Fractures of coccyx and coccygodynia

The American Journal of Surgery

1937, Volume 36, Issue 1, April, Pages 303-307

John C. McCauley Jr.

New York University College of Medicine New York U.S.A. and Bellevue Hospital New York U.S.A.

Abstract

The anatomy of the coccyx is reviewed, and considered from the standpoint of injury and as the site of coccygodynia. Fractures and dislocations, both from external and internal forces are discussed with their treatment.

Comments are made upon the various etiological possibilities of coccygodynia. Those cases resulting from trauma are considered most important and the treatment outlined in some detail.

INTRODUCTION

The coccyx is usually formed of four rudimentary vertebras, the number may be increased to five or diminished to three. (1) Its contour is normally the continuation of the curve of the lower sacrum. The first segment resembles the last sacral vertebra with large rudimentary articular processes called cornua. The cornua project upward to articulate or approximate the cornua of the sacrum thus completing the foramen for the exit of the posterior division of the fifth sacral nerve. The articulation between the sacrum and coccyx is homologous with the intervertebral joints, with interposed fibrocartilage, in some instances the coccyx is freely movable on the sacrum and a synovial membrane is present. Such mobility is notably present during pregnancy.

The remaining segments are separated likewise by discs of fibrocartilage. In the adult male all the pieces become ossified together at a comparatively early period. At a more advanced age the coccyx often fuses with the sacrum, this is especially true in females.

Normally there are very limited movements forward and backward between the sacrum and the coccyx, and between the segments of the latter.

The coccyx gives attachment to the levator ani and coccygei muscles which together form a muscular diaphragm for support of the pelvic viscera. Posteriorally the lateral surfaces give rise to the inferior fibers of the gluteus maximus, and the sphincter ani externus takes its origin from the tip.

The anterior division of the fifth sacral nerve enters the pelvis between the sacrum and the coccyx, while that of the coccygeal nerve curves forward below the rudimentary transverse process of the first segment.

The pudendal plexus is not sharply demarcated from the sacral plexus. It is usually formed by branches from the anterior divisions of the second and third sacral nerves, all of the anterior divisions of the fourth and fifth sacral, and the coccygeal nerves. Branches are distributed to the coccygeus, levator ani, sphincter ani externus, the muscles of the urogenital region, to the external genitalia, bladder, rectum and vagina; to the integument about the anus, between the anus and the coccyx, to the scrotum and labium majus. Communication is established with the perineal branch of the femoral cutaneus and the pelvic plexuses of the sympathetic.

The posterior divisions of the lower two sacral and coccygeal nerves unite in a loop formation to supply the skin over the coccyx.

We have then an anatomical foundation whose make up allows of various pathological possibilities, in the production of symptoms referable to the coccygeal region.

To injury from locally directed external forces little protection is offered by the overlying soft parts. From internal forces, injury is inevitable under certain conditions of malposition or fixed deformity, either to the coccyx or to the adjacent structures entering into the production of such forces.

Contusion, strain, sprain, fracture displacement, and irritative phenomena of nerve elements are the common resultant possibilities of trauma.

Morbid processes to which the component parts may be subject, other than trauma induced, make up a second group of possibilities and third, a group of symptom complexuses not arising in the coccyx, but referred to it by reason of the complex nerve environment.

FRACTURES

Fractures of the coccyx compared to many other fractures are not common, but injuries to the tip of the spine do occur sufficiently often so that the average practitioner on more than one occasion is confronted with them and their problems for treatment.

Dislocations and displacements are included in this discussion as of equal importance with fracture. Lewin (2) has stressed dislocation as the most important of these clinical disturbances.

It is interesting to cite as a classical description the report of a case by Jobi Meekren (3) published in 1682. The patient, a woman, sat down suddenly on the closed seat of a toilet. Because of pain she could neither stand nor walk and was carried to bed. On the second day her pain became worse, Meekren was then called in consultation with her ordinary medical attendant. They suspected the trouble but she would not allow herself to be touched. During the following night her suffering became intolerable and the medical advisors were summoned early in the morning. Reduction of a dislocated coccyx was accomplished per rectum and she was instantly relieved of her symptoms.

