Treatment of Displaced Coccyx Fracture
For displaced coccyx fractures, initial conservative management with analgesics and activity modification should be attempted for 2-3 months, but if pain remains refractory, surgical intervention with open reduction and internal fixation or coccygectomy provides superior outcomes compared to continued conservative therapy.
Initial Conservative Management
- Start with non-surgical treatment including NSAIDs, lateral recumbency positioning, and activity modification for the first 2-3 months after injury 1, 2.
- Most coccyx fractures heal with conservative therapy alone, making this the appropriate first-line approach 1, 2.
- Monitor clinical response closely during this period, as the majority of patients will experience resolution of symptoms 3.
Indications for Surgical Intervention
Proceed to surgery if any of the following are present:
- Persistent, refractory coccydynia after >2 months of adequate conservative treatment 1, 4.
- Manipulative reduction failures with documented instability on X-ray examination 4.
- Severe rectal irritation symptoms that interfere with daily activities 4.
- Pain severity that prevents normal sitting or daily function despite conservative measures 3.
Surgical Options
Open Reduction and Internal Fixation (ORIF)
- This is the preferred surgical approach for displaced coccyx fractures when anatomic reduction is achievable 4.
- Achieves 92.6-100% excellent clinical outcomes at final follow-up 4.
- VAS improvement rate of 97.6%, which represents excellent pain relief 4.
- Hardware removal at 1-2 years post-operatively typically results in complete symptom resolution (VAS 0) 4.
Coccygectomy
- Reserve coccygectomy for cases where ORIF is not feasible or when traumatic coccygodynia persists despite other interventions 3.
- Traumatically-induced coccygodynia has significantly better surgical outcomes (88% good/excellent results) compared to idiopathic coccygodynia (38% good/excellent results) 3.
- This distinction is critical: patients with documented traumatic fractures benefit substantially more from coccygectomy than those with idiopathic pain 3.
Alternative Conservative Options for Refractory Cases
If the patient refuses surgery or is a poor surgical candidate:
- Low-level laser therapy applied weekly can provide significant pain reduction and promote bone healing in refractory cases 1.
- Pulsed radiofrequency therapy, extracorporeal shockwave therapy, or local drug injections may be considered 2.
- Coccygeoplasty (percutaneous injection of polymethylmethacrylate cement) can provide immediate symptom relief, though evidence is limited to case reports 5.
Critical Clinical Pitfalls
- Do not delay surgical consultation beyond 2-3 months in patients with persistent severe symptoms, as prolonged conservative management in refractory cases leads to worse quality of life without improving outcomes 4, 3.
- Obtain X-ray confirmation of fracture stability before committing to extended conservative management, as unstable fractures are unlikely to respond to non-surgical treatment 4.
- Document the traumatic etiology clearly, as this predicts significantly better surgical outcomes compared to idiopathic coccygodynia 3.