What is the treatment for a fractured coccyx?

Management of Fractured Coccyx

Conservative treatment is the first-line approach for most coccyx fractures, consisting of pain management, cushioning, and physical therapy, with surgical options reserved only for cases with persistent pain after 2 months of failed conservative treatment.

Initial Assessment and Management

When evaluating a patient with a suspected coccyx fracture:

• Look for signs of trauma, localized pain, swelling, tenderness, and difficulty with sitting
• Assess for abnormal mobility of the coccyx, which is the most common pathological finding (70% of patients) 1
• Consider imaging (lateral X-rays in standing and sitting positions) to confirm diagnosis and assess for abnormal mobility

Treatment Algorithm

First-Line: Conservative Management (0-8 weeks)

1. Pain Management

   • NSAIDs for initial pain control 2
   • Consider calcitonin for acute fractures (within 0-5 days of injury) for 4 weeks 3
   • Avoid prolonged opioid use due to limited evidence of benefit

2. Physical Measures

   • Use of specialized coccyx cushion with cutout to reduce pressure on the tailbone
   • Lateral recumbent position when resting
   • Avoid prolonged sitting or activities that exacerbate pain

3. Physical Therapy

   • Gentle stretching of the levator ani muscle
   • Mobilization techniques for the coccyx when appropriate
   • Exercise program focused on strengthening supporting muscles

Second-Line: Interventional Approaches (if pain persists >8 weeks)

• Local anesthetic and corticosteroid injections to painful structures 1
• Consider nerve blocks (e.g., L2 nerve root block for specific cases) 3
• Extracorporeal shockwave therapy 4
• Pulsed radiofrequency therapy 5
• Low-level laser therapy/laser acupuncture (shown to be effective in refractory cases) 2

Third-Line: Surgical Management

• Indication: Refractory coccydynia persisting >2 months despite conservative treatment 2, 6
• Procedure: Total coccygectomy is preferred over partial coccygectomy (better outcomes) 6
• Expected outcomes: Complete pain relief in approximately 68% of cases, with 75% patient satisfaction 6

Special Considerations

• Fracture Type: Extracapsular fractures generally cause more pain than intracapsular fractures due to greater periosteal disruption 3
• Abnormal Mobility: Patients with abnormal mobility of the coccyx or bony spicules respond best to surgical treatment 1
• Complication Risk: Surgical intervention carries risks including infection, delayed healing, and persistent pain
• Alternative Therapies: Consider shock wave therapy and caudal block injections before proceeding to surgery 4

Monitoring and Follow-up

• Regular assessment of pain levels using numerical rating scales
• Radiographic follow-up to assess bone healing
• Evaluate functional improvement in daily activities, particularly sitting tolerance

Pitfalls to Avoid

1. Misdiagnosis as simple contusion or dismissing as normal postpartum pain (in obstetric cases)
2. Premature surgical intervention before adequate trial of conservative measures
3. Incomplete surgical resection (partial coccygectomy) which is associated with poorer outcomes 6
4. Failure to identify extracoccygeal causes of pain (pilonidal cyst, perianal abscess, pelvic organ disorders)
5. Inadequate pain management leading to chronic pain syndrome

By following this structured approach, most patients with coccyx fractures can achieve significant pain relief and return to normal activities without requiring surgical intervention.