Excision of Symptomatic Spinous Process Nonunion in Adolescent Athletes
While clay-shoveler’s fractures in athletes are usually treated conservatively with rest, activity modification, and return to activities when symptoms abate, nonunion of these fractures can occur, given the ligamentous attachments and muscular forces acting on the fracture fragment. Surgical treatment for recalcitrant symptomatic nonunions in adolescent athletes has not been described in the literature.
We examined the medical records and radiographs of adolescent athletes who presented with persistent symptoms related to a T1 spinous process nonunion at our institution. Three adolescent athletes were identified who underwent surgical excision of a nonunited ossicle after a T1 spinous process fracture and failure of conservative treatment. All patients had complete pain relief and were able to return to sports after surgical excision. There were no surgical complications.
Persistent pain after a clay-shoveler’s fracture in athletes has been described in the literature. This is the first case series describing surgical excision of the nonunited ossicle in athletes unable to return to play because of persistent disabling pain at the nonunion site. Excision should be considered if patients experience persistent pain after this injury, with expectation of complete resolution of symptoms after surgery.
To our knowledge, this is the first report in the literature describing surgical excision of an ununited spinous process fracture in adolescent athletes. The original descriptive case series by Hall1 states “in the minds of surgeons who have seen many of these cases that early operative removal of the fragments is the proper routine treatment.” Since that original series, we have not found articles in the literature that support surgical removal; however, persistent symptoms after fracture are described.5 It is not surprising that these patients developed pain at the site of the fracture given the forces acting in that area. The trapezial and paraspinal muscles acting on that area are forceful and repetitive during activities, especially sports. All our patients had pain with attempts at activity and all had had a significant period of rest. In a recent article, this injury was described in adolescents without the patients having clear relief of symptoms despite a period of inactivity.5 While physical therapy is therapeutic in some patients experiencing pain, it can be a source of aggravation due to neck and shoulder motion and muscle contraction. It is not surprising that therapy would not help in most cases, as neck and shoulder motion and muscle contraction are the sources of continuing discomfort.
Clinical practice suggests that most patients with spinous process fractures will become pain-free; however, that is not universal. This series demonstrates that a small subset of patients with this injury will continue to have significant symptoms despite a period of rest. In those patients who desire a pain-free return to sports, we recommend consideration of surgical excision after confirmation of nonunion with radiographic studies. The inherent risks of surgical treatment are minimal with this procedure, and the benefits include return to pain-free sports activity, with the resultant physical and psychosocial benefits for adolescent athletes.
