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Fracture, Spinous and Transverse Processes

Ovid: 5-Minute Sports Medicine Consult, The

Fracture, Spinous and Transverse Processes
David E. J. Bazzo
Tara Robbins
  • Transverse and spinous process fractures are considered minor spine injuries and usually are stable and benign. Both types can be markers of considerable trauma and should encourage the physician to look for additional injury.
  • Fractures of the spinous process typically occur at C7 or any of the lower cervical or upper thoracic vertebrae. They are commonly avulsion-type injuries resulting from contraction of the trapezius, rhomboid minor, and/or serratus posterior.
  • Traditionally referred to as “clay shoveler injuries,” but now are found mostly after sudden deceleration in motor vehicle accidents or forced flexion of the neck, often in football players and weightlifters
  • Synonym(s): Minor spinal fracture
  • Spinous process fractures are relatively rare since mechanization replaced clay shovelers.
  • “Sentinel spinous process fractures” are associated with fractures of lamina and facets, which can lead to instability.
  • Up to 21% of transverse process fractures resulting from high-energy trauma (eg, motor vehicle accidents) are associated with visceral injuries, most commonly to the spleen and liver (1).
  • Up to 11% have other spine injuries not detected by plain radiographs but identified on CT scanning (1).
  • Transverse process fractures resulting from low-energy trauma (eg, playing football) do not generally have associated spinal, nerve root, or visceral injuries.
Risk Factors
Growth spurts, training errors, improper technique, and repetitive trauma predispose the athlete to spine fractures.
  • Forceful hyperflexion of the neck (eg, spearing in football) is associated with lower cervical spinous process fractures. Lumbar transverse process fractures usually result from direct trauma.
  • Pain with hip flexion indicates possible lumbar transverse process fracture. Pain with neck flexion suggests cervical spinous process fracture.
Physical Exam
  • Localized pain over injured area without radiation
  • Pain increased with neck flexion (lower cervical spinous process fracture) or hip flexion (lumbar transverse process fracture)
  • Careful neurologic examination for weakness, reflex changes, or sensory changes in a dermatomal distribution. As neurologic injuries are not commonly associated with minor fractures, abnormal results should raise suspicion of additional spinal injury.
  • Pain worse with hip flexion (site of iliopsoas origin) seen in lumbar transverse process fractures
  • Benign abdominal examination does not exclude coexistent intra-abdominal injury.
Diagnostic Tests & Interpretation
  • CT scan: Superior to plain films to evaluate extent of spinal fractures and rule out serious spine injury, but has limited field of view and high radiation dose
  • MRI: Only necessary if neurologic symptoms are present to evaluate extrinsic spinal cord compression or intrinsic cord injury
  • Radiographic appearance often lags behind clinical healing and should not be used as the primary criterion for return to play.
  • Cervical lateral radiograph:
    • Very important to visualize C7 spinous process, which often is obscured by the shoulders
    • Obtain “swimmer's view” if necessary to visualize C7–T1 junction.
    • Anteroposterior (AP) radiograph may show double shadow of spinous process due to avulsion.
    • Flexion-extension films to rule out ligamentous instability and lamina or facet injury
  • Thoracolumbar AP radiograph:
    • Relatively insensitive at identifying transverse process fractures
    • May show double shadow of spinous process due to avulsion
    • Hematoma may obscure evidence of transverse process fracture. Loss of normal psoas shadow may be most prominent finding.
    • Oblique radiograph to rule out defects in pars interarticularis
Differential Diagnosis
  • “Burst” fracture
  • Lumbar strain
  • Disc herniation
  • Spondylolysis and/or spondylolisthesis
Ongoing Care
Follow-Up Recommendations
Patients with isolated fractures do not need orthopedic or neurosurgical referral.
1. Patten RM, Gunberg SR, Brandenburger DK. Frequency and importance of transverse process fractures in the lumbar vertebrae at helical abdominal CT in patients with trauma. Radiology. 2000;215:831–834.
2. Boden BP, Jarvis CG. Spinal injuries in sports. Neurol Clin. 2008;26:63–78.
3. Giele BM, Wiertsema SH, Beelen A, et al. No evidence for the effectiveness of bracing in patients with thoracolumbar fractures. Acta Orthop. 2009;80:226–232.
4. Homnick A, Lavery R, Nicastro O, et al. Isolated thoracolumbar transverse process fractures: call physical therapy, not spine. J Trauma. 2007;63:1292–1295.
5. Tewes DP, Fischer DA, Quick DC, et al. Lumbar transverse process fractures in professional football players. Am J Sports Med. 1995;23:507–509.
Additional Reading
Krueger M, Green D, Hoyt D, et al. Overlooked spine injuries associated with lumbar transverse process fractures. Clin Orthop Rel Research. 1996;327:191–195.
Nicholas J, Nuber G, eds. The lower extremity and spine in sports medicine. St. Louis: Mosby, 1995.
Sturm JT, Perry JF. Injuries associated with fractures of the transverse processes of the thoracic and lumbar vertebrae. J Trauma. 1984;24:597–599.
  • 805.00 Closed fracture of cervical vertebra, unspecified level
  • 805.2 Closed fracture of dorsal (thoracic) vertebra without mention of spinal cord injury

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