https://doi.org/10.35827/cp.2020.19.2.138
접수일: 2020년 7월 27일, 게재승인일: 2020년 10월 4일 책임저자: 박영숙, 경남 창원시 마산회원구 팔용로 158
뿸 51353, 성균관대학교 삼성창원병원 재활의학과
Tel: 055-233-5450, Fax: 055-233-5454 E-mail: [email protected]
골프 초보자에서 나타난 흉추 2∼3번 극돌기의 견열 골절
성균관대학교 삼성창원병원 재활의학과
서재삼ㆍ박영숙ㆍ장현정ㆍ박진기ㆍ조은솔ㆍ구교훈
A Case Report of Golf-Swing-Induced T2∼T3 Clay-Shoveler’s Fractures
Jae Sam Seo, M.D., Young Sook Park, M.D., Ph.D., Hyun Jung Chang, M.D., Ph.D., Jin Gee Park, M.D., Eun Sol Cho, M.D. and Kyo Hoon Ku, M.D.
Department of Rehabilitation, Samsung Changwon Hospital, Sungkyunkwan Medicine University, Changwon, Korea Clay-shoveler’s fractures are rare stress-type avulsion fractures of the spinous processes especially in sports. There have been two case reports that discussed clay-shoveler’s fractures in golf. A 36-year-old beginner golfer presented with a pain in the back after practicing golf swing. No fractures were detected using cervical radiography; however, computed tomography (CT) and magnetic resonance imaging (MRI) revealed T2∼T3 spinous process fractures. The patient was treated conservatively and his pain subsided. The mechanism of injury is speculated to that of clay-shoveler’s fractures. Therefore, if a golfer suffers persistent pain in the cervicothoracic region, clay-shoveler’s fracture is one possibility to consider. (Clinical Pain 2020;19:138-141) Key Words: Clay-shoveler’s fracture, Spinous process fracture, Golf
INTRODUCTION
Golf is a non-contact sport that poses a low risk of injury. However, repeated swings can cause various injuries. There have been case reports of golf swing-related fractures of the ribs, ulna, sternum, and hamate. A clay-shoveler’s fractures, also known as an isolated spinous process fracture is a very rare stress-type avulsion fractures of the lower cervical or upper thoracic spinous processes.
Its name is derived from its common occurrence among clay shovelers in the past. It typically occurred either when clay stuck to the shovel during the throwing motion or when the shovel was suddenly obstructed, both causing an avulsion of the lower cervical and upper thoracic spinous processes.1 This type of fracture is more likely to occur during hard physical labor than during sports activities.1 Nevertheless, there have been a number of case reports of clay-shoveler’s fractures of C6∼C7 and T1∼T2 caused by golf swings.2,3 Here, we report a case of multiple golf
swing-related fractures of T2∼T3, a different site to those of previous studies. It could not be detected on radio- graphs; therefore, we used CT and MRI to confirm the diagnosis. The patient could return to golf after pain relief with conservative treatment.
CASE REPORT
A 36-year-old man visited our clinic with upper middle back pain that had lasted for 14 days. Two weeks before the onset of the pain, he started playing golf for the first time and practiced golf for an hour every day. During one such swing, he experienced a sudden stabbing pain in the upper middle thoracic region. The pain persisted with every subsequent rotation of the trunk, especially when hitting the ground instead of the ball with the club. He stopped playing golf because of persistent pain, then visited our clinic. He rated the severity of pain as 6 on the visual ana- logue scale (VAS), and it did not radiate to the upper extremities. There was no notable history of underlying disease. Upon physical examination, there was a localized tenderness in the area of the upper thoracic spine, but no swelling or redness. The findings of neurologic signs were normal. The severe tenderness in the upper thoracic spine was indicative of fractures. However, cervical radiographic
서재삼 외 5인: 골프 초보자에서 나타난 흉추 2∼3번 극돌기의 견열 골절
CLINICAL PAIN 139 Fig. 1. Antero-posterior (A) and lateral (B) radiographs.
Thoracic spinous processes are not visible due to the other struc- ture of patient.
Fig. 2. Sagittal CT scan (A) and sagittal T2-weighted MR image (B). They are clearly showing spinous process fracture of T2 and T3.
findings were inconclusive because of obstruction by the shoulder and surrounding tissue (Fig. 1). The severe ten- derness in the upper middle thoracic spine was indicative of fracture. Therefore, we performed CT and MRI. On the CT, the T2∼T3 fractures of the spinous processes were explicit. MRI, revealed the same fractures without spinal cord injury (Fig. 2). The patient was treated with 100 mg aceclofenac (Airtal; Daewoong Pharm Co., Ltd., Seoul, Korea), as well as 162.5 mg acetaminophen and 18.75 mg tramadol HCL (Atracet Semi Tablet,; PMG Pharm Co., Ltd., Ansan, Korea), two times a day, and was prescribed a cervical collar for 4 weeks. One month later, the pain subsided to a VAS score of 1, and no additional injuries or progression of the fracture were observed upon fol- low-up radiography. With conservative treatment, the pa- tient resumed golf after the pain was relieved.