Injury by external forces are usually direct in nature and of considerable violence, such as sitting forcibly on small or narrow objects, such as a child's block; kicks or blows received upon the tip of the spine; falls upon the buttocks, in the latter instance males are probably less susceptible to such trauma because of closer approximation of tuberosities of the ischia. The coccyx is driven forward in such instances and if the force is sufficient, displacement or fracture result. Fracture is more likely in those of advanced age.

It is conceivable that falls upon the contracted gluteal muscles, might result in injury by muscular pull upon the coccyx as well as by direct violence. Cyriax (4) has reported a case in an individual who made a sudden effort to save himself from falling. He also calls attention to the importance of minor displacements in coccygodynia.

Injury by Internal Forces. Pressure against the coccyx from within may be the cause of damage to this structure. Pressure of the descending head during labor may result in fracture or dislocation. McCusker (5) comments on these injuries by saying they most often occur in patients with a history of previous injury to the tip of the spine, and that in healing the mobility was lost or that ankylosis occurred in a forward displaced attitude. Vermillion (6) reports 2 such cases of fracture, neither of whom complained of very much pain and the only treatment needed was the rest in bed incident to the confinement. He believes the severity of the symptoms does not depend upon the severity of the injury.

Jolly (7) reports a case of fracture dislocation in a young primipara. It was reduced following a forceps delivery with relief of the symptoms. Nine days later the lower segment of the coccyx was passed from the rectum. No further difficulty was experienced by the patient.

Gant (8) speaks of a case in which anterior displacement and ankylosis of the coccyx required excision before delivery could be effected. He also cites as possible causes of such injuries evacuation of enormous impacted fecal tumors or expulsion from the rectum of foreign bodies.

TREATMENT

In cases where displacement or fracture exists, and whether the former or the latter, is probably more dependent upon the anatomical age of the coccyx, than upon the type of trauma received, the findings of deformity, preternatural mobility, and possibly crepitus will be present. Immediate reduction is ordinarily easy and is best carried out by grasping the coccyx between the fore finger inserted in the rectum and the thumb over the posterior surface. Anesthesia may be necessary. Splintage is practically impossible to apply with any effectiveness. In some cases maintenance of the reduction is difficult. Bed rest is necessary, four weeks being sufficient in the average case. The possibility of the fracture being compounded internally should be borne in mind. Badly fractured and displaced cases are best treated by excision. Persistent pain may be the aftermath, particularly in those cases where bony repair fails to take place, or where marked deformity obtains. In this class of case extirpation is unquestionably indicated. According to Da Costa (9) coccygodynia is seldom the result of fracture. The treatment of the less severe injuries will be discussed in the second part of this paper.

COCCYGODYNIA

Coccygodynia means literally pain in the coccyx. It is characteristically a paroxysmal aching or stabbing pain occurring spontaneously, and aggravated by any movement which brings into action the muscles attached to the coccyx, such as walking, sitting down or getting up from a chair, defecation and micturition.

Nott (10) was the first to describe the condition, when in 1844 he reported a case of neuralgia of the coccyx, requiring extirpation after all the articles in the materia medica had been exhausted. It is interesting to note that at operation he found the last segment of the coccyx to be carious and thinned out to a mere shell. Simpson (11) was the first to apply the term coccygodynia. In the first publication of his lectures he used the term coccyodynia. (12)

The condition was conceived originally to occur only in women, and was included in the nomenclature of Barnes (13) in his "Diseases of Women" in 1878. Jenks (14) stressed the frequency in women and thus its relationship to pelvic disorders, especially as a result of trauma to which the pelves of women alone are liable. He speaks of the analogy between coccygodynia, fissure of the anus, and vaginismus, in the latter two instances, irritation in the region of the muscle causes painful contraction and he was convinced that in some cases of coccygodynia, the pain was caused in the same way.

