Coccyx Fractures: Classification, Clinical Picture, Diagnosis and Treatment

Coccyx – a series of rudimentary vertebrae, usually three to five, forming the caudal end of the spine and located below the apex of the sacrum.

Coccyx fractures mainly affect the last segment of the axial skeleton and are often underestimated because of their relatively rare occurrence and unexpressed symptoms.

Etiology

Coccyx fractures most commonly occur due to the following causes:

1. Direct trauma to the tailbone (e.g., falling backwards from a sitting position).
2. High-energy trauma (e.g., motor vehicle accidents, sports injuries).
3. Birth trauma in women due to pressure during childbirth.

Mechanisms of damage:

1. The most common mechanism is direct axial loading, exemplified by falls in the sitting position where the force is transmitted directly to the coccyx.
2. When oblique or lateral impact forces occur, dislocations or angular fractures may occur.
3. During labor, the fetus can put significant pressure on the coccyx as it moves downward, especially during assisted or complicated labor.

Epidemiology

1. Frequency: coccyx fractures account for a small proportion of spinal injuries.
2. Demographics: more common in women, probably due to wider pelvic anatomy and obstetric factors.
3. Most common in adults and adolescents; rare in children due to greater bone flexibility.
4. Risk factors: osteoporosis, contact sports.

Classification of coccyx fractures

There is no generally accepted classification of coccyx fractures, but they can be described as follows:

1. Non-displaced fracture: fracture without displacement of bone fragments.
2. Displaced fracture: the bone fragments are displaced relative to each other.
3. Splinter fracture: the bone is broken into several pieces.
4. Dislocation or subluxation: displacement at the sacrococcygeal joint without a true fracture.

Diagnosis of coccyx fractures

Diagnosis of coccyx fracture is based on clinical evaluation and radiologic examination techniques.

Clinical evaluation

1. History: recent injury, fall, or childbirth; onset of pain.
2. Chiropractic examination: soreness on palpation in the coccyx area, swelling, bruising; pain increases when sitting or standing up.

Radiation methods of research

1. Lateral radiography: best for visualizing coccyx dislocations and fractures.
2. CT (computed tomography) and MRI (magnetic resonance imaging): sometimes used if the fracture is non-displaced or multifocal and to rule out other pathology (e.g. tumors).

Clinical Manifestations

Typical clinical presentation in coccyx fracture:

1. Pain: sudden, sharp pain localized in the coccyx, intensified by sitting, standing or defecation.
2. Local changes: pain with mechanical pressure on the coccyx, soft tissue swelling, bruising (in acute trauma).
3. Chronic discomfort: in untreated or misdiagnosed cases, chronic coccygodynia (persistent coccyx pain) can develop.

Treatment of coccyx fractures

Conservative treatment

Methods of conservative treatment of coccyx fracture:

1. Resting and avoiding pressure on the tailbone (such as using a donut-shaped pillow).
2. Analgesics to relieve pain.
3. Physical therapy: in persistent cases, techniques such as relaxation of the pelvic floor muscles and light stretching are used.

Indications for conservative treatment are:

1. Most non-displaced, minimally displaced, or isolated fractures.
2. Absence of significant neurovascular abnormalities, open wounds, or persistent symptoms after trauma.

The prognosis is usually favorable, with recovery occurring in a few weeks or months.

Surgical treatment

Surgical intervention is rarely required and is used in severe cases.

The surgical treatment method is coccygectomy: surgical removal of all or part of the coccyx; considered for chronic, unrelieved pain (coccygodynia) after unsuccessful conservative therapy.

Indications for surgical treatment are:

1. Persistent, unrelieved pain (chronic coccygodynia) that has not responded to conservative treatment for at least 6-12 months.
2. Improperly comminuted fractures with pronounced angular deformity.
3. Soft tissue infections, coccyx sores, neurologic deficits associated with acquired coccyx deformity.

Coccygectomy usually results in pain relief in certain, carefully selected patients, but carries risks such as wound healing problems or infection.

Prognosis in coccyx fracture

Unlike most long bones, the coccyx has a limited support function, but serves as an attachment point for the ligaments, tendons and muscles of the pelvic floor. Therefore, even minor fractures or distortions can lead to chronic pain (coccygodynia) and discomfort when sitting.

Factors affecting prognosis include: type of fracture, associated soft tissue injury, mobility of the coccyx prior to injury, age and activity level of the patient.

Summary of prognostic data in coccyx trauma depending on the form of fracture

In conservative treatment of non-dislocated fractures, healing occurs within 8 weeks and the development of chronic pain syndrome is rare. In about 30% of cases, chronic pain syndrome may develop during conservative treatment of coccyx fractures that are displaced or splintered.

Factors predisposing to the development of chronic pain syndrome:

• There’s a pronounced displacement of the fragments;
• Repetitive trauma to the coccyx;
• Inadequate initial treatment;
• Psychosocial factors.

In case of persistent pain syndrome (more than 6 months), radiological evidence of dislocation of the fragments, as well as ineffectiveness of conservative therapy, it is possible to perform surgery – coccygectomy (partial or complete removal of the coccyx). The effectiveness of surgical treatment is 70-85%, but there is a risk of infectious and dystrophic complications.

Early diagnosis, pain control in the acute period, effective rehabilitation, and patient education are critical to achieving the best possible outcomes regardless of the type of fracture.

Rehabilitation after coccyx fracture

The key principles of rehabilitation for coccyx fractures are:

• Pain control;
• Teaching the patient proper posture;
• Return to daily activities.

Stages of rehabilitation

1. Acute phase (0-2 weeks): the main goal is to control pain, minimize the load on the coccyx and prevent complications. To relieve pressure on this area, a doughnut-shaped pillow should be used and sitting upright should be restricted. Walking and standing have a favorable effect.
2. Subacute phase (2-6 weeks): pelvic and trunk stability should be restored and improved. During this period, you can gradually increase sitting time (using a cushion) and begin to strengthen and stretch the gluteal, pear and pelvic floor muscles.
3. Recovery phase (6-12 weeks): you should return to the level of activity you had before the injury. Aerobic exercise, swimming, stretching, and proprioception and balance training are allowed during this period.
4. Return to full activity (12+ weeks): expected to return to full activities of daily living and sports.

“Red flags” in the rehabilitation process are:

• Worsening of neurologic symptoms: numbness, weakness in the legs, loss of bowel or bladder control.
• Signs of infection (after surgery): fever, increasing swelling and redness in the area of the suture.
• Unusual pain that does not respond to conservative treatment.

If any of the above occur, it is worth seeking immediate medical attention.

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Treatment of chronic coccygeal pain syndrome

Treatment of chronic coccygeal pain syndrome is staged and involves three levels of treatment interventions:

1. Conservative therapy. Minimizing prolonged sitting, without special cushions. Non-steroidal anti-inflammatory drugs – systemically as well as locally – can provide temporary pain relief. Short courses of myorelaxants for muscle spasms are also possible. Physiotherapy treatment, manual therapy and therapeutic physical rehabilitation are also an integral part of the treatment process. Psychological support can also be effective.
2. Interventional methods:

• Injection therapy with glucocorticosteroids;
• Blockade of the unpaired ganglion;
• Gentle mobilization of the coccyx (performed under sedation).

3. Surgical treatment (coccygectomy). Coccygectomy is indicated in cases of clearly confirmed instability, dislocation or unresolved pain despite exhaustive conservative therapy for 6+ months. The treatment success rate is 85%, but the risk of postoperative complications should be considered.

Additional methods of treatment may include percutaneous electroneurostimulation, acupuncture, and psychotherapy.