Radiographically occult clay shoveler's fracture diagnosed with point of care ultrasound

Case Diagnosis: 50-year-old active duty military male presented with cervicothoracic spine pain and swelling after a lifting a person onto his shoulders, initial radiographs were unremarkable but subsequent point of care ultrasound revealed cortical irregularities and hypoechoic swelling that were confirmed to be a fracture of the T1 spinous process on CT and MRI.

Case Description or Program Description: This is a case of radiographically occult spinous process fracture that was detected on point of care ultrasound with in the setting of pain and swelling from athletic injury. Confirmatory imaging of the fracture by CT and MRI also ultimately lead to an incidental diagnosis of non-cardiac sarcoidosis.

Setting: Active duty military male performing fitness assessment with fireman's carry onto shoulders, seen in Sports Medicine clinic after general clinic.

Assessment/Results: Patient was diagnosed with T1 spinous process "clay shoveler's" fracture and incidental non-cardiac sarcoidosis. He was managed with non-surgical activity modification, NSAIDs, and rest, with subsequent imaging revealing resolution of the fracture.

Discussion (relevance): This case highlights the utility of point of care ultrasound as an effective adjunct diagnosing radiographically occult fractures, which can be useful in settings of high clinical suspicion, acute sports care, and/or resource-limited environments. It also contributes to the data linking sarcoidosis as an increased risk factor of cervicothoracic spine fractures, currently attributed to lower bone density.

Conclusions: This is a case of radiographically occult fracture detected by point of care ultrasound, lending diagnostic power to primary care or resource-limited setting. This could potentially reduce cost and risk with increased expedited disposition for patients. Additionally, this case adds evidence to increased risk of cervicothoracic spine fractures in sarcoidosis.