CPT® Code 27202

1. Indications

The open treatment of a coccygeal fracture, as described by CPT® Code 27202, is indicated for patients who have sustained a fracture of the coccyx, typically due to trauma or injury. The following conditions may warrant this procedure:

• Coccygeal Fracture A fracture of the coccyx that may result from falls, direct trauma, or other injuries.
• Severe Pain Persistent and severe pain in the coccygeal region that does not respond to conservative management after an adequate healing period.
• Abnormal Movement Evidence of abnormal movement of the coccyx detected during a rectal examination, indicating instability or displacement of the fracture.

2. Procedure

The open treatment of a coccygeal fracture involves several critical procedural steps to ensure proper management of the injury. The following steps outline the procedure:

• Incision An incision is made over the coccyx to provide direct access to the fracture site. This incision allows the physician to visualize and address the fracture effectively.
• Site Cleansing The fracture site is meticulously cleansed of any debris or foreign material that may interfere with the healing process. This step is crucial to prevent infection and promote optimal recovery.
• Reduction of Fracture Fragments The displaced fracture fragments are carefully reduced, meaning they are repositioned to their normal anatomical alignment. This step is essential for restoring function and alleviating pain.
• Excising the Coccyx In some cases, if the fracture is severe or if reduction is not feasible, the coccyx may be excised. This involves the surgical removal of the coccyx to relieve pain and prevent further complications.
• Wound Irrigation and Closure After addressing the fracture, the wound is irrigated to ensure it is clean, and then it is closed to facilitate healing. Proper closure techniques are employed to minimize scarring and promote recovery.

3. Post-Procedure

After the open treatment of a coccygeal fracture, patients are typically advised to rest to allow for proper healing. Pain management is an important aspect of post-procedure care, and patients may be prescribed pain medication to help alleviate discomfort. It is common for pain and tenderness to persist for several weeks or months following the procedure. Patients should be monitored for any signs of complications, and if severe pain continues beyond the expected healing time, further interventions, such as a steroid injection, may be considered. Follow-up appointments are essential to assess the healing process and address any ongoing issues related to the fracture.