. MR images show that there is a fracture of the posterior tip of the T1 spinous process with a 6 mm fluid-filled gap and mild T2 hyperintense marrow oedema in the spinous process proper. There is very subtle marrow oedema within the C7 and T2 spinous processes without a discrete fracture line. No further fractures were seen within the cervical or thoracic spine.
In most cases this injury can be visualised on x-rays (and no other investigations are needed). In this case an MRI scan was conducted because of the lack of x-ray findings, the level of the patient’s pain and a desire to confirm the diagnosis. He was treated with a period of rest combined with regular analgesics. At four weeks post-injury he had a normal cervical range of motion and the tenderness had also improved (but not resolved). From this point he was able to progress some aerobic conditioning. At eight weeks post-injury he had minor residual tenderness but otherwise had no other symptoms of signs. He was cleared to return to football.
A ‘clay shovelers fracture’ is an avulsion type facture of the spinous process. This most commonly occurs at C7 but can occur anywhere from C6 to T3. It almost always occurs in isolation and is not associated with any more significant bony injuries or ligamentous instability. When the injury occurs in isolation these injuries are stable, are not associated with neurological injury and have very high rates of union. As this case illustrates, most players can be managed symptomatically with a short period of rest, analgesics and a progressive return to football. Unfortunately, due to the ligamentous attachments and muscle forces acting on the fracture fragments, non-union can occasionally occur. Where there is persisting pain and evidence of non-union, the fractured spinous process can be excised.
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