What is your diagnosis?

An anterior subluxation of the terminal coccyx vertebrae without evidence of fracture or frank dislocation.

Image 2. Authors own image with annotations

• Pearl: Coccyx pain is also known as “coccydynia” or “coccygodynia” and can be idiopathic, infectious, malignant, neuropathic, referred, or traumatic in etiology [1].

• Pearl: There is significant heterogeneity in the structure and number of coccygeal vertebrae in humans numbering anywhere from 3-5 vertebrae (median 3) with variable fusion at different levels. Our patient has 3 coccygeal vertebrae with Cxy1 and Cxy2 fused [1].

What are the key exam findings?

The patient will typically present with lower back or buttock pain. When focusing on the exact location of tenderness, patients will typically not have tenderness over the lumbar or sacral spine but will instead have tenderness over the coccyx which is palpated in the gluteal cleft. 

What kind of forces cause these injuries?

For traumatic coccydynia, a patient typically falls straight backward onto the coccyx causing direct compressive or anterior forces creating a contusion, fracture, or subluxation/dislocation.

What is your management in the ED? Do I need to consult Orthopedics?

As with any spinal injury, a thorough neurologic exam is warranted. Assuming no neurologic deficits and no other concerns for concomitant injuries, management of a coccyx fracture or subluxation is directed at pain control. Orthopedics does not need to be consulted in the ED and the patient can be referred to either orthopedics or sports medicine for follow-up and further pain management. 

• Pearl: Management is typically conservative initially starting with padded seating (doughnut pads) and oral analgesia moving to physical therapy as needed. The most invasive treatment is surgery involving correction of angles or complete resection of the coccyx[2].

• Pearl: Conservative treatment seems to be less successful for traumatic coccydynia vs other causes while surgical correction/resection is typically more effective [3].