Rosen & Barkin's 5-Minute Emergency Medicine Consult (666 page)

• Usually results from a fall that ends with the victim in sitting position
  
• Fall usually occurs from standing height
  
• Can occur during childbirth
  
• More common in women
  

See “Description.”

DIAGNOSIS

• Tenderness localized over the coccyx
  
• Ecchymosis over the gluteal fold
  
• Pain with sitting, especially when leaning forward, and with defecation
  

Patient or witness to provide full history of accident including any earlier events that might influence mechanism of fall or insult

A full physical exam:

• Including rectal exam to assess tenderness or mobility of coccyx
  
• No evidence of neurologic deficit should be found in isolated coccygeal fractures.
  

Most often isolated injury, but if other spinal injury of concern, spinal immobilization should be instituted.

Routine radiographic imaging unnecessary:

• Concern about unnecessary radiation to gonads when diagnosis can be made clinically
  
• Imaging is indicated if concern for other spine injuries.
  
• Radiographs can be hard to interpret because coccyx has normal variant positions that can be confused with fracture.
  
• Lateral radiograph is a best view for fracture and dislocation.
  

• Coccygodynia
  
• Levator ani syndrome
  
• Pilonidal cyst
  
• Perirectal abscess
  

TREATMENT

• Pain management
  
• Assess for other injuries
  

• Usually none required; if patient unstable, consider other diagnoses.
  
• Medicate for pain.
  

• Pain medication
  
• Reduction of displaced coccygeal fracture, but rarely necessary.
  

Recommend donut-shaped seat cushion for comfort.

• Medication for pain if and as needed
  
• Stool softener
  

Reduction may be attempted if displaced coccygeal fracture evident, but rarely needed or successful.

FOLLOW-UP

Admission is generally not required.

Coccygeal fracture can be managed on an outpatient basis unless other intercurrent injury makes admission necessary.

• Cwinn AA. Pelvis. In: Marx J, ed.
  Rosen’s Emergency Medicine: Concepts and Clinical Practice.
  5th ed. St. Louis, MO: Mosby; 2002:632–633.
  
• Gutierrez PR, Más Martínez JJ, Arenas J. Salter-Harris type I fracture of the sacro-coccygeal joint.
  Pediatr Radiol
  . 1998;28:734.
  
• Traub S, Glaser J, Manino B.
  Coccygectomy for the treatment of therapy-resistant coccygodynia
  .
  J Surg Orthop Adv.
  2009;18(3):147–149.
  

CODES

• 805.6 Closed fracture of sacrum and coccyx without mention of spinal cord injury
  
• 847.4 Sprain of coccyx
  
• 959.19 Other injury of other sites of trunk
  

BASICS

• Flexion compression fracture:
  
  • Wedge compression:
    
    • If <50% anterior compression of the vertebral body, injury considered stable
      
    • No ligamentous injury
      
    • No neurologic deficit
      
  • Burst fracture:
    
    • Vertebral body fracture with retropulsion of bone into the neural canal
      
    • Kyphosis evident on lateral radiograph
      
    • Posterior ligamentous injury
      
    • Anterior compression, lower extremities, calcaneal fractures
      
    • Possible neurologic deficit
      
• Flexion distraction (lap belt injury):
  
  • Abdominal injuries likely
    
  • Chance fracture:
    
    • Purely bony injury; fracture line through spinous process, pedicles, and vertebral body
      
    • No kyphosis evident on lateral radiograph
      
    • Often no neurologic deficit
      
  • Facet dislocation:
    
    • Mostly soft tissue injury; no fracture
      
    • Complete disruption of posterior ligaments and intervertebral disc
      
    • Neurologic deficit may be present.
      
• Flexion rotation:
  
  • Unstable injury
    
  • Neurologic deficit often present
    
• Extension:
  
  • Unstable, uncommon
    
  • Disruption of anterior longitudinal ligament and intervertebral disc
    
  • Neurologic sequelae rare but possible
    
• Shear injuries (translational injuries):
  
  • Anterior, posterior, or lateral translation of superior vertebral segment over the inferior segment
    
  • Complete ligamentous disruption
    
  • Neurologic deficit present
    
• Simple fractures:
  
  • Isolated spinous process fracture:
    
    • Ligamentous disruption
      
    • No neurologic deficit
      
  • Isolated transverse process fracture:
    
    • Ligamentous disruption
      
    • Neurologic deficit possible; rare isolated root injury
      

• Blunt trauma with axial distraction, axial compression, or translational forces applied to lumbar region
  
• Fall from height landing on the feet (associated calcaneal fractures) or on the buttocks
  
• Motor vehicle accidents (MVA)
  

• Rare reports of child abuse presenting as lower extremity flaccid paralysis owing to lumbar spine fracture.
  
• Spinal cord terminates at L3 in newborn and recedes to T12 by adulthood; direct cord damage possible in children with high lumbar fractures.
  
• End plate avulsion fractures: Adolescent injury usually at L4–L5 or L5–S1 level; ligament pulls off vertebral body end plate; associated neurologic findings.
  

DIAGNOSIS

• Pain or localized tenderness to palpation in lumbar midline
  
• Ecchymosis or deformity overlying lumbar region; palpable deformity; paraspinal muscle spasm
  
• Increased interspinous distance by palpation
  
• Step-off (anterior or posterior displacement of spinous process) by palpation
  
• Neurologic deficits referable to lumbar spinal nerves:
  
  • Loss of bladder control
    
  • Motor: Hip flexion (L1–L4), leg extension (L3, L4), ankle dorsiflexion (L4, L5), toe extension (L5)
    
  • Sensory: Inguinal crease (L1), medial thigh (L2–L3), knee (L4), lateral calf (L5)
    
  • Reflexes: Knee jerk (L2–L4)
    
• Pain may be masked by associated distracting injuries (e.g., pelvis, calcaneal fractures).
  
• Patients with multiple injuries and altered mental status have an unreliable clinical exam and require imaging.