What is the appropriate management for a small coccygeal fracture in a 27-year-old woman who sustained the injury while snowboarding?

Management of Small Coccygeal Fracture in a 27-Year-Old Female

Conservative management with analgesics, activity modification, and a coccyx cushion is the appropriate treatment for this small tailbone fracture, as most coccygeal fractures recover with non-surgical therapy. 1, 2

Initial Pain Management and Activity Modification

• Initiate appropriate analgesic therapy immediately to control pain and facilitate early mobilization 3
• Prescribe NSAIDs or acetaminophen as first-line agents for pain control 1
• Recommend decreased sitting time and use of a doughnut-shaped cushion to avoid direct pressure on the coccyx 2, 4
• Advise rest and avoidance of activities that increase coccygeal pressure (prolonged sitting, cycling, rowing) 1, 4
• Apply local heat to the affected area for symptomatic relief 4

Physical Therapy and Rehabilitation

• Begin coccygeal massage and stretching of the levator ani muscle once acute pain subsides 1
• Implement manual therapy including mobilization of the coccyx to address any developing stiffness 1
• Start early physical training and muscle strengthening of the pelvic floor and core muscles after the initial acute phase 3
• Incorporate long-term balance training to prevent future falls and injuries 3

Expected Timeline and Follow-Up

• Most coccygeal fractures improve significantly within 4-8 weeks of conservative treatment 4
• Schedule follow-up at 4-6 weeks to assess pain improvement and functional recovery 4
• If pain persists beyond 2 months despite conservative therapy, the condition is considered refractory and requires additional evaluation 5, 2

Management of Refractory Cases (If Conservative Treatment Fails)

For patients with persistent coccydynia beyond 2 months:

• Obtain dynamic radiographs (lateral X-rays in standing and sitting positions) to assess for abnormal coccygeal mobility, which is present in 70% of patients with chronic coccydynia 1, 2
• Consider diagnostic injection of local anesthetic into the sacrococcygeal disc or intercoccygeal disc to confirm coccygeal origin of pain 1
• Trial therapeutic injections of local anesthetic plus corticosteroid into painful structures 1, 2
• Alternative therapies include laser acupuncture, which has shown success in refractory cases 5
• Coccygectomy is reserved only for refractory cases with documented abnormal mobility or spicule formation who have failed all conservative measures 1, 2

Common Pitfalls to Avoid

• Do not rush to surgical intervention, as nonsurgical management remains the gold standard for coccygeal fractures 2
• Avoid prolonged bed rest, which can lead to deconditioning and delayed recovery 3
• Do not dismiss persistent pain as normal posttraumatic discomfort—refractory cases require systematic evaluation with dynamic imaging 1, 6
• Be aware that coccygectomy has a high complication rate and should only be considered after exhausting conservative options 5, 2

Special Considerations for This Young Patient

• At age 27, this patient does not require osteoporosis evaluation or pharmacological fracture prevention, as these recommendations apply to patients aged 50 years and older 7, 3
• Focus on return to activities including snowboarding once pain resolves and functional recovery is complete 2
• Counsel regarding potential for introital dyspareunia and pelvic floor tension if pain becomes chronic, though this is more common with fracture-dislocation 4