Diseases of the Rectum and Anus

Designed for Students and Practitioners of Medicine

F.A. Davis Company, Publishers, 1902

Samuel Goodwin Gant

Diseases, Injuries, and Tumors of Coccyx

Page 159

Fractures, Dislocations, Injuries, and Necrosis of the Coccyx

The os coccyx, like other bones of the body, is frequently the seat of injury. Fractures and dislocations of the coccyx are not uncommon, and are usually caused by a blow, kick, fall, or the passage of the child's head during labor.

Other injuries gunshot, stab, and extensive lacerated wounds are occasionally met with in this region. The author treated a thief who had been shot in the anus while trying to escape; the ball came out near the sacro-coccygeal articulation, carrying part of the bone with it. Bellamy treated a boy who was accidentally shot. The coccyx was torn off, and an opening the size of an orange was made in the rectum, through which gas and feces escaped, and fragments of the bone were plainly visible. Numerous cases of injury to the coccyx, caused by gunshot and bayonet wounds, are to be found in the medical and surgical history of the War of the Rebellion.

Symptoms and Diagnosis.

Fractures, dislocations, and injuries to the coccyx cause a heavy, dull, aching pain in this region, which is made worse by contraction of the attached muscles, walking, and sitting. These sufferers are relieved when lying upon the abdomen. Pressure over the end of the bone causes agonizing pain, both in the region of the coccyx and up the back and down the limbs. Suffering is intense during and for a short while after defecation. Hemorrhage is seldom encountered, except in cases where the wound is extensive and involves the hemorrhoidal vessels. Where the rectum has been punctured, both gas and fecal matter escape, producing an offensive odor. Fractures and dislocations improperly treated frequently result in enlargement, ankylosis, and displacement of the coccyx, which, in time, cause coccygodynia or neuralgia.

Necrosis.

Necrosis of the coccyx, ending in abscess and fistula, is a frequent sequel of injury to this bone. This condition may also be the result of syphilis, tuberculosis, and malignant diseases. In such cases the amount of bone destroyed is considerable. Again, it may be caused by any disease or injury which destroys the periosteal covering. The immediate manifestations of dead bone in this region do not differ from a similar condition in other parts. There is a fistulous opening, a discharge of pus, and the grating sound produced by the probe coming in contact with eroded bone. The openings may be single or multiple, and when they become stopped up a chill, rise of temperature, and increased pain follow shortly, caused by the formation of an abscess.

Diagnosis.

Fractures and dislocations are easily recognized by introducing the finger into the bowel, when the coccyx may be seized and examined; flesh wounds over the bone by their presence, and necrosis by the finding of dead bone by aid of the probe. A clear history of the case goes far toward establishing the diagnosis in doubtful cases.

Treatment.

Extensive wounds involving both the soft parts and bony structures demand prompt and careful attention. When the parts are lacerated the edges of the wound should be trimmed, all fragments of bone removed, and the wound closed with catgut. Drainage is unnecessary, unless there is danger of leakage from the rectum.

When the coccyx is fractured or badly displaced better results are to be had in most instances from partial or complete resection. It is an extremely difficult matter to retain it in place and to secure complete rest by splints, sutures, or other appliances.

Skey attempted to retain the coccyx in position in a case of dislocation by placing a wire spring in the rectum. This broke, and he then anchored the bone to a wooden splint on the back by means of a silk thread. This did not entirely relieve the pain, but the patient was discharged twenty days later much improved.

Some surgeons tampon the rectum, but the results have not been satisfactory, for the reason that the tampon does not retain its position, and, in addition, pain is greatly intensified by retention of gases. The author obtained a good result in one case by placing a finger in the bowel and pressing the bone outward. A needle carrying chromicized catgut was then passed through the skin down to the bone, catching the tendinous attachments, and brought out near the point of entrance, where the suture was tied across a small gauze pad. Pain was relieved immediately, and the patient was discharged in two weeks feeling perfectly well.

In exceptional cases properly-adjusted adhesive straps give a sense of support to the parts and diminish pain. When surgical aid is declined, complete rest in bed, a semisolid diet, and hot applications over the ano-coccygeal region will do much toward making the sufferer comfortable. If used at all, opiates should be discontinued after the first few days. Necrosed bone should be removed.

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