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Transverse Process Fracture

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Other Names

  • Cervical Transverse Process Fracture
  • Thoracic Transverse Process Fracture
  • Lumbar Transverse Process Fracture
  • TP Fracture (TPF)
  • Isolated Transverse Process Fracture (ITPF)

Background

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  • This page describes transverse process fractures of the cervical, thoracic and lumbar spine

History

  • Historically attributed to Giovanni Battista Morgagni, who described spinal fractures in his seminal work De sedibus et causis morborum per anatomen indagatis, published in 1761[1]

Epidemiology

  • More often single level (90%) than multiple level (10%) in the cervical spine[2]
  • Thoracolumbar TP fractures are more commonly multilevel (46%) than single level (44%)[3]
  • TP fractures of the lumbar spine represent the majority of lumbar spine injuries after blunt trauma at 48%[4]

Introduction

Transverse process anatomy
Illustration of thoracic vertebrae showing vertebral body, pedicles, facets, transverse process, rib joints, spinous process, and lamina[5]
Anteroposterior radiograph of the lumbar spine shows a fracture of the left second, third and fourth lumbar transverse processes (arrows).[6]
Three-dimensional CT showing inferior rib and L1-L5 transverse process fractures on the right side (black arrow)[7]

General

  • Generally considered minor, stable fractures but can be associated with significant pain and functional limitations
  • Istolated fractures do not involve lamina, pedicle or facets
  • Often extend into multiple segements, can accompany other more significant pathology
  • Management of isolated TP fractures is nonsurgical

Etiology

  • Typically high energy blunt trauma from a motor vehicle accident or collision sport
  • Less commonly, falls, asasult, penetrating injury, crush injury, bicycle accident
  • Isolated TP fractures due to MVC more common in chikdren than adults
  • Isolated TP fractures due to falls more common in adults
  • Can be seen in the setting of extreme rotation and/or side bending

Anatomy of the Transverse Process

  • Protruding bone structures on the sides of the cervical, thoracic and lumbar vertebrae[8]
    • Projects laterally from region where pedicle meets lamina
    • In upper 6 cervical spinal levels, the Vertebral Artery passes through the transverse foramen
    • Thoracic and lumbar TPs do not have a transverse foramen
  • Primary role is attachment point for paraspinal muscles and ligaments
    • They do not carry a significant spinal load

Associated Injuries

  • Cervical TP fracture
  • Thoracolumbar TP fracture
    • Abdominal injuries
    • Pediatric thoracic TP fractures has a 70% correlation with head or chest injury, 20% with abdominal[9]
    • Pediatric lumbar TP fractures correlate with chest (41%), head (30%) injuries

Predictor of Concometant Trauma

  • While considered a non-life threatening injury
  • Multiple studies have shown TP Fractures predict[10][11]
    • Major abdominal, pelvic trauma
    • Additional spinal injuries

Risk Factors

  • Unknown

Differential Diagnosis

Differential Diagnosis Neck Pain

Differential Diagnosis Back Pain

Clinical Features

History

  • Typically report a history of trauma
  • It is important to characterize the mechanism of injury, presence, location and severity of pain
  • Any symptoms suggestive of associated injuries (hematuria, abdominal pain, chest pain, neurological symptoms, etc)
  • Evaluate for risk factors or red flags such as distracting injuries, history of malignancy, anticoagulation, etc
  • TP fractures typically cause localizing back pain which is worse with movements
  • These injuries may not be obvious if there are comcomitant injuries

Physical Exam: Physical Exam Neck, Physical Exam Back

  • Inspect the back for abrasions, contusions and evidence of trauuma
  • Point tenderness at the site of fracture and corresponding paraspinal musculature
  • Be certain to palpate the entire spine and not just the area where they endorse pain
  • A thorough neurovascular exam is important to help evaluate for more substantial trauma

Evaluation

Axial cut of T7 demonstrating non-displaced right transverse process fracture
AP radiograph demonstrating right L1 transverse process fracture

