01Approach to the Critical Patient/attcp43

Red flags and immediate threats

›Cauda equina syndrome triggers

›New urinary retention or incontinence

›Fecal incontinence

›Saddle anesthesia

›Progressive bilateral lower extremity weakness

›If any present, emergent MRI and spine surgery consultation

›High-energy mechanism concerns

›Pelvic instability signs

›Hemodynamic compromise

›SBP < 90 mmHg

›If unstable, activate trauma team and CT pelvis with contrast

›Open fracture with rectal injury

›Rectal bleeding after trauma

›Visible bony fragment near anal region

›If suspected, emergent general surgery consultation

›Pathologic fracture concern

›Pain without adequate trauma history

›Known malignancy

›Constitutional symptoms present

Monitoring and targets

›Vital sign assessment

›Heart rate and blood pressure for hemodynamic stability

›Tachycardia or hypotension raises concern for associated pelvic fracture

›Pain score quantification with numeric scale

›Neurologic monitoring

›Lower extremity motor strength

›Perianal sensation and rectal tone

02History/hx53

Mechanism and onset

›Mechanism of injury

›Direct fall onto buttocks (most common)

›Direct blow or kick to the sacrococcygeal region

›Repetitive microtrauma (cycling, rowing)

›Obstetrical injury during vaginal delivery

›Onset and character of pain

›Acute onset immediately after trauma

›Midline pain below the sacrum and above the anus

›Sitting exacerbates pain especially on hard surfaces

›Sit-to-stand transitions worsen pain

›Prolonged sitting aggravates symptoms

›Standing and lying down alleviate pain

Aggravating and alleviating factors

›Pain aggravation pattern

›Defecation worsens pain

›Sexual intercourse worsens pain

›Leaning forward while seated reduces pain by shifting weight to ischial tuberosities

›Functional limitations

›Inability to sit at work

›Difficulty driving

›Sleep disturbance from repositioning

Alarm features in history

›Neurologic symptoms

›Numbness or tingling in the groin or saddle area

›Lower extremity weakness or numbness

›Gait disturbance

›Loss of bowel or bladder control

03Physical Exam/exam35

Vital signs and general appearance

›Stability assessment

›Heart rate and blood pressure

›Tachycardia or hypotension suggesting associated pelvic injury

›Gait assessment for ability to ambulate

›Pain behavior

›Antalgic posture with forward lean

›Difficulty transitioning from sitting to standing

Sacrococcygeal inspection and palpation

›Inspection findings

›Ecchymosis over the sacrococcygeal region

›Swelling or edema

›Skin breakdown or sinus tracts suggesting pilonidal disease

›Perianal erythema or fluctuance suggesting abscess

›Palpation findings

›Focal point tenderness directly over the dorsal coccyx — hallmark finding

›Point tenderness with trauma history is suggestive of fracture

›Crepitus with palpation

›Assess for step-off or displacement

Rectal and bimanual examination

›Bimanual coccygeal exam

›One finger intrarectal, one external over dorsal coccyx

›Assess coccygeal mobility and pain reproduction

›Crepitus with motion assessment

›Rectal tone and sphincter function

›Rules out rectal injury

Neurologic examination

›Lower extremity neurologic screen

04Differential Diagnosis/ddx52

Life-threatening differentials

›Cauda equina syndrome

›ICD-10 G83.4

›Saddle anesthesia, urinary retention, fecal incontinence

›Emergent MRI required

›High-energy pelvic fracture

›ICD-10 S32.8

›Hemodynamic instability, inability to weight bear

›CT pelvis with contrast

›Sacral fracture

›ICD-10 S32.1

›Higher-energy mechanism, broader posterior pain

›CT superior to plain films

Common musculoskeletal mimics

›Coccyx contusion without fracture

›ICD-10 S30.0

›Identical presentation to fracture

›Management is identical — clinical distinction not required in ED

›Sacrococcygeal subluxation or dislocation

›ICD-10 S33.1

›May coexist with fracture

›Dynamic radiographs helpful in outpatient setting

›Sacroiliac joint dysfunction

›Pain more lateral than midline

›Positive provocative SI joint tests (FABER, FADIR)

