How should an adult with an isolated transverse process fracture from blunt trauma and no neurological deficits be managed?

Management of Isolated Transverse Process Fractures

Isolated transverse process fractures in neurologically intact adults require only conservative symptomatic management with analgesics and early mobilization—no bracing, no surgical intervention, and no spine service consultation is necessary. 1, 2

Initial Assessment and Imaging

• CT imaging is the diagnostic modality of choice for identifying transverse process fractures, with sensitivity approaching 100% for detecting these injuries. 3
• When transverse process fractures are identified, actively search for associated injuries: approximately 95% of patients have other system injuries, and 30-35% have associated abdominal injuries requiring attention. 1, 2
• Exclude other spinal injuries before classifying as "isolated"—if additional vertebral fractures, facet dislocations, or discoligamentous injuries are present, management changes entirely. 2, 4
• Standing radiographs in a brace may be warranted if the mechanism involves high-energy trauma or if multiple contiguous transverse process fractures are present, as rare cases of occult instability have been reported. 4

Conservative Treatment Protocol

Pain management forms the cornerstone of treatment:

• NSAIDs and muscle relaxants provide effective analgesia, reducing pain from an average of 8.8/10 to 5.2/10 on visual analog scale. 5
• Flexible support corsets may be used for comfort during the acute phase (first 1-2 weeks), but rigid bracing is unnecessary in 97.7-100% of cases. 1, 2

Early mobilization is critical:

• Begin ambulation and range of motion exercises as soon as pain permits, typically within days of injury. 1, 5
• Physical therapy may be recommended in 10-15% of cases for persistent pain or deconditioning. 6
• Prolonged immobilization beyond 48-72 hours increases morbidity without benefit. 3

Expected Outcomes and Follow-Up

Long-term prognosis is excellent with conservative management:

• 100% of patients remain neurologically intact at follow-up. 1, 6
• 97.8% achieve full ambulation without assistive devices. 1
• Among patients with ≥6 months follow-up, only 1.1% report persistent back pain related to the fracture. 1
• No patient in multiple case series required surgical intervention specifically for an isolated transverse process fracture. 1, 2

When Spine Service Consultation IS Required

Consultation becomes necessary only when:

• Additional unstable spinal injuries are present (vertebral body fractures, facet dislocations, ligamentous disruption). 2
• Neurological deficits develop or are present on examination. 1, 6
• Multiple contiguous transverse process fractures with subtle facet joint distraction on CT—this rare pattern may indicate occult discoligamentous injury requiring MRI evaluation. 4

Critical Pitfalls to Avoid

• Do not over-treat these injuries with unnecessary bracing, prolonged bed rest, or routine spine service consultation—this wastes resources and may increase patient morbidity. 1, 2
• Do not miss associated injuries—the high-energy mechanism that causes transverse process fractures frequently produces concomitant abdominal, thoracic, or other skeletal injuries requiring treatment. 6, 2
• Do not assume all transverse process fractures are benign—when multiple contiguous levels are fractured bilaterally or when high-energy mechanisms are involved, obtain standing radiographs and consider MRI to exclude rare but serious discoligamentous instability. 4