DISCUSSION
Golf is played by 10% to 20% of the population of many countries.4 It is a low-intensity sport; however, among ama- teurs, golf-related injuries range from 16% to 62%.4-6 Such injuries include the following: fractures affecting the elbow, wrist, neck, shoulder, and lower back; compression frac- tures due to osteoporosis; vertebral artery dissection; and intracranial hemorrhage by a golf ball impact.3 Stress frac- tures are the most common type of golf-related injury, more than caused by accident, a patient’s predisposition.
There have been a number of reports of golf swing-re-
lated multiple isolated spinous process fractures of the cervi- cothoracic vertebrae. Kang et al.2 reported on a 40-year-old man who suffered acute fracture of the T1 spinous process and a delayed fracture of the T2 spinous process. The latter occurred after the patient restarted golf practice. Kim et al.3 reported on a 45-year-old woman who presented with pos- terior neck pain. She was initially diagnosed with a cervical sprain; however, the pain was not alleviated even with con- servative treatment. Eventually, MRI revealed fractures in the spinous processes of C6∼C7. The authors speculated that the mechanism of the injury was similar to that of clay-shoveler’s fractures.
Currently, a clay-shoveler’s fracture mainly occurs in in- dividuals practicing sports that involve rotational move- ments of the upper spine. Recently, it has also been re- ported to occur during Nintendo Wii activity, volleyball, powerlifting, car accidents, and golf.2,3
Clay-shoveler’s fractures are most common in T1, fol- lowed by C7, T2, T3, and C6.7,8 The spinous processes of the lower cervical and upper thoracic spine are long and thin when compared to those of adjacent vertebrae.
Therefore, they are considered less resistant to heavy loads.
Furthermore, as their orientations are almost horizontal, forces are exerted perpendicularly to their long axis, in- creasing the risk of fracture. The spinous processes of the cervical spine are the insertion sites of the ligamentum nu-
chae, which extends down from the occipital protuberance.
The upper trapezius originates from the ligamentum nu- chae; the middle fibers of the trapezius arise from the spi- nous processes of C7∼T3. Furthermore, the rhomboid mi- nor originates from the spinous processes of C7∼T1; the rhomboid major originates from the spinous processes of the T2∼T5.1 According to Kim et al.,3 for a right-handed golf swing, the right upper and middle trapezius contract during the back swing, whereas the left middle trapezius contracts during the forward swing. As the contraction of the muscle changes side, a shearing force is generated. In addition, the pectoral muscles amplify this force during the acceleration phase. If the club hits the ground instead of the ball during the swing, the force will be transmitted to the spinous processes where the trapezius is attached. If a sufficient force is transmitted through the trapezius tendon, the spinous process can fracture.3 Thus, a powerful unilat- eral pull of especially the trapezius and rhomboids can avulse the lower cervical and upper thoracic spinous processes. The common denominator in the above-men- tioned two cases, and that in our case, is that all of the patients recently started playing golf. Presumably, be- ginners’ frequency of hitting the ground tends to increase their risk of fracture compared to that of seasoned players.
Two-dimensional radiography is usually sufficient to confirm the diagnosis of spinous process fracture. Intact spinous processes project as a triangle in the anteropos- terior view, whereas a fractured spinous process is detected as a “double spinous” sign. In the lateral view, fracture lines are generally visible.8 However, clay-shoveler’s frac- tures can remain undetected with conventional radiographs.
Especially spinous processes of the lower cervical and up- per thoracic spine, may not be visible on lateral radio- graphs due to obstruction by the patients’ shoulder and soft tissues.8,9 If the clinical features are indicative of a fracture (such as localized tenderness and intractable or severe pain) despite negative radiographs, CT or MRI is needed for the detection of fractures and injuries including the spinal cord.9
Clay-shoveler’s fractures are generally stable and treated conservatively. Its management consists of rest for 4∼6 weeks, and nonsteroidal anti-inflammatory drugs (NSAIDs).
If symptoms subside (which may occur after 3 weeks to 4 months), normal activity may be resumed. Immobilization with a cervical collar (4∼6 weeks, on average) reduces movement of the fractured processes, which reduces pain
in the acute period. Physical therapy, however, has not yielded any advantages in the recovery, to date.6 Golf re- lated injuries increase without warming up. So, warm-up exercise before playing golf helps to prevent golf-related injuries.10
Our case was consistent with those in previous reports.
The medical history was typical: the patient recently started playing golf and started experiencing persistent and intract- able pain in the region of the cervicothoracic spine. The clinical features were very similar to those reported by Kang et al.2 and Kim et al.3 However, the location of the fracture differed in our case: the T2∼T3 vertebrae.
Fractures at these locations are relatively rare, although it can be explained by their shape and the attachment of mus- cle to these spinous processes. As the fractures were un- clear on radiographs, CT and MRI scans were necessary for the confirmation of the diagnosis.
Golf-related clay-shoveler’s fractures are easily over- looked because of its rareness and the perceived low risk of injury in golf. However, a patient experiences persistent, intractable pain in the cervicothoracic spine, with history of golf practice, the clinician should consider clay-shov- eler’s fracture. In addition, localized midline tenderness may be the clue for the fracture. Once a fracture is sus- pected, it is also important to perform CT or MRI regard- less of the radiography result.
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