›Absence of focal coccygeal tenderness

›Lumbosacral radiculopathy or disc herniation

›Radiation below knee

05Laboratory Tests/lt21

Routine labs — isolated coccyx fracture

›Lab testing not indicated for isolated low-energy coccyx fracture

›Clinical diagnosis based on history and exam

›Routine labs do not change ED management

›Reserve labs for specific clinical concerns

Labs for suspected associated injury

›High-energy mechanism with hemodynamic instability

›Complete blood count for hemorrhage assessment

›Type and screen for transfusion planning

›Lactate for tissue perfusion assessment

›Lactate >= 2 mmol/l indicates hypoperfusion

›Suspected pathologic fracture

›Complete blood count for marrow infiltration assessment

›Comprehensive metabolic panel for renal and hepatic function

›Erythrocyte sedimentation rate and CRP for systemic inflammation

›Alkaline phosphatase for bone metabolism

›PSA in men over 50 years with no trauma history

›Serum protein electrophoresis for myeloma screen

Labs for suspected infection

›Fever or immunosuppression

›Complete blood count with differential

›CRP and ESR as inflammatory markers

›Blood cultures if systemic sepsis suspected

›Wound swab if skin breakdown present

06Diagnostic Tests/dt62

Scoring Systems

›Maigne classification of coccyx fractures

›Type 1 — flexion fracture at upper coccyx

›Most common traumatic type

›Generally heal spontaneously with conservative treatment

›Type 2 — compression or nutcracker fracture at middle coccyx

›Often unstable

›Higher risk of persistent pain and subluxation

›Type 3 — extension or obstetrical fracture at lower coccyx

›Progressive fragment separation over time

›Associated with vaginal delivery mechanism

›Benditz-Konig classification for displaced coccyx

›Radiological classification for displaced os coccyx

›Guides surgical decision-making in refractory cases

›Chronic coccydynia outcomes data

›Over 50% of patients with chronic coccydynia have persistent symptoms at 36 months despite conservative treatment

›Longer duration of symptoms before treatment associated with unfavorable outcomes (OR 1.04 per month)

›Early multimodal treatment recommended

MRI

›MRI indications

›Suspected cauda equina syndrome — emergent indication

›Persistent symptoms beyond 4 to 6 weeks despite conservative treatment

›Suspicion for neoplasm or chordoma

›Suspected infection or osteomyelitis

›Red flag symptoms present without clear diagnosis

›MRI findings in coccyx pathology

›Bone marrow edema at fracture site

›Soft tissue involvement assessment

07Disposition/dispo33

Discharge criteria

›Standard discharge criteria

›Isolated coccyx fracture or contusion with no red flags

›Hemodynamically stable vital signs

›Adequate pain control achieved

›Ability to ambulate

›No neurologic deficits

›No evidence of rectal injury or open fracture

›Discharge with conservative management

›Coccygeal cushion prescribed

›Analgesia regimen established

›Return precautions provided

›Follow-up arranged within 1 to 2 weeks

Admission indications

›Criteria warranting admission or further evaluation

›Cauda equina syndrome — emergent spine surgery

›Associated sacral fracture with pelvic instability

›Hemodynamic instability after high-energy mechanism

›Open fracture or suspected rectal injury

›Pathologic fracture with systemic concern

›Intractable pain unresponsive to ED analgesia

›Inability to ambulate safely

›Neurologic deficit on examination

Specialist consultation triggers

›Consultation indications

›Orthopedics or spine surgery for sacral fracture, neurologic deficit, or open fracture