Radiographs

  • Standard radiographs of the appropriate spinal levels can be considered
    • CT scan has generally supplanted them as the imaging modality of choice
  • Diagnostic Characteristics[12]
    • Sensitivity is not great
    • Ranges from 22% to 82% for thoracolumbar injuries
    • May be missed on up to 11% of patients undergoing evaluation after trauma[13]
  • Projections
    • Anteroposterior and lateral projections are standard
    • Additional views are required to properly view the transverse processes

CT

  • Imaging modality of choice for spinal trauma, including transverse process fractures
  • Sensitivity approaches 100%
  • Advantages[14]
    • Provides superior visualization of bony anatomy
    • Allows for multiplanar reconstruction
    • Reliably detects both isolated and complex fractures

MRI

  • Not routinely indicated for isoalted transverse process fractures
  • Advantageous for evaluating associated soft tissue, ligamentous and spinal cord injuries
  • Indicated when a more complex injury pattern is suspected

Ultrasound

  • Can detect cortical discontinuity, hematoma, and step-off deformity in lumbar transverse process fractures
  • Diagnostic accuracy is high when used by experienced operators[15]
  • Roll in the setting of trauma is not well defined, especially when CT is available

Classification

  • N/A

Management

Nonoperative

  • Indications
    • Standard of care for transverse process fractures
  • Some studies event suggest no specific treatment or restrictions
  • Medications
  • Bracing with Cervical Collar, Corset for comfort[16]
    • Not intended to stabilize the spine
    • No evidence that these devices promote healing, prevent worsening of injuries
  • Exercise therapy
    • Early mobilization is encouraged once assocaited injuries are exluded
    • Physical Therapy for patients with persistent pain or functional lmitations

Operative

  • Indications
    • None for isolated TP fractures

Rehab and Return to Play

Rehabilitation

  • Weeks 1-4[17]
    • As pain allows
    • Progress to gentle range of motion, isometric core strengthening
    • Gradually increase activities of daily living, light aerobic exercise
    • Avoid contact, impact and rotational activities
  • Sports Specific training 4-6
    • Initiate progressive resistance and dynamic core strengthening
    • Begin sport specific drills, functional testing
    • Full, pain free range of motion
    • Restoration of baseline strength and neuromuscular control

Return to Play

  • General[18]
    • Complete anatomical and functional healing
    • No pain at rest or with sport specific activities
    • Demonstrated ability to perform all sport specific skills safely, effectively
  • Timeline
    • Can begin non contract training around 2-4 weeks
    • Full contact can usually begin 4-6 weeks

Prognosis and Complications

Prognosis

  • As isolated injuries, patients have an excellent prognosis
  • One study reported 100% of patients neurologically intact at presentation which was preserved at 19 months followup[9]
  • A second study found cervical range of motion and mean neck disability index to be normal at 27 months follow up[19]
  • Approximately 1% report persistent TP fracture related back pain[20]

Complications

  • Complications are very uncommon
  • Persistent, localized pain
    • Typically resolves with appropriate conservative management[21]
  • Missed Associated Injuries
  • In cervical spine, Vertebral Artery injury

