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Basics ⬇

Author(s): JohnMunyak, MD, YaffaIlyaguyeva and AmityTung, MD

Description

  • Fall landing in sitting position is most common.
  • Also can occur during childbirth (1)
  • Surgical procedures performed in area of coccyx
  • Fractures of the coccyx are usually transverse.
  • More common in women

Etiology and Pathophysiology

  • The coccyx is made up of 3 to 5 fused vertebrae with attachments of several important muscles and ligaments. The muscles include the levator ani group, which supports the pelvic floor and aids in maintaining fecal continence, and the gluteus maximus, which aids in thigh extension.
  • The coccyx has limited movement at the sacrococcygeal junction and a curvature such that the tip curves into the pelvis.
  • Coccyx injuries are often belittled by physicians, but it should be kept in mind that the pain can be extremely severe and debilitating to the patient. Additionally, the coccyx is a weight-bearing structure in the seated position, and an ill-managed coccyx fracture can cause the patient to apply more weight on the ischial tuberosities, causing bursitis.

Risk-Factors

  • Predominantly occur in females because the female pelvis is broader, and the coccyx is more exposed
  • Advanced age
  • Osteoporosis
  • Decreased balance causing more falls
  • Congenital bone disorder such as osteogenesis imperfecta
  • Involvement in activities such as skating or skateboarding

General Prevention

  • Calcium and vitamin D supplements to prevent osteoporosis
  • Refraining from activities that would predispose to falling on the buttocks, especially if elderly or if underlying medical conditions such as osteogenesis imperfecta are present

Diagnosis ⬆ ⬇

  • Mechanism of injury
  • Look for ecchymosis and palpate for tenderness in the gluteal fold.
  • Prehospital:
    • Evaluate for other associated injuries (other potential life-threatening injuries such as head injuries may be missed if the focus is on the pain from the coccyx injury).

History

  • Mechanism of injury (fall vs. assault vs. childbirth)
  • Factors leading up to the fall (mechanical fall vs. syncope)
  • Other associated injuries (other potential life-threatening injuries such as head injuries may be missed if the patient is focusing on the pain from the coccyx injury)
  • Use of blood thinners (for ecchymosis out of proportion to the severity of injury)
  • Low back pain, buttock pain, rectal bleeding (if associated rectal tear)
  • Pain when sitting or defecating—document the PQRST of pain: Palliative or Precipitating factors, Quality, Region or Radiation, Severity (1 to 10), and Timing
  • Risk for cancer (pathologic fracture): bright red blood per rectum (BRBPR), abnormal vaginal bleeding, weight loss

Physical Exam

  • Palpation of the sacrococcygeal joint for pain
  • Digital rectal examination can be diagnostic with mobility and/or crepitus of the coccyx.
  • Assess sacrococcygeal joint mobility by palpating the coccyx anteriorly (digital rectal exam) and posteriorly (externally).
  • Anoscopy should be performed if gross blood is present to evaluate for possible rectal perforation (very rare).
  • Examination of the entire spine is necessary to evaluate for concomitant injury.
  • Neurologic exam of the lower extremities to assess radiculopathy
  • Radiographs will identify other suspected spinal injuries.
  • Displaced coccyx fractures can be seen best on the lateral coccyx view radiograph.
  • Radiographs are not necessary if isolated coccyx fracture is apparent on rectal exam.
  • Nondisplaced fractures are difficult to see on x-ray.
  • When x-rays are used in the diagnosis, three views needed: anteroposterior (AP), lateral, and cone-down (focused) coccyx view
  • More extensive diagnostic imaging is unnecessary in traumatic coccyx injuries (2).

Differential Diagnosis

Treatment ⬆ ⬇

Emergency department (ED) treatment:

  • Symptomatic treatment
  • Rarely, bed rest until ambulation can be tolerated
  • Oral analgesics are key; may range from over-the-counter (OTC) acetaminophen or ibuprofen to prescription topical agents based on severity of pain
  • Aim for conservative management in the pediatric population given high healing rates (3).
  • Attempted manipulation and reduction of the displaced fracture by digital rectal approach is not necessary and futile because the coccyx cannot be stabilized.
  • If there is an associated rectal injury, call for a surgical consult immediately. Prescribe antibiotics to cover for enteric pathogens: cefoxitin, cefotetan, and metronidazole.
  • Cushions (“doughnuts”)
  • Sitz baths
  • Stool softeners may help to reduce pain during bowel movements.