›Neurosurgery for cauda equina syndrome

›General surgery for suspected rectal injury

08Treatment/t53

Immediate conservative measures

›Acute phase interventions

›Ice application to sacrococcygeal region

›15 to 20 minutes several times daily for first 48 to 72 hours

›Avoid prolonged sitting

›Lean forward when seated to shift weight to ischial tuberosities

›Coccygeal offloading cushion

›Wedge-shaped cushion with posterior cutout preferred

›Offloads the coccyx during sitting

›Avoid donut-type cushions — may increase perineal pressure

›American Spinal Injury Association guidelines support coccygeal offloading

Pharmacologic analgesia — first line

›Topical NSAIDs — first-line per ACP/AAFP guidelines

›Diclofenac gel applied to sacrococcygeal region

›Class I recommendation for musculoskeletal pain

›Preferred initial approach before systemic agents

›Oral NSAIDs

›Ibuprofen 400 to 600 mg orally every 6 to 8 hours with food

›Maximum 2400 mg per day

›Naproxen 250 to 500 mg orally every 12 hours

›Maximum 1000 mg per day

›Avoid in GI bleeding risk, renal disease, or cardiovascular disease without gastroprotection

›Acetaminophen

›650 to 1000 mg orally every 6 to 8 hours

›Maximum 4000 mg per day

›Maximum 2000 mg per day in hepatic impairment or alcohol use

›Adjunct or alternative when NSAIDs contraindicated

09Special Populations/sp57

Pregnancy

›Pregnancy-specific considerations

›Obstetrical fractures are a distinct fracture subtype

›Prolonged labor and instrumental delivery (forceps) are risk factors

›Extension-type (Maigne Type 3) fractures associated with obstetrical mechanism

›Progressive fragment separation may occur postpartum

›Imaging in pregnancy

›Avoid plain radiographs unless clinical need outweighs radiation risk

›If imaging required, lateral view only with pelvic shielding

›MRI preferred when advanced imaging needed — no ionizing radiation

›CT avoided unless associated high-energy pelvic injury suspected

›Analgesia in pregnancy

›Acetaminophen first-line analgesic in pregnancy

›NSAIDs generally avoided especially in third trimester — premature ductus arteriosus closure risk

›Topical diclofenac — minimal systemic absorption — use with caution especially near term

›Opioids avoided unless severe refractory pain — neonatal withdrawal risk

›Stool softeners safe in pregnancy — docusate sodium preferred

›Postpartum management

›Coccygeal cushion recommended for postpartum coccydynia

›Physical therapy and pelvic floor rehabilitation often effective

›Corticosteroid injection deferred until after breastfeeding when possible

Geriatric

›Age-related fracture risk

›Increased fracture risk with low-energy mechanisms due to osteoporosis

›Falls from standing height can produce significant coccygeal injury

›Evaluate for underlying fall cause

›ECG if fall preceded by syncope, presyncope, or palpitations

›Medication considerations in older adults

10Background/b54

Epidemiology

›Frequency and burden

›Coccydynia accounts for 1% to 3% of back pain presentations

›Female-to-male ratio approximately 5:1

›Women more susceptible due to wider pelvis and more prominent coccyx

›Obesity is an independent risk factor — higher loading during sitting

›Obstetrical injuries represent a distinct epidemiologic subgroup

›Outcomes data

›Most isolated coccyx fractures heal within 4 to 6 weeks

›Over 50% of patients with chronic coccydynia report persistent symptoms at 36 months

›Longer duration of symptoms before treatment associated with worse outcomes (OR 1.04 per month)

›Surgical intervention rarely required — less than 1% of cases

›ED utilization

›Coccyx radiographs in the ED have low yield

›Study of 687 patients: 8.4% positivity rate with no surgical interventions in any positive case

›Authors recommended eliminating routine ED coccyx radiographs

Pathophysiology

›Fracture mechanisms

›Flexion fractures — upper coccyx, from posterior fall onto flexed spine

›Compression or nutcracker fractures — middle coccyx, from axial load

›Extension or obstetrical fractures — lower coccyx, from anterior force during delivery

›Anatomy and vulnerability

›Coccyx is the terminal segment of the spine — 3 to 5 fused coccygeal vertebrae

›Sacrococcygeal joint allows limited flexion and extension

›Limited muscular protection compared to other spinal regions

›Thin body habitus provides less gluteal padding

›Pain mechanisms

›Fracture fragments can impinge on surrounding soft tissue

11Patient Discharge Instructions/pdi31

copy discharge instructions

›Coccyx fracture home care

›Use a wedge-shaped coccyx cushion with a rear cutout when sitting

›Avoid donut-type cushions as these may increase pressure

›Lean forward when sitting to take weight off the tailbone

›Limit prolonged sitting and take standing breaks frequently

›Apply ice wrapped in cloth to the tailbone area for 15 to 20 minutes several times a day for the first 2 to 3 days

