In a 12‑year‑old girl with multiple prior fractures and a slight irregularity of the L3 transverse process on plain radiograph, is this most likely a healing fracture rather than a congenital anomaly, and what are the appropriate next imaging and management steps?

L3 Transverse Process Irregularity in a 12-Year-Old with Multiple Fractures

In a 12-year-old girl with multiple prior fractures and an L3 transverse process irregularity on plain radiograph, this finding warrants immediate evaluation for non-accidental trauma (child abuse) given that spinous process fractures have high specificity for abuse, and the presence of multiple fractures has moderate specificity for physical abuse. 1

Critical Context: Child Abuse Assessment

High-Risk Features Present

• Spinous process fractures (which include transverse process fractures) are classified as having HIGH specificity for child abuse 1
• Multiple fractures have MODERATE specificity for physical abuse, particularly when they involve different skeletal areas or are of different ages 1
• While 80% of abuse-related fractures occur in children younger than 18 months, abuse remains a significant consideration in older children with multiple fractures 1

Immediate Diagnostic Steps

1. Complete Skeletal Survey

• Obtain a complete skeletal survey following ACR guidelines: frontal and lateral skull views, lateral cervical and thoracolumbosacral spine, single frontal views of long bones, hands, feet, chest, and abdomen, plus oblique rib views 1
• The skeletal survey should use high-detail imaging systems with coned views of each body part 1
• A repeat skeletal survey at 2 weeks can detect additional fractures in up to 12% of cases and better characterize healing stages 1

2. Advanced Imaging of the Spine

• CT scan of the lumbar spine is essential because approximately 11% of patients with transverse process fractures have associated spine injuries that are missed on plain radiographs 2
• CT provides superior detection and characterization compared to plain radiographs 2, 3
• Look specifically for vertebral body fractures, which have moderate specificity for abuse 1

3. Neuroimaging Evaluation

• Obtain non-contrast head CT even without clinical signs of head injury, as 29% of abused children without clinical suspicion of intracranial injury have positive neuroimaging findings 1
• This is particularly important in children under 12 months, but remains relevant in older children with multiple fractures 1

Differential Diagnosis Considerations

Metabolic/Nutritional Causes (Lower Priority in This Case)

While metabolic conditions can cause skeletal abnormalities, they do NOT typically produce the high-specificity fracture patterns seen in abuse:

• Rickets: Produces metaphyseal widening, fraying, and cupping—NOT isolated transverse process irregularities 4
• Copper deficiency: Extremely unlikely in a 12-year-old; primarily affects premature infants <6 months or those on prolonged TPN 4
• Vitamin D insufficiency alone does NOT produce high-specificity skeletal lesions like spinous/transverse process fractures 4

Trauma-Related Causes

• Isolated transverse process fractures typically result from high-energy blunt trauma (motor vehicle accidents, direct impact) 5, 3
• In the pediatric population, 87.8% of such fractures result from vehicular accidents 5
• The history provided must be consistent with the mechanism required to produce this injury 1

Congenital Anomalies

• Congenital osseous bridging of transverse processes is extremely rare and typically presents with low back pain in adults, not as an acute finding in children 6
• This diagnosis should only be considered after excluding trauma and abuse 6

Management Algorithm

Step 1: Immediate Safety Assessment

• Report to child protective services if abuse is suspected based on inconsistent history, multiple fractures, or high-specificity fracture patterns 1
• Document all injuries with photographs and detailed descriptions 1

Step 2: Complete Imaging Workup

• Full skeletal survey 1
• CT lumbar spine 2
• Head CT 1
• Consider bone scan if skeletal survey is negative but clinical suspicion remains high 1

Step 3: Laboratory Evaluation

• Screen for metabolic bone disease only if clinical features suggest it (osteopenia, pathologic fractures, systemic symptoms) 4
• Check vitamin D, calcium, phosphorus, alkaline phosphatase, PTH if indicated 4
• Copper levels only if specific risk factors present (prematurity, TPN history) 4

Step 4: Multidisciplinary Team Involvement

• Involve child abuse pediatrician or child protection team 1
• Social work evaluation 1
• Consider forensic consultation 1

Critical Pitfalls to Avoid

• Do NOT dismiss spinous/transverse process fractures as benign without thorough abuse evaluation, as they have high specificity for inflicted injury 1
• Do NOT rely solely on plain radiographs for transverse process fractures—CT is mandatory to exclude associated spine injuries 2
• Do NOT assume older children (>18 months) are at low risk for abuse when multiple fractures are present 1
• Do NOT attribute multiple fractures to metabolic disease without excluding abuse first, as abuse is far more common 1
• Do NOT accept inconsistent or changing histories from caregivers—this is a red flag for abuse 1

Conservative Management (If Abuse Excluded)

If comprehensive evaluation excludes abuse and confirms isolated traumatic injury:

• Conservative management with pain control is appropriate 5, 3
• No bracing or surgical intervention needed for isolated transverse process fractures 5, 3
• Physical therapy may be beneficial 5
• All pediatric patients with isolated transverse process fractures in one study had excellent outcomes with conservative management 5