How should a 76-year-old male with an acute hairline fracture of the first coccygeal body (CY1) and mild osteopenia be treated?

Management of Acute Coccygeal Fracture in a 76-Year-Old Male with Osteopenia

This patient should be managed conservatively by the primary care provider with pain control, activity modification, and initiation of osteoporosis treatment; referral to orthopedics is not necessary for an isolated, non-displaced coccygeal fracture. 1, 2

Immediate Fracture Management

Conservative treatment is the standard of care for acute coccygeal fractures and achieves satisfactory results in the majority of patients. 1, 2

• Initiate appropriate pain control with acetaminophen as first-line therapy, avoiding NSAIDs given the patient's age and likely cardiovascular comorbidities (bilateral hip arthroplasties suggest significant medical history). 3

• Prescribe a coccyx cushion (donut-shaped or wedge cushion) to reduce direct pressure on the coccyx during sitting. 1

• Recommend activity modification including avoiding prolonged sitting, using the cushion consistently, and rising carefully from seated positions. 1, 2

• Avoid prolonged bed rest, as this accelerates bone loss, muscle weakness, and increases risk of deep vein thrombosis—particularly critical in this elderly patient with bilateral hip hardware. 3

Osteoporosis Evaluation and Treatment

Given the presence of mild osteopenia on imaging and an acute fragility fracture, this patient requires systematic fracture risk evaluation and pharmacological osteoporosis treatment. 4, 3

Diagnostic Workup

• Order DXA scanning of the lumbar spine and hip to quantify bone mineral density and establish baseline T-scores, as current diagnostic and treatment criteria for osteoporosis rely on DXA measurements. 4, 5

• Obtain laboratory assessment including serum calcium, albumin, creatinine, thyroid-stimulating hormone, and erythrocyte sedimentation rate to identify secondary causes of osteoporosis. 5

Pharmacological Management

Initiate oral bisphosphonate therapy (alendronate or risedronate) as first-line treatment, which reduces vertebral fractures by 47-48%, non-vertebral fractures by 26-53%, and hip fractures by 51%. 3, 5

• Prescribe calcium supplementation of 1000-1200 mg/day and vitamin D 800 IU/day, which reduces non-vertebral fractures by 15-20% and falls by 20%. 4, 3, 5

• For patients with GFR <30 mL/min or oral intolerance, consider denosumab 60 mg subcutaneously every 6 months as an alternative. 3

• Plan for 3-5 years of initial bisphosphonate therapy, with longer duration if high fracture risk persists. 4, 5

Non-Pharmacological Interventions

• Recommend smoking cessation and limiting alcohol intake to 1-2 alcoholic beverages per day to improve bone mineral density. 4, 3

• Prescribe weight-bearing exercise programs as tolerated to improve BMD and muscle strength, reducing fall risk. 4, 3

• Implement multidimensional fall prevention assessment, addressing environmental hazards in the home and reviewing medications that may increase fall risk. 3

Follow-Up and Monitoring

Establish systematic follow-up with regular monitoring for medication tolerance and adherence, as adherence rates reach 90% with structured follow-up. 5

• Reassess fracture risk every 1-3 years with repeat DXA scanning, performing earlier reassessment (within 1 year) given this patient's history of fragility fracture. 4

• Monitor coccygeal pain at 2-4 week intervals; if pain persists beyond 6-8 weeks despite conservative measures, consider advanced imaging or specialist referral. 1, 2

When to Consider Specialist Referral

Referral to pain management or interventional radiology is indicated only if conservative treatment fails after 2-3 months. 1, 6, 2

• Refractory cases may benefit from local anesthetic and corticosteroid injections, radiofrequency ablation, or rarely coccygeoplasty (polymethylmethacrylate cement augmentation). 1, 6, 7

• Surgical coccygectomy is reserved for cases with abnormal coccygeal mobility or bony spicules that fail all conservative and interventional treatments. 1

Critical Pitfalls to Avoid

• Do not dismiss this fracture as trivial—it represents a fragility fracture requiring full osteoporosis evaluation and treatment to prevent future hip or vertebral fractures. 4

• Do not delay osteoporosis treatment waiting for DXA results; in elderly patients with a recent fracture and radiographic osteopenia, treatment can be initiated immediately. 4

• Do not prescribe NSAIDs without careful consideration of renal function, cardiovascular risk, and gastrointestinal risk in this elderly patient. 3