Atypical presentation of clay shoveler’s fracture: A case report and literature review

The name originated in the 1930s among clay miners in Australia who dug ditches and tossed clay, several feet above their heads with shovels. Instead of separating, the wet clay sometimes stuck to the shovel causing a sudden fl exion force in the neck or back muscles resulting in the fracture. Some of the workers would feel a sudden pain between the shoulder blade which prevented them from working [1,2].


Introduction
Clay shoveler's fracture is defi ned as a fracture that involves the Spinous processes of the lower cervical or upper thoracic vertebrae most commonly found at the midpoint between the spinolaminar line and tip of the Spinous processes of C6 -T3 spine levels with the most common occurring at C7 [1].
The name originated in the 1930s among clay miners in Australia who dug ditches and tossed clay, several feet above their heads with shovels. Instead of separating, the wet clay sometimes stuck to the shovel causing a sudden fl exion force in the neck or back muscles resulting in the fracture. Some of the workers would feel a sudden pain between the shoulder blade which prevented them from working [1,2].
The mechanism of the injury involves excessive rotational forces exerted by the trapezius and rhomboid muscles attached to the Spinous process and refl ex pull on the supraspinous ligament or through direct trauma to the posterior part of the neck in a fl exed position [3,4].
This case report looks at fractures involving the Spinous process at C5 and spinolaminar line of C6 which makes it atypical as compared to the classical clay shoveler's fracture which involves the spinous process of C6 -T3.
Classical clay shoveler's fracture becomes atypical when it involves the Spinous process of other cervical or thoracic vertebrae not within C6-T3 [11]. He had an intense neck pain which was graded as 8 with the numeric rating scale [5] . The pain radiated to his shoulders and upper back with limitations to fl exion and extension of the neck.

Case report
There was no history suggestive of bleeding from any craniofacial orifi ces, no loss of consciousness, he also had no history of diffi culty with breathing nor dizziness, no history of weakness in the upper or lower limbs.
He was managed using the Advanced Trauma Life Support (ATLS) protocol with a Glasgow coma scale of 15/15,airway was clear ,oxygen saturation was 96% at room air and a blood pressure of 120/80mmHg. He had tenderness at the posterior aspect of the neck, devoid of swelling nor bruise, no differential warmth, normal gait, sensation was normal, power was 4 /5 on his upper and lower limbs, normal muscle tone , tendon refl exes were adequate and had a normal score (grade E) for neurological function based on the American Spinal Injury Association (ASIA) impairment scale [6].
Intravenous access was secured with necessary blood samples taken. His neck was stabilized with a Philadelphia Cervical Orthosis and was sent for trauma series X-rays and a cervical 3D reconstruction CT scan.
He was admitted into the orthopedic ward and treated conservatively with a Philadelphia Cervical Orthosis with analgesics and muscle relaxants administered.
He was observed at the hospital for 1 week post trauma to check for signs of Neurological defi cit which were all absent.
Importance was taken to monitor signs of neurological defi cit by keeping a daily chart of his power, tone ,refl exes and sensation due to the location of the injury.
Follow up in the outpatient department was done for 8 weeks and was uneventful with no complications. He was also advised not to engage in any form of vigorous activity for the said period of time.

Discussion
Clay shoveler's fracture though rarely reported is a well known pathology in orthopedics [7].
Fracture of the cervical spinous process is not common , a study by Stiell found only 12 of these fracture pattern,examining 8924 stable patients with blunt trauma to the head or neck during a study done in Canada [8].
However some reported cases from other countries within this region have been cited [9].
Trauma is the most common cause for vertebral fractures in most of the cases involved [10].
The usual mechanism of injury being sudden neck hyperfl exion was also the possible scenario in this patient as the car summersaulted several times.
Factors that would have contributed to this fracture include senile osteoporosis based on the age of the patient involved. This report is similar to a study done by Feldman VB which reported an atypical clay shoveler's fracture involving the spinolaminar line of C7 [11].  An MRI was not indicated for in this patient as he made good clinical improvement had no sign of neurological defi cit.
The role of MRI cannot be ignored in cases that involve neurological defi cit following blunt trauma to the spine as it is a good modalty for assessing soft tissue damage within the spinal canal [12].
Concerning stability, the fracture pattern is quite stable since it only involved the posterior elements outlined by the Dennis classication of the 3 column concept and the treatment given to this patient remains the standard of care for stable fractures such as this and surgery is not indicated as documented in literature [13].
The prognosis for clay shoveler's fracture are favorably good based on reports worldwide [14].
However the risk of non-union and malunion of the fractured Spinous process still remains in medical literature due to the muscular pull in this region [15]. He presented with an atypical clay shoveler's fracture at the Spinous process of C5 and fracture at the spinolaminar line of C6 as opposed to the classical clay shoveler's fracture which occurs at the midpoint of the Spinous processes of C6 to T3.

Differential diagnosis
This report of an atypical clay shovelers fracture is similar to a study done by Feldman V.B [11].
The fracture was stable and only involved the posterior spinal column.
The patient made good clinical recovery after 8 weeks of conservative care using the Philadelphia Orthosis.