2. Clay Shoveler’s Fracture
• Clay shoveler’s fracture derives its name from a common
occurrence in clay miners in Australia during the 1930s
• Stable avulsion fracture through the spinous process of a vertebra
• Occurring at any of the lower cervical or upper thoracic
vertebrae
• Classically at C6 or C7
3. Mechanism of Injury
• It occurs with abrupt flexion of the head such as found
with motor vehicle accidents, diving, or wrestling injuries.
• Occurs with repeated stress caused by the pulling of the
trapezius and rhomboid muscles.
• Direct blows or trauma to the base of the neck.
4. Symptoms
–Sudden onset of pain between the shoulder
blades or base of neck
–Reduced head/neck ROM
–Tenderness
5. Diagnosis
• Radiographs
Cervical & Thoracic x-rays that should always be obtained on
evaluation
• CT SCAN
Indications
Routine CT imaging in high-energy trauma patients
Clinical criteria
– altered consciousness
– midline spinal pain or tenderness
– impaired CCJ motion
– lower cranial nerve paresis
– motor paresis
6. Treatment
Nonoperative
– NSAIDS, rest, immobilization in hard collar for comfort
• indications
– most common treatment for pain control
• modalities
– short term treatment with hard collar
• outcomes
– usually high union rates and excellent clincal outcomes
Operative
– surgical excision
indications
– persistent pain or non-union
– failed conservative treatment
8. Hangman’s Fracture
• The second most common fracture of
the second cervical vertebra.
• Involves a bilateral arch fracture of the
C2 pars interarticularis with variable
displacement of C2 on C3
9. Mechanism of Injury
The injury mainly occurs from falls, usually in older adults, and
motor accidents mainly due to impacts of high force
causing Extension of the neck and great axial load onto the
C2 vertebra.
The mechanism of the injury is forcible hyperextension of the
head, usually with distraction of the neck.
10. Classification
Type I: Non-displaced fractures with no
angulation between C2 and C3 and a
fracture dislocation of less than 3 mm
Type II: significant angulation (>11°)
and displacement (>3.5 mm)
11. type IIA: minimum displacement and
significant angulation (>11°)
type III: severe angulation and displacement
and concomitant unilateral or bilateral facet
dislocation C2–3.
12. Symptoms
• The most common symptom of hangman’s fracture is
neck pain following a fall or motor vehicle accident
• The most important concern with hangman’s fracture is
injury to the spinal cord.
• If the spinal cord is damaged, symptoms can include
pain, sensory loss, weakness, paralysis, and/or death.
13. Tests and Diagnosis
• X-ray - flexion and extension radiographs show subluxation
• Computed tomography scan (CT scan) -
study of choice to delineate fracture pattern
• Magnetic resonance imaging (MRI) - consider if suspicious of a
vascular injury to the vertebral artery
15. Closed reduction followed by halo immobilization for 8-12
weeks
Indications
– Type II with 3-5 mm displacement
– Type IIA
Reduction technique
– Type II use axial traction combined + extension
– Type IIA use hyperextension (avoid axial traction in Type IIA)
16. Operative
Reduction with surgical stabilization
Indications
• Type II with > 5 mm displacement and severe angulation
• Type III (facet dislocations)
Technique
• anterior C2-3 interbody fusion
• posterior C1-3 fusion
• bilateral C2 pars screw osteosynthesis
18. Odontoid Fracture
• The most common axis injury is a fracture through the
odontoid process.
• Translational motion of C1 on C2 is restricted by the
transverse atlantal ligaments that center the odontoid
process to the anterior arch of C1.
• With a fracture of the odontoid process, restriction of
translational atlantoaxial movement is lost.
19. Classification
Type I: oblique fractures through
the upper portion of the odontoid
process.
According to the classification of Anderson and D’Alonzo:
20. Type II: across the base of the
odontoid process at the
junction with the axis body.
21. • Type III: through the odontoid
that extends into the C2 body.
22. Mechanism of Injury
Flexion loading is the cause in the majority of patients, and
results in anterior displacement of the dens
Extension loading (forward fall onto forehead) occurs in a
minority of patients, and results in posterior displacement of
the dens;
23. Treatment
• A variety of non-operative and operative treatment
alternatives have been proposed for odontoid fractures
based on:
– fracture type
– degree of (initial) dens displacement
– extent of angulation
– patient’s age
24. Type II and Type III odontoid fractures should be considered for
surgical fixation in cases of:
– dens displacement of 5 mm or more
– dens fracture (Type IIA)
– inability to achieve fracture reduction
– inability to achieve main fracture reduction with external
immobilization
25. • Anterior trans articular screw fixation: As an augmentation of
the anterior dens screw or in cases of a salvage procedure.
• Screws can be inserted over Kirschner wires from a medial-
anterior-caudal to a lateral-posterior-cranial direction crossing
the atlantoaxial joint.