The intervening and more recent text descriptions comment on the predominance in females, to which, in many instances have been added the adjectives neurotic or neurasthenic. Burnett (15) reviewed this descriptive attitude, but believe it to be grossly overrated. One must not lose sight however, of the possibility of this region being the outlet for manifestations of a functional disturbance. In coccygodynia a history of injury is the rule, rather than the exception, so that it becomes quite necessary to investigate such a history, in that proper evaluation of the trauma can be made on a physical basis. It is in this type of case that operation and removal of the coccyx has failed to cure the coccygodynia, and thus has rightfully placed a question mark after the indiscriminate application of this treatment. Hamill (16) reported such a case. He compares the pain to that of vaginismus, and believed that understanding not surgery was the best therapeutic approach.

Drueck (17) stated coccygodynia was most apt to occur in women with a history of functional nervous disease, and believed the muscle spasm comparable to vaginismus, and was the result of a mental reflex rather than from real hyperesthesia of the parts. He advised prolonged applications of heat and attention to the mental attitude and emotional status.

We have mentioned before, the possibility of coccygeal symptoms as part of a symptom complex of referred pain. This consideration is an extremely important one in coccygodynia. Kleckner (18) has suggested the name pseudo-coccygodynia as more appropriate to this type of case and advised thorough investigation for anorectal pathology. He also cited utero-adnexal disease in women and pathology of the prostate seminal vesicals and urethra in men as other possibilities. Gant (8) has mentioned excruciating pain from ulceration of the rectum, resulting from pressure of the gut against the tip of a malformed and forward displaced coccyx. Perforation as well as ulceration may result.

Disease of the coccyx itself, must be borne in mind, particularly tuberculosis. David (19) reported 2 cases and collected 25 others from the literature. His conclusions were that trauma played no significant role, generalized tuberculosis was conspicuously absent. The onset was insidious. Difficulty was experienced in locomotion but pain with defecation was absent. Sinuses were apt to form through the overlying skin less often into the rectum. Treatment by excision gave a good prognosis.

The author has removed the coccyx in 2 cases, in which, while there was no evidence of an infectious process, there was marked atrophy and softening of the bone structure. They were both in middle aged persons, one male and one female. The onset of symptoms in each instance followed real trauma. Both had received prolonged conservative treatment without profit. Both cases were cured by excision. One is inclined to wonder whether there may occur in the coccyx in certain cases a condition akin to traumatic osteoporosis.

In the initial stage of tabes dorsalis, rectal crises may present the symptom picture of coccygodynia.

TREATMENT

The first consideration is the proper evaluation from a careful history and thorough examination, which includes good x-ray pictures of the sacrococcygeal region, the existence or non-existence of any factor or factors which might be expected to produce such a symptom picture.

The indications for treatment in cases of disease, and significant deformities of the coccyx have received comment. That proper attention to, and correction of, abnormalities existing in adjacent or related structures has been discussed. That recognition of coccygodynia as a manifestation of functional nervous disease, has been stressed as important, so that therapy may be applied to both ends of the spine in proper proportions.

We have left then to consider, a group of cases in which the disturbance resides in the coccyx itself and the treatment therefore is to be directed locally. These cases constitute the largest group, and they for the most part have symptoms resulting from trauma. The local findings are tenderness and increased pain on pressure or attempted movements of the coccyx. There is no significant deformity or evidence of disease.

In the more acute instances restriction of the activities which aggravate the pain must be enforced even to the point of rest in bed. This is of particular value in early cases. Attention to the bowels so as to avoid straining at stool must be observed. Tight strapping of the buttocks together, preferably as part of a low back strapping may afford some relief.

The use of an inflated rubber ring, for all sitting activities is very helpful. The size of the ring is important. If the diameter is such that the gluteal muscles are put on a stretch, increased discomfort may result. It should be considerably wider than the distance between the midpoint on each buttock. It should be inflated sufficiently so that the weight is borne entirely by the structures resting on the perimeter of the ring. Its particular advantage and usefulness is obvious in thin individuals. The ring may be enclosed in a pillow cover for those using the ring in an office. Its use should be continued until after the disappearance of the symptoms.

