In a 12-year-old girl with a history of multiple fractures, what does a slight irregularity of the left transverse process of L3 on lumbar spine X‑ray indicate and how should it be managed?

Evaluation and Management of L3 Transverse Process Irregularity in a 12-Year-Old with Multiple Prior Fractures

In a 12-year-old girl with a history of multiple fractures, the slight irregularity of the left L3 transverse process requires immediate evaluation for underlying bone fragility disorders (osteogenesis imperfecta, osteoporosis) and consideration of non-accidental trauma, followed by advanced imaging with MRI if there is any clinical concern for ligamentous injury, associated spinal column fractures, or if the patient has neurologic symptoms or persistent pain. 1

Initial Diagnostic Approach

Radiographic Interpretation Limitations

• Plain radiographs have only 15-35% sensitivity for detecting stress fractures and may show subtle or nonspecific findings such as periosteal reaction or cortical irregularity 1
• Approximately 11% of patients with transverse process fractures have additional lumbar spine fractures that are missed on plain radiographs alone 2
• CT scanning should be strongly considered for all acute transverse process fractures to exclude overlooked spinal injuries, as it provides 94-100% sensitivity compared to 67-82% for plain radiographs 1, 2

Critical Red Flags in This Case

• The history of multiple prior fractures in a 12-year-old is a major red flag that mandates evaluation for underlying bone fragility disorders 1
• Multiple fractures or fractures of different ages have moderate specificity for physical abuse and require careful clinical correlation 1
• Persistent nighttime back pain refractory to rest occurs in 25-30% of children with spinal neoplasm 1

Advanced Imaging Indications

When to Obtain MRI

• MRI of the lumbar spine should be obtained if there is any clinical suspicion for ligamentous injury, spinal cord compression, neurologic deficits, or if the mechanism of injury is unclear or inconsistent with the radiographic findings 1
• MRI is particularly important in pediatric patients with suspected infection, inflammation, or neoplasm, as it has high sensitivity and specificity for detecting pathologies including primary neoplasms and inflammatory processes 1
• In cases where multifocal disease is suspected (given the history of multiple fractures), complete spine MRI rather than targeted imaging should be performed 1

When CT is Appropriate

• CT without contrast should be obtained if there is concern for additional fractures not visible on plain radiographs, particularly if the patient has significant pain or mechanism suggests higher energy trauma 1, 2
• Sagittal and coronal reformats from existing CT data provide 94-99% sensitivity while being radiation-sparing 1

Differential Diagnosis Considerations

Bone Fragility Disorders

• The history of multiple fractures in a 12-year-old requires evaluation for osteogenesis imperfecta, juvenile osteoporosis, or other metabolic bone diseases 1
• Classic metaphyseal lesions and rib fractures have high specificity for abuse, but multiple fractures of different ages should prompt consideration of both abuse and bone fragility 1

Stress Fractures vs. Acute Trauma

• Transverse process fractures most commonly occur from backward falls or direct blows to the back, typically low-energy "coronal injuries of the spine" 3
• However, stress fractures can develop in patients with normal bone from repetitive athletic activity, though these are less common in the transverse processes 1
• The "non-profusion" terminology in the radiology report is unclear and requires clarification from the radiologist regarding whether this represents a fracture, developmental variant, or artifact 1

Management Algorithm

If Isolated Transverse Process Fracture is Confirmed

• Isolated transverse process fractures without other spinal injuries are neurologically and structurally stable injuries that do not require spine service consultation or surgical intervention 4
• Treatment consists of NSAIDs, muscle relaxants, flexible support corset, and early mobilization to prevent muscle deconditioning 3
• Average pain intensity decreases from 8.8/10 to 5.2/10 with this conservative protocol 3

If Additional Injuries are Identified

• Any associated spinal column fractures, ligamentous injuries, or neurologic deficits require immediate spine surgery consultation 1, 5
• Multiple transverse process fractures can rarely be associated with significant discoligamentous injuries and spinal instability, even when CT shows only subtle changes 5
• Standing radiographs in a brace may be necessary to detect occult instability if there is concern for ligamentous injury 5

Critical Pitfalls to Avoid

Do Not Dismiss Multiple Fractures Without Investigation

• Never attribute multiple fractures in a child to "normal childhood activity" without thorough evaluation for bone fragility disorders or non-accidental trauma 1
• Approximately 80% of all fractures caused by child abuse occur in children younger than 18 months, but abuse remains in the differential for older children with multiple fractures 1

Do Not Rely on Plain Radiographs Alone

• Plain radiographs miss 33-51% of thoracolumbar fractures and up to 89% of transverse process fractures may have associated injuries 1, 2
• When seemingly benign spinal injuries result from high-energy trauma or unclear mechanisms, careful scrutiny for associated instability is essential 5

Do Not Overlook Associated Abdominal Injuries

• Approximately 30% of patients with transverse process fractures have associated abdominal injuries that require evaluation 4
• Diligence in searching for other spinal injuries or visceral injuries should be exercised when transverse process fractures are identified 4

Follow-Up Considerations

Bone Health Evaluation

• All pediatric patients with multiple fractures require comprehensive metabolic bone evaluation including calcium, phosphate, alkaline phosphatase, vitamin D, and consideration of bone density assessment 1
• Referral to pediatric endocrinology or genetics may be warranted depending on clinical suspicion for underlying disorder 1

Healing Timeline

• Transverse process fractures typically heal with conservative management, though specific healing timelines are not well-established in the literature 4, 3
• Fracture union is a gradual process best assessed by clinical improvement in pain and function rather than arbitrary time points 6