Medication

  • Cefotetan: adult: 2 g intravenous (IV); children: 80 mg/kg/day divided q6–8h (used with rectal injury)
  • Cefoxitin: adult: 2 g IV; children: 80 to 160 mg/kg/day divided q6h (used with rectal injury)
  • Metronidazole: adult: 0.5 to 1 g IV; children: 30 mg/kg/day divided q12h (used with rectal injury)
  • Acetaminophen
  • NSAIDS
  • Lidoderm 5% patch
  • Voltaren 1% gel

Additional Therapies

Prescription “doughnut pillows” provide comfort until the fracture heals. They are helpful even if only a contusion is present.

Surgery/Other Procedures

Surgery is usually not required. Very rarely, severe trauma results in a comminuted fracture requiring coccygectomy (4).

Admission, Inpatient, and Nursing Considerations

  • Initial stabilization:
    • Spine immobilization for suspected concomitant cervical, thoracic, or lumbar injuries
    • Pain control with nonsteroidal anti-inflammatory drugs (NSAIDs) or narcotic analgesics
  • Admission criteria:
    • Nearly all patients can be managed on an outpatient basis.
    • Only patients with severe pain, an inability to walk or to take care of themselves, other serious injury, or requiring surgery need to be admitted.
  • Discharge criteria:
    • Most patients can be managed as outpatients with appropriate follow-up.
    • The patient is discharged home when other conditions are ruled out, and pain is under control.

Ongoing Care ⬆ ⬇

Follow-up Recommendations

  • Healing is slow.
  • Pain may become chronic.
  • Orthopedic consultation and possible coccygectomy may be required in severe cases.

Patient Education

  • Avoid activities requiring prolonged sitting such as horseback riding, long travel, biking, and so forth.
  • Lean forward while sitting to avoid weight-bearing on the coccyx.

Prognosis

Pain usually resolves about a week after callous forms.

Complications

Rarely, chronic pain or instability may require coccygectomy (4).

Additional Reading ⬆ ⬇

  • RockwoodC, GreenD, eds. Fractures in Adults. 8th ed. Philadelphia, PA: Lippincott-Raven; 2014.
  • Simon R, Sherman SC. Emergency Orthopedics: The Extremities. 6th ed. Norwalk, CT: Appleton & Lange; 2011.
  • Tibble CD, Gibbs M. Pelvic fractures. In: WolfsonAB, CloutierRL, HendeyGW, et al, eds. Harwood-Nuss’ Clinical Practice of Emergency Medicine. 6th ed. Philadelphia, PA: Wolters Kluwer; 2015:277–284

References ⬆ ⬇

  1. Kaushal R, Bhanot A, Luthra S, et al. Intrapartum coccygeal fracture, a cause for postpartum coccydynia: a case report. J Surg Orthop Adv. 2005;14(3):136–137.
  2. Hanna TN, Sadiq M, Ditkofsky N, et al. Sacrum and coccyx radiographs have limited clinical impact in the emergency department. AJR Am J Roentgenol. 2016;206(4):681–686.
  3. Hamoud K, Abbas J. Fracture dislocation of the sacro-coccygeal joint in a 12-year-old boy. A case report and literature review. Orthop Traumatol Surg Res. 2015;101(7):871–873.
  4. Ramieri A, Domenicucci M, Cellocco P, et al. Acute traumatic instability of the coccyx: results in 28 consecutive coccygectomies. Eur Spine J. 2013;22(Suppl 6):S939–S944.

Clinical Pearls ⬆

  • More common in women
  • May occur owing to falls or during childbirth (1)
  • A self-limited condition
  • Treatment includes pain management with oral anti-inflammatory medications, topical agents, and doughnut pillows.
  • If there is an associated rectal injury, call for a surgical consult immediately. Prescribe antibiotics to cover for enteric pathogens.