What is the best management approach for an elderly female with a coccygeal fracture?

Management of Coccygeal Fracture in an Elderly Female

Conservative management with aggressive pain control, early mobilization, and multidisciplinary orthogeriatric care should be the initial approach for coccygeal fractures in elderly females, with surgery reserved only for cases with persistent, intractable pain after 6-12 months of failed conservative therapy.

Immediate Assessment and Pain Management

• Provide immediate multimodal analgesia before diagnostic workup, as pain control is critical for preventing immobility-related complications in elderly patients 1
• Avoid opioids as first-line treatment due to increased risk of falls, delirium, and mortality in the elderly 2
• Consider local anesthetic injections into the sacrococcygeal disc, intercoccygeal disc, or surrounding muscle attachments for diagnostic confirmation and therapeutic relief 3
• Apply ice and recommend use of a coccyx cushion (donut pillow) to reduce pressure when sitting 3

Comprehensive Geriatric Assessment

Implement immediate orthogeriatric comanagement to reduce morbidity, mortality, and hospital length of stay 1

Systematic evaluation must include:

• Nutritional status (malnutrition assessment) 1
• Electrolyte and volume status (dehydration is common in elderly) 1
• Anemia screening (CBC with attention to hemoglobin) 1
• Cardiac and pulmonary comorbidities (ECG, chest X-ray if indicated) 1
• Cognitive function baseline (screen for delirium and dementia) 1
• Complete medication review, particularly anticoagulants and antiplatelets 2
• Renal function (creatinine clearance affects medication dosing) 1

Conservative Treatment Protocol (First-Line for 6-12 Months)

Conservative therapy achieves satisfactory results in the majority of coccygodynia patients 3

Non-Pharmacological Interventions

• Enforce rest from prolonged sitting, bicycling, and rowing activities 3
• Prescribe physical therapy focusing on stretching and massage of levator ani muscle 3
• Manual mobilization of the coccyx by trained therapist 3
• Consider acupuncture as adjunctive therapy 3

Interventional Options for Refractory Pain

• Local anesthetic plus corticosteroid injections into painful structures (sacrococcygeal disc, first intercoccygeal disc, Walther's ganglion) 3
• Pulsed radiofrequency ablation of coccygeal discs and Walther's ganglion 3, 4
• Extracorporeal shockwave therapy 4, 5
• Caudal block injections 5
• Coccygeoplasty (polymethylmethacrylate cement injection) for select fracture cases 6

Imaging and Diagnostic Confirmation

• Obtain dynamic lateral radiographs (standing and sitting positions) to assess for abnormal coccygeal mobility, which is present in 70% of coccygodynia cases 3
• Standard lateral X-ray may show fracture, subluxation, luxation, or bony spicule 3
• MRI is particularly useful for confirming fracture and excluding other pathology when diagnosis is unclear 5

Prevention of Immobility Complications

Early mobilization is critical to prevent thromboembolism, pressure ulcers, pneumonia, and deconditioning 1, 2

• Implement pharmacologic VTE prophylaxis with low molecular weight heparin (adjusted for renal function and weight) as soon as bleeding risk allows 2
• Use mechanical prophylaxis (intermittent pneumatic compression) if anticoagulation contraindicated 2
• Begin early physical therapy to maintain mobility and prevent functional decline 2, 7

Surgical Intervention (Reserved for Treatment Failures)

Coccygectomy should only be considered after 6-12 months of failed conservative management 3, 8

Indications for Surgery

• Persistent, intractable pain unresponsive to all conservative measures 3, 8
• Best surgical outcomes occur in patients with abnormal coccygeal mobility and bony spicules 3
• Unstable coccygeal fracture with documented hypermobility on dynamic imaging 8

Surgical Outcomes

• High satisfaction rate with low complication rates when properly selected 8
• Mean VAS pain scores decrease from 51.88 preoperatively to 2.76 at 24 months postoperatively 8
• Excellent or good results in all properly selected cases 8
• Requires minimum 5 days antibiotic prophylaxis perioperatively 8

Secondary Fracture Prevention

This fracture represents a fragility fracture requiring osteoporosis evaluation 9

• Systematically evaluate for risk of subsequent fractures 1, 7
• Consider starting anti-osteoporotic treatment even without DXA scan in typical fragility fracture patterns 9
• Implement fall prevention strategies including home safety assessment and balance training 9
• Refer to Fracture Liaison Service for comprehensive secondary prevention 7

Common Pitfalls to Avoid

• Do not delay pain management waiting for imaging—provide analgesia immediately 1
• Do not rush to surgery—30% of coccygodynia is idiopathic and may resolve with time 3
• Do not overlook extracoccygeal causes of pain (pilonidal cyst, perianal abscess, hemorrhoids, pelvic organ disease, lumbosacral spine pathology) 3
• Do not immobilize excessively—prolonged bed rest increases mortality risk in elderly patients 1
• Do not prescribe opioids as first-line due to heightened risks in geriatric population 2