Management of Acute Coccygeal Fracture

Immediate Fracture Management

The American College of Physicians recommends initiating appropriate pain control with acetaminophen as first-line therapy, avoiding NSAIDs given the patient's age and likely cardiovascular comorbidities 1
Avoid prolonged bed rest, as this accelerates bone loss, muscle weakness, and increases risk of deep vein thrombosis—particularly critical in this elderly patient with bilateral hip hardware 1

The National Osteoporosis Foundation suggests that given the presence of mild osteopenia on imaging and an acute fragility fracture, this patient requires systematic fracture risk evaluation and pharmacological osteoporosis treatment 2, 3, 1
The American College of Rheumatology recommends initiating oral bisphosphonate therapy (alendronate or risedronate) as first-line treatment, which reduces vertebral fractures by 47-48%, non-vertebral fractures by 26-53%, and hip fractures by 51% 1, 5

The American Academy of Family Physicians suggests ordering DXA scanning of the lumbar spine and hip to quantify bone mineral density and establish baseline T-scores, as current diagnostic and treatment criteria for osteoporosis rely on DXA measurements 4, 5
Obtain laboratory assessment including serum calcium, albumin, creatinine, thyroid-stimulating hormone, and erythrocyte sedimentation rate to identify secondary causes of osteoporosis 5

The American College of Rheumatology recommends prescribing calcium supplementation of 1000-1200 mg/day and vitamin D 800 IU/day, which reduces non-vertebral fractures by 15-20% and falls by 20% 6, 1, 5
For patients with GFR <30 mL/min or oral intolerance, consider denosumab 60 mg subcutaneously every 6 months as an alternative 1
Plan for 3-5 years of initial bisphosphonate therapy, with longer duration if high fracture risk persists 2, 5

The American College of Sports Medicine recommends prescribing weight-bearing exercise programs as tolerated to improve BMD and muscle strength, reducing fall risk 6, 1
Implement multidimensional fall prevention assessment, addressing environmental hazards in the home and reviewing medications that may increase fall risk 1

Establish systematic follow-up with regular monitoring for medication tolerance and adherence, as adherence rates reach 90% with structured follow-up 5
Reassess fracture risk every 1-3 years with repeat DXA scanning, performing earlier reassessment (within 1 year) given this patient's history of fragility fracture 6

Do not dismiss this fracture as trivial—it represents a fragility fracture requiring full osteoporosis evaluation and treatment to prevent future hip or vertebral fractures 2, 3
Do not delay osteoporosis treatment waiting for DXA results; in elderly patients with a recent fracture and radiographic osteopenia, treatment can be initiated immediately 3
Do not prescribe NSAIDs without careful consideration of renal function, cardiovascular risk, and gastrointestinal risk in this elderly patient 1