Disclosures: Ike B. Hasley, MD: No financial relationships or conflicts of interest

Case Description: The patient was referred to Sports Medicine after 5 weeks of upper back pain that started suddenly while lunging to kick a soccer ball. There was no direct blow or trauma. He was in the midst of a competitive swim season, and noted increased pain with return to swimming. He denied radiculopathy symptoms. Exam notable for tenderness to palpation over the T1 spinous process. Neurological exam and cervical ROM were normal, with minor pain during flexion. Radiographs demonstrated a small fragment along the posteroinferior T1 spinous process, consistent with a minimally displaced spinous process fracture. Decision was made to treat conservatively with pain-limited rest and PT. At follow-up 8 weeks post-injury, he noted minimal improvement. Given his persistent symptoms and desire to return to swimming, consideration was given to ultrasound-guided anesthetic/corticosteroid injection for diagnostic and potentially therapeutic purposes.

Setting: Tertiary care hospital

Patient: 14 year-old healthy male competitive swimmer Assessment/

Results: After a risk/benefit discussion with family, he underwent ultrasound-guided anesthetic/corticosteroid injection into the T1 spinous process nonunion with no complications. At two-week follow up, he demonstrated complete resolution of pain/symptoms. PT was progressed, and he successfully returned to swimming.

Discussion: Clay shoveler’s fracture is a C7 or T1 spinous process avulsion fracture that can occur with powerful neck extensor contraction. Most patients recover with rest. Treatment options are limited for occasional cases of non-union fracture that cause ongoing symptoms, with some reports of surgical excision of the non-union fragment. To our knowledge, this is the first case of an ultrasound-guided injection treating this condition. While in this case the injection provided definitive symptomatic resolution, there may also be a role for diagnostic confirmation prior to surgical excision.

Conclusion: This case demonstrates a novel treatment for refractory pain in the setting of nonunion clay shoveler’s fracture, providing symptom relief and rapid return to sport.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/persistent-pain-after-clay-shovelers-fracture-non-union-is-there-a-role-for-ultrasound-guided-corticosteroid-injection/