See Also

Internal

External

References

  1. ↑ Zampieri, Fabio, Alberto Zanatta, and Gaetano Thiene. "An etymological “autopsy” of Morgagni's title: De sedibus et causis morborum per anatomen indagatis (1761)." Human Pathology 45.1 (2014): 12-16.
  2. ↑ . Schotanus M, van Middendorp JJ, Hosman AJ. Isolated transverse process fractures of the subaxial cervical spine: a clinically insignificant injury or not?: a prospective, longitudinal analysis in a consecutive high-energy blunt trauma population. Spine (Phila Pa 1976). 2010;35:E965-E970.
  3. ↑ Patten RM, Gunberg SR, Brandenburger DK. Frequency and importance of transverse process fractures in the lumbar vertebrae at helical abdominal ct in patients with trauma. Radiology. 2000;215:831-834.
  4. ↑ Holmes JF, Miller PQ, Panacek EA, Lin S, Horne NS, Mower WR. Epidemiology of thoracolumbar spine injury in blunt trauma. Acad Emerg Med. 2001;8:866-872.
  5. ↑ Bijendra, Dangol, et al. "Adjacent level vertebral fractures in patients operated with percutaneous vertebroplasty." Open Journal of Orthopedics 8.3 (2018): 116-126.
  6. ↑ Lee, Jung Sub, Chang Won Kim, and Kuen Tak Suh. "Lumbar artery injury combined with a transverse process fracture of the lumbar spine presenting with hypovolemic shock after a fall-a case report." Journal of the Korean Orthopaedic Association 43.3 (2008): 400-403.
  7. ↑ Reinhold, M., C. Knop, and M. Blauth. "Acute traumatic L5–S1 spondylolisthesis: a case report." Archives of Orthopaedic and Trauma Surgery 126.9 (2006): 624-630.
  8. ↑ Willard, Frank H., et al. "The thoracolumbar fascia: anatomy, function and clinical considerations." Journal of anatomy 221.6 (2012): 507-536.
  9. ↑ 9.0 9.1 Akinpelu BJ, Zuckerman SL, Gannon SR, Westrick A, Shannon C, Naftel RP. Pediatric isolated thoracic and/or lumbar transverse and spinous process fractures. J Neurosurg Pediatr. 2016; 17:639-644
  10. ↑ Krueger, Michelle Ann, et al. "Overlooked spine injuries associated with lumbar transverse process fractures." Clinical Orthopaedics and Related Research® 327 (1996): 191-195.
  11. ↑ Holmes, James F., et al. "Epidemiology of thoracolumbar spine injury in blunt trauma." Academic emergency medicine 8.9 (2001): 866-872.
  12. ↑ Hassankhani, Alvand, et al. "ACR Appropriateness Criteria® Acute Spinal Trauma: 2024 Update." Journal of the American College of Radiology 22.5 (2025): S48-S66.
  13. ↑ . Krueger MA, Green DA, Hoyt D, Garfin SR. Overlooked spine injuries associated with lumbar transverse process fractures. Clin Orthop Relat Res. 1996:191-195
  14. ↑ Izzo, Roberto, et al. "Imaging of thoracolumbar spine traumas." European journal of radiology 154 (2022): 110343.
  15. ↑ Maeda, Manabu, et al. "Diagnosis of lumbar transverse process fractures in orthopedic clinics using sonography." Journal of Ultrasound in Medicine 41.7 (2022): 1825-1835.
  16. ↑ Nagasawa, Daniel T., et al. "Isolated transverse process fractures: a systematic analysis." World Neurosurgery 100 (2017): 336-341.
  17. ↑ Gültekin, Güliz D., et al. "Transverse process fractures: a clinical series and coronal injury of the spine." World Neurosurgery 124 (2019): e25-e38.
  18. ↑ Brynin, Rona, and Laura Gardiner. "Missed lumbar transverse process fractures in a high school football player." Journal of manipulative and physiological therapeutics 24.2 (2001): 123-126.
  19. ↑ Schotanus M, van Middendorp JJ, Hosman AJ. Isolated transverse process fractures of the subaxial cervical spine: a clinically insignificant injury or not?: a prospective, longitudinal analysis in a consecutive high-energy blunt trauma population. Spine (Phila Pa 1976). 2010;35:E965-E970
  20. ↑ r JH, Lovasik BP, Baum GR, Frerich JM, Allen JW, Grossberg JA, et al. Implications of isolated transverse process fractures: is spine service consultation necessary? World Neurosurg. 2016;95:285-291.
  21. ↑ Boulter, Jason H., et al. "Implications of isolated transverse process fractures: is spine service consultation necessary?." World Neurosurgery 95 (2016): 285-291.
Created by:
John Kiel on 4 July 2019 09:28:46
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5 October 2025 02:17:16
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