Prolonged applications of heat are important. Hot sitz-baths, may be prescribed. Rectal irrigations are difficult for the patient to use effectively at home. Local elevation of temperature by diathermy is of value in most cases when used properly. Careful massage through the rectum is tolerated in some instances and is of real help.

Injection of alcohol was advocated by Yeomans (20) on the basis that following trauma contracture occurred in the dense surrounding tissues with nerve compression. Ten to 20 minims of 80 per cent alcohol was injected at the most tender spot, inserting one finger into the rectum to avoid puncture of that structure. Usually several injections were made. Kleckner (18) advocated quinine and urea hydrochloride as an agent for injections. Excision is not indicated as an immediate form of treatment in this type of case.

SUMMARY

The anatomy of the coccyx is reviewed, and considered from the standpoint of injury and as the site of coccygodynia. Fractures and dislocations, both from external and internal forces are discussed with their treatment.

Comments are made upon the various etiological possibilities of coccygodynia. Those cases resulting from trauma are considered most important and the treatment outlined in some detail.

REFERENCES

1. GRAY. Anatomy of The Human Body. Ed. 21. Phila., Lea and Febiger, 1924.

2. LEWIN, P. Coccyx, its derangements and their treatment. Surg. Cynec. and Obst., 45: 705 (Nov.) 1927.

3. MEEKREN, JOBI A. Observationes medico-chirurgicae ex Belgico in Iatinum translatae ab Abrahmao Blasio Amsterdam, Henrici & Viduae, Theodori Boom 1682.

4. CYRIAX, E. F. Minor displacements of the coccyx. Glasgow Med. Jour., 98: 98 (Aug.) 1922.

5. MCCUSKER, H. Injuries of the coccyx. Rhode Island Med. Jour., 17: 77 (May) 1934.

6. VERMILLION, E. L. Injuries to the coccyx. Jour. Kansas Med. Soc, 30: 217 (July) 1929.

7. JOLLY, W. J. Fracture of coccyx and passage of the segment per anum. Med. Record, p. 762 (Dec. 7) 1887.

8. GANT, S. G. Diseases of the Rectum, Anus and Colon. Phila., W. B. Saunders Co., 1923. Vol. 1, chap. IX, p. 160.

9. DA COSTA, J. C. Modern Surgery. Ed. 9. Phila., W. B. Saunders Co., 1925.

10. NOTT, J. C. Facts illustrative of the practical importance of a knowledge of the anatomy and physiology of the nervous system. New Orleans Med. Jour., 1: 57 (May) 1844.

11. SIMPSON, SIR JAMES Y. Ed. by Alexander R. Simpson. Clinical Lectures on Diseases of Women. New York, 1872.

12. SIMPSON, SIR JAMES Y. Clinical Lectures on Diseases of Women. Phila., Blanchard & Lea, 1863, Lecture XVII, p. 209.

13. BARNES, ROBERT. A Clinical History of the Medical and Surgical Diseases of Women. Phila., H. C. Lea, 1878.

14. JENKS, E. W. A lecture on coccygodynia. Med. Record of New York, 17 (April 17) 1880.

15. BURNETT, S. G. Medical Herald and Physical Therapist, 49: 287 (Aug.) 1930.

16. HAMILL, RALPH C. Coccygodynia. Med. CI. N. Am., 5: 37-44 (July) 1921.

17. DRUECK, CHAS. J. Coccygodynia. Jour. Indiana Med. Assn., 19: 275 (July) 1926.

18. KLECKNER, M. S. Coccygodynia: the present day interpretation and treatment. Tr. Am. Proc. Soc, 34: 100, 1933.

19. DAVID, V. C. Tuberculosis of the os coccygis. J. A. M. A., 82: 21 (Jan. 5) 1924.

20. Yeomans, F. C. Coccygodynia - a new method of treatment by injections of alcohol. Med. Record, (Aug. 22) 1914.

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