FRACTURES OF THE CALCANEUS WITH DISPLACEMENT OF

THE THALAMI#{231} PORTION

ROBERT SOEUR and ROBERT REMY, BRUSSELS, BELGIUM

From La Clinique Orthopedique and le Dispensaire de Compagnies et

Caisses Communes d’Assurances, Brussels

The thalamus is the part ofthe calcaneus that supports the posterior articular facet and continues forward,
becoming thinner towards the groove of the sinus tarsi. The main displacements after fracture depend on
1) a primary fracture line dividing the bone into anterior and posterior fragments, and 2) a semilunar fragment
in the thalamic region. In the operation advised the sinus tarsi is exposed and the semilunar fragment is
reduced by rotation in the opposite direction and is fixed to the medial fragment (the sustenaculum tali not
being displaced) by a transverse Kirschner wire. The two main fragments are fixed by an antero-posterior
wire. Plaster is applied and is retained for twelve weeks. Weight-bearing is not permitted for the first four
weeks. There were no major complications in fifty-eight operations. The anatomical results were good:
restoration of the tuber-joint angle by reduction of the semilunar fragment was maintained. The functional
results were very satisfactory: permanent disability was slight or mild.

The distribution of the compact bone and lamellae TABLE I

CLASSIFICATION OF I I 2 FRACTURES OF THE CALCANEUS IN
in the calcaneus is a significant factor in the mechanism
105 PATIENTS
and management of fractures of the calcaneus. The
thalamic portion of the calcaneus is that part of the bone, Type of fracture Nwnber Percentage
formed of a layer of compact bone tissue, which supports
I. Non-thalamic fracture 19 17
the posterior articular facet and continues forward, .

becoming thinner towards the groove of the sinus tarsi. Anterior end . . . 4
This feature, to which reference has often been made in Medial tubercle . . 4
Lateral tubercie . . 2
the continental literature (Lenormant, Wilmoth and Body of the calcaneus . 3
Lecoeur 1928, 1929; Leriche 1929; Paitre and Boppe Sustentaculum tali . . I
Plantar spur . . . 3
1935; Stulz 1956; Soeur 1972), has received attention in Posterior beak fracture . 2
only one English publication (Warrick and Bremner H. Thalamic fractures . . 93 83
1953). The purpose of this paper is to discuss the
mechanism and management of fractures involving this By vertical compression 2 2
By shearing and compression 91 98
important part of the calcaneus.

Seven patients had bilateral fractures of the cal-

MATERIAL
caneus. Associated injuries in the same part of the limb
One hundred and twelve fractures of the calcaneus were included a fracture of the lateral malleolus with a chip
studied. There were 105 patients : ninety-four men and fracture of the talus, a fracture of the talus with tibio-
eleven women seen in a practice mainly concerned with a fibular diastasis, a subluxation of the ankle and a fracture
working population. Ninety-three fractures (83 per cent) of the lateral tubercle of the talus. More distant lesions
involved the thalamic portion of the calcaneus (Table I). included a fracture of the femur and three fractures of
The commonest cause of injury was a fall on to the feet the spine-a compression fracture of the body of the
from a height of 2 to 3 metres (7 to 10 feet), though second lumbar vertebra, compression fractures of the
there were three men, over the age of fifty, who had bodies of the eleventh and twelfth thoracic vertebrae and
fallen a distance of only 50 centimetres (20 inches) and a fracture of the transverse process of the third lumbar
suffered a fracture with considerable displacement, and vertebra.
one who had fallen only 25 centimetres (10 inches).
The least severe trauma occurred in a man aged forty-five
who simply twisted his foot. Among building workers MECHANISM AND RADIOLOGICAL
and individuals attempting suicide who had fallen a FEATURES
distance of several floors, there were four compound frac- Fractures involving the thalamic portion of the calcaneus
tures, one of which necessitated amputation. may occur in one of two ways.

Dr Robert Soeur, Charg#{233}

de Cours d’Orthop#{233}die a l’Universit#{233}, 102 Rue 1040 Brussels,
Marie-Th#{233}r#{234}se, Belgium.
Dr Robert Remy, 111 Rue Franz Merjay, 1060 Brussels, Belgium.

VOL. 57-11, No. 4, NOVEMBER 1975 413

414 R. SOEUR AND R. REMY

., .‘.

FIG. I
The calcaneal surface of the subtalar joint has been compressed by the corresponding surface of talus. Direct vertical
compression of this type is rare.

FIG. 2
The normal mechanism of first degree thalamic fractures. The lateral process of the talus, acting as a wedge, splits the
calcaneus into two parts. (Note that the foot has been placed in dorsiflexion by the radiographer.)

