Management of Multiple Transverse Process Fractures
Conservative management with pain control, mobilization, and careful exclusion of associated spinal instability is the appropriate treatment for isolated multiple transverse process fractures, without requiring spine service consultation. 1
Initial Assessment and Imaging
Rule out spinal instability and associated injuries first, as this determines the entire management pathway:
- Obtain CT imaging of the entire spine to detect overlooked injuries—approximately 11% of patients with transverse process fractures have additional spinal fractures missed on plain radiographs alone 2
- Look specifically for facet joint distraction, vertebral body fractures, or other spinal column injuries on CT 3
- Obtain standing or upright radiographs in a brace before discharge to unmask occult instability that may not be apparent on supine imaging 3
- Consider MRI if CT shows subtle findings like facet distraction, as this can reveal significant discoligamentous injuries involving the anterior longitudinal ligament, posterior longitudinal ligament, annulus fibrosus, and posterior ligamentous complex 3
- Screen for associated abdominal injuries (kidney, liver, spleen), which occur in approximately 30-35% of cases 1
Critical Pitfall to Avoid
High-energy trauma mechanisms (motor vehicle accidents, significant falls) warrant heightened suspicion for instability even when initial CT appears benign—one case report documented marked subluxation on standing films despite only subtle CT findings 3. Do not discharge patients with high-energy mechanisms without upright imaging.
Treatment for Isolated Stable Fractures
When spinal instability and associated injuries are excluded, no spine service consultation is needed 1:
Pain Management Protocol
- Scheduled NSAIDs (not acetaminophen as first-line, contrary to other fracture types) combined with muscle relaxants 4
- Short-course opioids only for breakthrough pain not controlled by NSAIDs 4
- Consider CT-guided fracture site in situ block with local anesthetic and steroids if pain persists beyond 1 week of conservative management—this allows rapid return to activities 5
Mobilization and Support
- Flexible support corset for comfort during mobilization 4
- Early mobilization as tolerated—do not enforce bed rest 4
- No rigid bracing required for isolated stable fractures 1
Expected Outcomes
Pain typically improves from 8.8/10 to 5.2/10 on visual analog scale within days of initiating this protocol 4. Patients can return to daily activities almost immediately after fracture site block if conservative measures fail 5.
Management When Instability is Present
Immediate surgical consultation is mandatory if any of the following are identified:
- Facet joint distraction or subluxation on standing films 3
- MRI evidence of discoligamentous injury 3
- Associated vertebral body fractures requiring stabilization 2
- Neurological deficit (rare but requires urgent decompression) 1
Surgical management typically involves posterior instrumentation and fusion spanning the injured segments 3.
Follow-Up Monitoring
- Re-examine all imaging carefully if pain persists despite appropriate treatment—missed fractures at other levels occur and explain treatment failure 5
- No routine spine service follow-up needed for isolated stable fractures 1
- Patients can be managed by primary trauma service or emergency medicine 1
Key Clinical Pearls
- Transverse process fractures result from backward falls or direct blows to the back in 98% of cases—this "coronal injury of the spine" mechanism is typically low-energy 4
- All isolated transverse process fractures are neurologically intact and mechanically stable 1
- The fractures themselves never require surgical stabilization or bracing—only associated injuries do 1
- CT may reveal that 78% of cervical transverse process fractures extend into the intervertebral foramen, potentially involving neural or vascular structures, though this is less relevant for lumbar fractures 6