Do cervical transverse process fractures require a cervical collar?

Cervical Transverse Process Fractures and Collar Use

Cervical transverse process fractures do not require a cervical collar. These are stable injuries that do not threaten spinal cord integrity, and the documented harms of collar use—including increased intracranial pressure, pressure ulcers, airway complications, and ventilator-associated pneumonia—far outweigh any theoretical benefit in this specific injury pattern. 1, 2

Understanding the Injury Pattern

Cervical transverse process fractures are mechanically stable injuries that do not compromise the structural integrity of the spinal column or threaten the spinal cord. 2 Unlike fractures involving the vertebral body, pedicles, or posterior elements, isolated transverse process fractures:

• Do not affect spinal stability since the transverse processes are lateral projections that serve primarily as muscle attachment points 2
• Carry no risk of spinal cord injury when isolated 3
• Require only symptomatic management with analgesics and activity modification as tolerated 2

Evidence Against Collar Use

The American Heart Association explicitly recommends against routine cervical collar application by first aid providers, citing growing evidence of harm without proven benefit. 1 This recommendation is based on:

Documented Harms of Cervical Collars

• Increased intracranial pressure by 4.69 mm Hg (95% CI: 1.95-7.43), particularly dangerous in trauma patients who may have co-existing head injuries 1, 2, 3
• Pressure ulcers develop in 38% of patients with prolonged collar use (>24 hours), with each ulcer costing approximately $30,000 to treat and requiring prolonged healing time 2, 3, 4, 5
• Airway management complications due to reduced mouth opening and difficult intubation 2, 6
• Ventilator-associated pneumonia and delirium from prolonged immobilization 2, 3
• Poor oral care leading to bacteremia and sepsis 2

Lack of Proven Benefit

• No good quality evidence demonstrates clinical benefit of cervical collar use for injured patients 1, 2, 3
• Cervical collars provide incomplete immobilization, particularly at the craniocervical and cervicothoracic junctions where most injuries occur 2, 3
• The practice is based primarily on expert consensus and tradition rather than strong evidence 1, 2

Clinical Management Algorithm

For a patient with an isolated cervical transverse process fracture:

1. Confirm the injury is isolated through appropriate imaging (CT cervical spine at 1.5-2mm collimation) to exclude other fractures or ligamentous injury 3

2. Do not apply a cervical collar for this stable injury pattern 1, 2

3. Provide symptomatic management:

   • Analgesics for pain control 2
   • Activity modification as tolerated by the patient 2
   • Encourage the patient to remain as still as possible if symptomatic, but this is for comfort, not spinal protection 1

4. Monitor for associated injuries since transverse process fractures can be markers of high-energy trauma 2

Critical Caveats

Do not confuse isolated transverse process fractures with unstable cervical spine injuries. If imaging reveals additional fractures involving the vertebral body, facets, pedicles, or posterior elements, or if there is evidence of ligamentous injury, the management approach changes entirely. 2, 3

Prolonged immobilization beyond 48-72 hours causes morbidity that may exceed the risks of a missed cervical spine injury, with complications including pressure sores, increased intracranial pressure, and ventilator-associated pneumonia having attributable mortality approaching that of unstable spine injury itself. 2, 3

First aid providers may not be able to accurately discriminate between high-risk and low-risk patients, which is why the American Heart Association recommends against routine collar application in the field, favoring manual stabilization or having the person remain still while awaiting EMS arrival. 1, 2

Duration of Observation

For isolated transverse process fractures, no specific immobilization period is required. 2 Patients should be advised to:

• Limit activities that cause pain for comfort 2
• Follow up if neurological symptoms develop (which would be unexpected with this injury pattern) 2
• Resume normal activities as pain permits, typically within days to weeks 2