Initial Management of Coccyx Fracture
Conservative management with immediate pain control and activity modification is the recommended initial approach for coccyx fractures, as the vast majority heal successfully without surgical intervention.
Immediate Pain Management
Administer regular paracetamol (acetaminophen) as first-line analgesia unless contraindicated, as this is the recommended initial analgesic approach for traumatic fractures 1
Use opioids cautiously with dose reduction, particularly in patients with renal dysfunction or elderly patients, as approximately 40% may have moderate renal impairment requiring careful dosing 1
Avoid NSAIDs initially or use only after checking renal function, as this population has high rates of renal dysfunction and NSAIDs carry significant risks in this context 1
Physical Examination and Positioning
Assess for localized pain, swelling, tenderness, and bruising over the coccygeal region, which are characteristic findings of coccyx fractures 2
Evaluate for difficulty with movement and sitting, as these are pathognomonic features that enable early clinical recognition 3, 2
Immobilize the patient in a position of comfort and recommend lateral recumbency (side-lying position) to minimize pressure on the fractured coccyx 4
Activity Modification
Instruct patients to avoid prolonged sitting and use cushioning devices (donut cushions or wedge cushions) to reduce direct pressure on the coccyx during the healing phase 5, 4
Advise against activities that place direct stress on the coccyx until pain significantly improves, typically over 2-12 weeks 5, 3
Diagnostic Imaging
Obtain initial radiographs (X-rays) of the coccyx in both standing and sitting positions to evaluate fracture pattern, displacement, and coccygeal hypermobility 3
Consider CT or MRI if initial X-rays are inconclusive or if symptoms persist beyond expected healing time, as MRI is particularly useful for detecting soft tissue injuries and assessing fracture healing 3, 2
Expected Clinical Course
Most coccyx fractures improve gradually over 2-12 weeks with conservative management, and patients should be counseled about this typical recovery timeline 5, 4
Monitor for development of chronic coccydynia (pain persisting beyond 2 months), as this occurs in a subset of patients and may require escalation of treatment 5, 6
Critical Pitfalls to Avoid
Do not delay pain assessment and initiation of analgesia, as early and effective pain control is crucial for patient comfort and functional recovery 1
Do not prescribe NSAIDs without first checking renal function, particularly in elderly patients or those with comorbidities 1
Do not dismiss persistent pain as normal postpartum discomfort in obstetric patients, as intrapartum coccygeal fractures can be misdiagnosed and lead to prolonged disability if not properly evaluated 2
Do not rush to surgical intervention, as conservative treatment is successful in the majority of cases, and surgery should be reserved for refractory cases after at least 2 months of failed conservative therapy 5, 6