What is the treatment for a coccyx fracture?

Treatment of Coccyx Fracture

Conservative management is the mainstay of treatment for coccyx fractures, including pain control, cushioning, and physical therapy, with surgical intervention reserved only for cases refractory to conservative measures after at least 2 months.

Initial Management

• Pain control:

  • Non-steroidal anti-inflammatory drugs (NSAIDs) are first-line for pain management 1
  • Opioid analgesics may be considered for severe pain, though evidence for their specific use in coccyx fractures is limited 2

• Cushioning:

  • Special coccyx cushions with a cutout area to relieve pressure on the tailbone 3
  • Avoid prolonged sitting; when sitting is necessary, use the cushion consistently

• Activity modification:

  • Avoid activities that exacerbate pain (bicycling, rowing, horseback riding) 1
  • Rest is recommended initially, though no specific guidelines exist regarding duration 2

Follow-up Care

• Radiographic monitoring:

  • Regular radiographic follow-up at 2-week intervals initially to monitor healing 2
  • Dynamic radiographs (lateral X-rays in standing and sitting positions) are most useful for assessing abnormal mobility, which is present in approximately 70% of patients with coccygodynia 1

• Physical therapy interventions:

  • Manual therapy including massage and stretching of the levator ani muscle 1
  • Mobilization of the coccyx by a trained physical therapist 1
  • Begin gentle exercises after initial acute pain subsides

Advanced Interventions for Persistent Pain

• Therapeutic injections (for pain persisting >2 months):

  • Local anesthetic and corticosteroid injections into painful structures (sacrococcygeal joint, first intercoccygeal disc, Walther's ganglion) 1, 4
  • These injections can both diagnose and treat coccygeal pain

• Alternative therapies to consider:

  • Laser acupuncture has shown promise in case reports for refractory coccydynia 5
  • Radiofrequency ablation of coccygeal discs and Walther's ganglion for persistent pain 1

Surgical Management

• Indications for coccygectomy (partial or total removal of the coccyx):

  • Reserved for cases that fail conservative management for at least 2 months 6
  • Most appropriate for patients with demonstrated abnormal mobility or coccygeal spicules 1
  • Success rates are highest in patients with radiographically demonstrated abnormalities 4

• Surgical considerations:

  • Wound complications are common (wound breakdown reported in some patients) 6
  • Should only be considered after exhausting all conservative options

Important Clinical Pearls

• Most coccyx fractures heal with conservative treatment alone 5
• Abnormal mobility of the coccyx is the most common pathological finding in patients with coccygodynia (70% of patients) 1
• Always rule out other causes of coccygeal pain (pilonidal cyst, perianal abscess, hemorrhoids, pelvic organ disorders) 1
• In approximately 30% of patients with coccygodynia, the cause of pain cannot be identified (idiopathic coccygodynia) 1
• For patients over 50 years with fragility fractures, calcium (1000-1200 mg/day) and vitamin D (800 IU/day) supplementation should be considered 2

Treatment Algorithm

1. First 4-6 weeks: Conservative management (NSAIDs, cushioning, activity modification)
2. If pain persists 6-8 weeks: Consider local injections and specialized physical therapy
3. If refractory >2-3 months: Evaluate for surgical candidacy with dynamic radiographs
4. Surgery only if: Persistent severe pain AND radiographic abnormalities AND failure of all conservative measures