Transverse process fracture is a rare and stable fracture of the spine. It occurs as a result of sudden and extreme trauma. Although the fracture is not associated with spinal cord damage and neurological deficits, the extreme force of the injury can cause visceral injuries and internal hemorrhage. Diagnosis of a transverse process fracture is based on computed tomography.
Transverse process is a bony protrusion from the posterior aspect of the vertebra. Every cervical, thoracic and lumbar vertebra has a transverse process on either side. Although transverse process fractures (TPF) are considered minor spinal injuries, they occur as a result of major force and are often related to other serious injuries. Cervical transverse process fractures frequently appear in the context of other cervical spine fractures [1], vertebral artery dissection and blunt cerebrovascular injury (BCVI) while 35% patients with lumbar transverse process fractures have intraabdominal (hepatic, splenic, genitourinary and diaphragmatic) injuries [2]. Lumbar TPF are more common, involve the upper lumbar spine and are usually multiple [1]. They can occur as a result of blunt trauma e.g during motor vehicle accidents; violent lateral flexion-extension injuries e.g. during football or other sports; avulsion injury of the psoas muscle; or Malgaigne fractures of the pelvis.[3] [4] [5]. Although TPF have been reported to be associated with visceral injuries [2] [4], they can also occur in the absence of other vertebral and visceral injuries [6].
Patients usually present with sudden onset of severe pain following the injury with decreased range of motion in the region of the affected part of the spine. The pain may be aggravated with movement and there may be swelling and tenderness around the fracture site. If there are visceral injuries, patients may present with features of hypovolemic shock. Patients with isolated transverse process fractures do not present with neurological deficits.
Transverse process fractures are known to occur after high-velocity trauma and therefore all patients must be evaluated thoroughly for the presence of serious visceral injuries [3] [4] [7]. After eliciting the history of the type of injury, the physician should examine the cervical, thoracic and lumbar spine and abdominopelvic region followed by a detailed neurological evaluation. Laboratory tests are not helpful in diagnosis but can help to evaluate comorbid medical conditions. So complete blood count, blood sugar, serum chemistries, blood grouping, cross matching and urinalysis depending on the clinical presentation should be ordered. Urinalysis can help to identify renal injury while elevated amylase levels may be an indication of pancreatic injury and elevated cardiac markers can indicate cardiac contusion.
Conventional radiographs are not very helpful as they are frequently unable to detect TPF and concomitant visceral injuries in the emergency setting in the presence of bowel gas [1] [3] [8]. Computed tomography is, therefore, the investigation of choice as it can identify TPF successfully, as well as related visceral injuries [1] [4] [9]. Magnetic resonance imaging may be required if spinal cord trauma is suspected.