What is the treatment for a patient with a non-displaced fractured coccyx?

Treatment of Non-Displaced Coccyx Fracture

Non-displaced coccyx fractures should be managed conservatively with rest, analgesics, activity modification, and supportive measures—surgery is reserved only for refractory cases after prolonged conservative treatment failure.

Initial Conservative Management

The cornerstone of treatment for non-displaced coccyx fractures is conservative therapy, which successfully manages the majority of cases 1, 2, 3.

Pain Control Strategy

• Initiate simple analgesics such as paracetamol (acetaminophen) on a regular scheduled basis as first-line therapy 4
• NSAIDs can be added for anti-inflammatory effect, though use cautiously in patients with renal dysfunction or gastrointestinal concerns 4, 1
• Opioids should be used sparingly and only for severe pain in the acute phase, particularly avoiding in patients with renal impairment 4

Activity Modification and Positioning

• Minimize sitting time as much as possible during the acute healing phase 1, 3
• Use a coccyx cushion (donut-shaped or wedge cushion) when sitting is unavoidable to reduce direct pressure on the coccyx 1, 3
• Avoid activities that increase coccygeal stress including prolonged sitting, bicycling, rowing, and horseback riding 1

Physical Therapy Interventions

• Manual therapy including massage and stretching of the levator ani muscle can provide significant relief 1
• Coccygeal mobilization performed by trained therapists may improve outcomes 1, 3
• Postural adjustments to reduce coccygeal loading during daily activities 3

Expected Healing Timeline

Most non-displaced coccyx fractures heal within weeks to months with conservative management 5. The typical recovery period ranges from 2-3 months, though some patients may experience symptoms for longer 2, 6.

Advanced Conservative Options for Persistent Pain

If pain persists beyond 2-3 months despite initial conservative measures, consider escalating to interventional therapies before considering surgery 2, 5:

Injection Therapy

• Local anesthetic and corticosteroid injections into painful coccygeal structures (sacrococcygeal disc, intercoccygeal disc, or surrounding soft tissues) 1, 3
• Caudal block injections may provide significant pain relief in refractory cases 6

Alternative Therapies

• Acupuncture has shown benefit in some patients 1
• Low-level laser therapy (laser acupuncture) may be effective for refractory coccydynia, with one case report showing significant improvement after 11 weeks of weekly treatment 2
• Shock wave therapy has been used successfully in select cases 6
• Radiofrequency ablation of coccygeal discs and Walther's ganglion for persistent pain 1

Monitoring and Follow-Up

• Clinical reassessment should occur at 2-4 week intervals initially to ensure adequate pain control and functional improvement 2, 6
• Radiographic follow-up is generally not necessary for non-displaced fractures unless there is concern for displacement or failure to improve clinically 1
• Patients should return immediately if symptoms worsen significantly or new neurological symptoms develop 4

Surgical Intervention: When and Why

Coccygectomy (partial or total) is reserved for refractory cases where conservative treatment has failed after prolonged trial (typically >6 months) 1, 5, 3.

Indications for Surgery

Surgery should be considered only when 1, 5, 3:

• Conservative treatment has failed for at least 6 months to 1 year
• Abnormal coccygeal mobility is documented on dynamic radiographs (lateral X-rays in standing and sitting positions showing hypermobility, subluxation, or luxation)
• Coccygeal spicule (bony excrescence) is present causing mechanical irritation
• Pain significantly impairs quality of life and ability to perform daily activities

Surgical Outcomes

• Traumatic coccygodynia (from fracture) has significantly better surgical outcomes than idiopathic coccygodynia: 88% good-to-excellent results versus only 38% in idiopathic cases 5
• Patients with documented abnormal coccygeal mobility or spicules respond best to surgical treatment 1, 3
• Surgery carries risks including infection, wound complications, and potential for persistent pain 2, 6

Critical Clinical Pitfalls to Avoid

• Do not rush to surgery: The vast majority of non-displaced coccyx fractures heal with conservative management; premature surgical intervention exposes patients to unnecessary risks 1, 2, 5
• Do not dismiss persistent pain: While most cases resolve, some patients develop chronic coccydynia requiring escalation of conservative therapies or eventual surgical consideration 2, 6
• Do not overlook alternative diagnoses: Ensure pain is truly coccygeal in origin and not from pilonidal cyst, perianal abscess, hemorrhoids, pelvic organ pathology, lumbosacral spine disorders, or sacroiliac joint dysfunction 1
• Do not forget functional impact: Coccydynia can severely impair quality of life, particularly for patients whose occupations require prolonged sitting 6