COCCYGEAL FRACTURES IN ADULTS AS A RESULT OF FALL ON FROZEN SNOW DURING Bashir Ahmed Mir et al WINTER IN KASHMIR

COCCYGEAL FRACTURES IN ADULTS AS A RESULT OF FALL ON FROZEN SNOW DURING WINTER IN KASHMIR

IJCRR Bashir Ahmed Mir, Muzamil Ahmad Baba, M.A. Halwai, Adil Bashir Shikari, Vol 05 issue 16 Maajid Shabeer, Naila Nazir Section: Healthcare Category: Research Received on: 14/07/13 Department of Orthopaedics, Govt. Medical College Srinagar, J&K, India Revised on: 03/08/13 Accepted on: 26/08/13 E-mail of Corresponding Author: [email protected]

ABSTRACT Background There is not much literature available on coccygeal fractures, only a few case reports. We present a first series of 15 cases of coccygeal fractures in adults as a result of similar mode of trauma due to fall on frozen snow during the winter months in the valley of Kashmir. Material and Methods: The study included patients with coccygeal fractures that occurred as a result of direct fall due to slip on ice during the winter months, December to February in the valley of Kashmir. Study was done over a period of 5 years (2007 to 2012) and included a total of 15 patients. Results: 15 cases of coccygeal fractures with an age group of 48 to 72 (average 65 years), 12 females and 3 males is presented. All patients were managed conservatively with uneventful recovery. Conclusion: Our study revealed coccygeal fractures mostly occur in elderly age group with underlying . Although most cases can be managed conservatively with uneventful recovery, measures should be taken to avoid fall related trauma in winters especially in older age group. Keywords: , Conservative management, snow fall, Kashmir.

INTRODUCTION review board approval and informed consent from The coccyx is usually formed of four rudimentary the patients, all cases with coccygeal fractures vertebras; the number may vary from three to five, were included in the study. Patients with previous with its contour normally the continuation of the pathology in the area, chronic history of coccygeal lower .6 Fractures of the coccyx are and those with doubtful diagnosis of a uncommon injuries, but trauma accounts for about fracture were excluded from the study. To our one third of all cases of coccygodynia.4 surprise all cases occurred during the months of Dislocations and displacements are of equal winter in our valley as a result of snowfall. Initial importance as compared to the fractures. Lewin radiographs of with both hips were taken to has stressed dislocation as important cause of the rule out other associated fractures. Lateral views clinical disturbances.10 We over a period of 5 years of the coccyx with hips flexed were taken to reveal (2007 to 2012) collected data. Our study added a the fracture. total of 15 cases to the sparse literature available regarding coccygeal fractures. RESULTS In our series 15 patients with coccygeal fractures, MATERIAL AND METHODS the average age of the patients was 58.67 years The present study was carried out over a period of (range of 44-72 years). 12 (80%) patients were 5 years from 2007 to 2012 at the Postgraduate females and 3 (20%) males (Table 1). department of orthopaedics, Government Medical There were other associated fractures in two cases, College Srinagar. After obtaining the institutional a right sided colle’s fracture in one female aged 67

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COCCYGEAL FRACTURES IN ADULTS AS A RESULT OF FALL ON FROZEN SNOW DURING Bashir Ahmed Mir et al WINTER IN KASHMIR years (managed with close reduction and cast) and structures entering into the production of such an undisplaced in a male aged 49 forces.7 Clinically, patients describe immediate, years (managed in a scaphoid cast for 8 weeks). severe pain in the area of coccyx. Pain on Both had an uneventful recovery (Table 1). defecation may be present as well as pain on rectal The cause of trauma was similar in all our cases examination. Radiographic identification may be due to fall on ice during the months of December difficult at times, although lateral x-rays of the to February, the peak months of winter in the coccyx with the hips flexed maximally may reveal valley with temperature touching -200 centigrade. the fracture (Fig.1). Patients with more than 2 weeks of trauma, The coccyx may appear to be acutely angulated previous history of coccygeal pain and in cases which is a normal anatomical variant and should where fracture was not identified on X-rays were not be confused with a fracture. CT and MRI excluded from the study. Of the falls causing the scanning may be helpful in differentiating between fracture 11 occurred in the early morning hours physeal plates and fracture lines.1 When in doubt a due to frozen condition outside and 4 cases rectal examination may reveal tenderness and occurred in the evening. abnormal mobility of the coccygeal fragment. All patients were managed conservatively with Injury by external forces usually occur as a result activity restriction for a few days and continuous of considerable violence such as sitting forcibly on use of an inflatable rubber ring for all sitting hard objects; kicks or blows received upon the tip purposes. Analgesics (NSAIDS) were prescribed of the spine; falls upon the buttocks, in the latter for the first couple of days of trauma. The use of instance due to fall upon the buttocks, males are the rubber ring was continued until patient was probably less susceptible to such trauma because symptom free which was two to three months in of closer approximation of tuberosities of the most of the cases. None of the patients developed ischia.4 This is in concordance with our study with any complications during the treatment. One case 90% of our cases being females and all of our of a female, aged 70 years continued with pain cases occurred due to direct fall on the buttocks. after the trauma for 11 months. A wait and watch Among other causes in various reports injury by policy with continuous use of inflatable ring internal forces, pressure against the coccyx from during sitting finally led to her complete recovery. within may be the cause of damage and even case All patients were managed on outpatient basis and of descending head during labour may result in none required admission. fracture or dislocation.5 Treatment is conservative in majority of the cases DISCUSSION consisting of activity restriction and use of an Coccyx fractures commonly occur as isolated inflated doughnut cushion with return to full injuries due to direct fall on the buttocks and activities in 4 to 6 weeks.2,7, 11 rarely have associated injuries. Our series revealed In our cases we used an inflated rubber ring, for all two cases with associated fractures a colle's sitting activities. Patients were advised to inflate fracture in one patient and an undisplaced the ring sufficiently so that the weight was borne scaphoid fracture in other case. entirely by the structures resting on the perimeter To injury from locally directed external forces of the ring. The use of the ring was continued till little protection is offered by the overlying soft disappearance of symptoms in our study. All parts.7 From internal forces injury is inevitable patients had uneventful recovery in our study under certain conditions of malposition or fixed except one case that developed chronic coccygeal deformity, either to coccyx or to the adjacent