›Pain medications

›Take pain medication as directed by your doctor

›Use anti-inflammatory medication with food to protect your stomach

›Take stool softeners as prescribed to prevent straining during bowel movements

›Straining worsens tailbone pain significantly

›Bowel and diet care

›Drink plenty of water and eat high-fiber foods to prevent constipation

›Avoid straining during bowel movements

›Use stool softeners until tailbone pain has resolved

›Activity guidance

›Most tailbone fractures heal in 4 to 6 weeks

›Some discomfort may persist for several months — this does not mean something is wrong

›Avoid activities that put direct pressure on the tailbone

›You may return to normal activities as pain allows

›Warning signs to return to ER

›New numbness or tingling in the groin or inner thighs (saddle area)

›Loss of bladder control or inability to urinate

›Loss of bowel control

›Progressive weakness in the legs

›Fever or increasing redness and swelling over the tailbone

›Worsening pain not improving with medication after several days

12References/r23

Guidelines and key sources

›Key clinical studies

›Hanna TN et al. — Sacrum and Coccyx Radiographs Have Limited Clinical Impact in the Emergency Department — AJR 2016 — PubMed 26867062

›Carayannopoulos NL et al. — Disorders of the Coccyx and Sacrococcygeal Joint: Etiology, Diagnosis, and Management Strategies — The American Journal of Medicine 2026 — PubMed 41241121

›Benditz A, Thoma R — Coccygodynia: Diagnosis and Treatment — Deutsches Arzteblatt International 2025 — PubMed 40991348

›Maigne JY et al. — Classification of Fractures of the Coccyx From a Series of 104 Patients — European Spine Journal 2020 — PubMed 31637549

›Skalski MR et al. — Imaging Coccygeal Trauma and Coccydynia — Radiographics 2020 — PubMed 32609598

›Charriere S et al. — Conservative Treatment for Chronic Coccydynia: A 36-Month Prospective Observational Study of 115 Patients — European Spine Journal 2021 — PubMed 34216237

›Foye PM — Coccydynia: Tailbone Pain — Physical Medicine and Rehabilitation Clinics of North America 2017 — PubMed 28676363

›Kleimeyer JP et al. — Surgery for Refractory Coccygodynia: Operative Versus Nonoperative Treatment — Spine 2017 — PubMed 28800569

›Konig MA et al. — A Novel Radiological Classification for Displaced Os Coccyx: The Benditz-Konig Classification — European Spine Journal 2022 — PubMed 34495391

Clinical practice guidelines

›Analgesic management guidelines

›Qaseem A et al. — Nonpharmacologic and Pharmacologic Management of Acute Pain From Non-Low Back Musculoskeletal Injuries — ACP and AAFP Clinical Guideline — Annals of Internal Medicine 2020

›Amaechi O et al. — Pharmacologic Therapy for Acute Pain — American Family Physician 2021 — PubMed 34264611

›Earwood JS et al. — Acute Low Back Pain: Diagnosis and Management — American Family Physician 2025 — PubMed 41252835

›Buelt A et al. — Management of Low Back Pain: Guidelines From the VA/DoD — American Family Physician 2023 — PubMed 37054430

›White WD et al. — The Interdisciplinary Management of Coccydynia: A Narrative Review — PM&R 2022 — PubMed 34333873

Coding and classification standards

›ICD-10 codes

›ICD-10 S30.0 — contusion of lower back and pelvis

›ICD-10 S32.2 — fracture of coccyx

›ICD-10 S33.1 — subluxation of sacrococcygeal joint

›ICD-10 M53.3 — coccygodynia

›ICD-10 G83.4 — cauda equina syndrome

›ICD-10 C41.4 — malignant neoplasm of pelvic bones

Evidence & Review

Evidence & Review