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COCCYGEAL FRACTURES IN ADULTS AS A RESULT OF FALL ON FROZEN SNOW DURING Bashir Ahmed Mir et al WINTER IN KASHMIR pain but with a wait and watch policy patient was of vascular and interventional radiology. 2006 pain free at 11 months after trauma. May; 17(5): 909-12. Following a coccyx fracture, is not usually 4. George H. Thiele. Coccygodynia: causes and required and often yields disappointing results; treatment. Diseases of the colon and rectum. however, if the pain continues even after the November-December, 1963, volume 6, issue fracture has healed, and is severe enough to 6, pp 422-436. cause disability, a coccygectomy may be required. 5. Grant Cooper MD, Mike S. Lee MD and 8,12 All our cases were managed conservatively Gregory E. Lutz MD. Fracture of coccyx and none required any form of surgical during : a case report of an unusual intervention. cause of coccygodynia. Archives of Physical Medicine and Rehabilitation Volume 84, Issue CONCLUSION 9 , September 2003, Page E15 Although rare injuries coccygeal fractures are 6. GRAY. Anatomy of the Body. Ed. 21. more frequently seen in elderly patients with other Phila., Lea and Febiger, 1924. risk factors. Conservative management yields 7. John C. McCauley Jr. Fractures of coccyx and excellent results and should be tried in all cases. coccygodynia. The American Journal of As all our patients were a result of fall related Surgery1937, Volume 36, Issue 1, April, trauma during winters, measures should be taken Pages 303-307. to avoid such fractures as well as other fall related 8. Key, J. A.: Operative treatment of injuries. coccygodynia. J. Bone & Joint Surg. n.s.19: 759, 1937. ACKNOWLEDGEMENTS 9. Kim WY, Han CW, Kim YH. Joystick We thank Dr. Shakir, Dr. Manan and Dr. Omar for reduction and percutaneous pinning for an helping us in compiling the data. We also thank acutely anteriorly dislocated coccyx: a case Mr. Hameed for his technical assistance. report Journal of Orthopaedic Trauma 2004 Jul; 18 (6): 388-9. REFERENCES 10. LEWIN, P. Coccyx, its derangements and 1. Broome DR, Hayman LA, Herrick RC, et al. their treatment. Surg. Cynec. and Obst., 45: Postnatal maturation of the sacrum and 705 (Nov.) 1927. coccyx: MR imaging, helical CT, and 11. Rockwood and Wilkins Fractures in Children. conventional radiography. AJR Am J Fractures of the pelvis. 7th edition, Chapter Roentgenol 1998;170(4):1061-1066. 20/Page 759-760. 2. Caldwell, G. A.: Minor injuries of the lumbar 12. Spence, K. F., Jr.: Coccygectomy. Am. J. spine and coccyx. S. Clin. North America, Surg.102: 850, 1961. October 1951, p. 1345. 3. Dean LM, Syed MI, Jan SA, Patel NA, Shaikh A, Morar K, Shah O. Coccygeoplasty: treatment for fractures of the coccyx. Journal

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COCCYGEAL FRACTURES IN ADULTS AS A RESULT OF FALL ON FROZEN SNOW DURING Bashir Ahmed Mir et al WINTER IN KASHMIR

Fig.1. X-ray Lateral view of pelvis with hips flexed revealing a coccygeal fracture (arrow) in a 55 year old patient.

Table 1: Showing the various parameters of all the patients. Serial no. Age Gender Associated fractures Duration of Average symptoms (58.67) (MONTHS) 1 52 F None 3 2 65 F None 4 3 63 F None 2 4 72 F None 4 5 46 F None 2 6 52 M None 3 7 67 F Colle’s Fracture (L) 4 8 44 F None 3 9 70 F None 11 10 59 M None 2 11 49 M Scaphoid Fracture (L) 4 12 55 F None 3 13 51 F None 5 14 66 F None 2 15 69 F None 4

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