By direct vertical compression-In this mechanism there First degree: simple shearing (the primarv fracture line)-.
is a pure vertical depression of the posterior articular The talus acting as a wedge shears the calcaneus and
facet of the calcaneus by the corresponding surface of divides it into two fragments, an antero-medial consisting
the talus (Fig. I). This mechanism is rare and only two of the anterior part of the bone and the anterior end of the
instances were seen. sustentaculum tali, and the other consisting of the thalamic
By shearing or a combination ofshearing and compression- portion and the remainder of the bone. There is minimal
Ninety-one fractures were produced by this mechanism or no displacement. The radiograph shows a line, the
(Table 11). With the foot in equinus or in valgus, the primary fracture line described by other authors (Warrick
and Bremner 1953). In the lateral view, this line starts
TABLE II at the bottom of the sinus tarsi and, passing vertically or
CLASSIFICATION OF THALAMIC FRACTURES slightly backwards, ends on the plantar aspect of the
calcaneus (Fig. 2). In the antero-posterior view it appears
Type of fracture Number Percentage as a line perpendicular to the articular surface separating
First degree-shearing alone . . . 33 36 the sustentaculum tall from the rest of the bone. The line
is also visible in Anthonsen’s oblique projection.
Second degree-shearing plus compression 56 62
There were thirty-three fractures in this group.
Third degree-comminuted . . . 2 2 Second degree: shearing and compression (secondary frac-
Total . . . . . . . 91 100 ture lines with semilunar or comet fragments)-The
fracture is more complex, with secondary fracture lines
in both main fragments (Fig. 3).
lateral process of the talus is forced into the base of the In the anterior main fragment there are longitudinal
sinus tarsi. The damage to the calcaneus is proportional cracks due to splitting of the lateral
wall of the calcaneus.
to the violence of the impact and can be classified into These secondary fracture lines delimit a number of
three degrees. fragments, of which two types are found frequently. One

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 FRACTURES OF THE CALCANEUS WITH DISPLACEMENT OF THE THALAMIC PORTION 415

is a triangular plate with its base on the plantar surface.

The other is a small rod-shaped cortical fragment detached
from the edge of the base of the sinus tarsi. In addition,
the anterior end of the calcaneus may be split longitudi-
nally by one or more fracture lines extending into the
calcaneo-cuboid joint.
In the posterior main fragment, the characteristic
lesions are situated in relation to the thalamic portion
of the bone and in the subjacent cancellous bone. A new
fracture line separates from the primary fracture line
slightly in front of the anterior border of the posterior
articular surface, passes in a semicircle round the thalamic
portion of the bone and ends on the superior surface of
the calcaneus behind the articular surface. This line
delimits a characteristic semilunar piece of bone (Fig. 4).

FIG. 3
Less often, in one in five cases, the secondary line passes
Drawing the most
of common fragments : The semilunar fragment posteriorly to cut off a much larger comet-shaped frag-
of the thalamus (1). The triangular plate (2) and the rod-shaped ment from the superior aspect of the bone (Fig. 5).
cortical fragments (3) both issue from the splitting of the lateral wall.
The longitudinal split (4) of the anterior end of the bone. The displacement of the semilunar or comet-shaped

FIG. 4
Second degree thalamic fracture. There is a semilunar fragment rotated to 90 degrees, so that its articular surface faces forwards. With
the foot in equinus, the lateral process of the talus acting as a wedge has been driven into the base of the sinus tarsi. There are crack
fractures in the anterior part of the calcaneus.

FIG. 5
Second degree thalamic fracture. There is a large comet-shaped fragment which is rotated by the same mechanism as in
Figure 4 but with separation of a much larger slice of the superior surface of the calcaneus.

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416 R. SOEUR ANI) R. RFM\’

FIG. 6
Third degree thalamic fracture. There is severe comminution. The semilunar fragment is lying near the Plantar surface of
the calcaneus.

fragments represents a well defined pathological lesion. Second degree fractures were the comnionest and
Under pressure from the lateral process of the talus it occurred in fifty-six cases.
sinks more and more into the gap of the primary fracture Third degree: comminuted-These are fractures with very
line, and the anterior border of the posterior articular extensive displacement. The semilunar fragment can be
facet of the calcaneus penetrates into subjacent cancellous recognised but it is buried near to the plantar cortex,
hone. The fragment rotates to a degree that may some- surrounded by a large number of crushed fragments
times reach 90 degrees on a transverse axis passing defying description (Fig. 6). There were only two such
through the posterior part of the thalamus. With increas- cases in this series.
ing rotational displacement, the articular surface of the
fragment progressively loses its relationship with the
CLiNICAL AND RADIOLOGICAL
corresponding surface of the talus.
ASSESSMENT
In two out of three cases, the displaced fragment
occupies the whole width of the bone as seen in the The study that follows is concerned especially with second
antero-posterior view. In other cases, only the lateral degree fractures involving the thalamic portion of the
half or third displaces, being separated from the rest of calcaneus. Clinical examination shows the typical features
the bone by a sagittal split and, in nine patients, the of pain, bruising, swelling of the hindfoot, and flattening
thalamus was split into three pieces each rotated to a and valgus of the heel which, by themselves, do not
different degree and showing various displacements in permit sufficient accuracy of diagnosis.
the transverse plane. Only radiographs give a complete picture of the

&.,

Fiu. 7 FIG. 8 FIG. 9

Figure 7-First degree thalamic fracture. There is a step at the site of the fracture with small chip fractures along the
medial border and flaking of the lateral wall of the anterior fragment. Figure 8-Second degree thalamic fracture. The
fracture line divides the sustentaculum tali from the remainder of the bone. Obliquity of the subtalar joint indicates
rotation of a semilunar fragment. Figure 9-Second degree thalamic fracture. The posterior main fragment is divided
into three portions, medial, middle and lateral.

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 FRACTURES OF THE CALCANEUS WITH DISPLACEMENT OF THE THALAMIC PORTION 417

extent of the lesions. Four views are taken. 1) A lateral OPERATION

view, which shows the primary fracture line, the fragments
related to the lateral cortex, and the degree of rotation Position-A tourniquet is applied. The patient lies on
of the semilunar or comet-shaped fragment (Figs. 1 to 6). the uninjured side with the fractured limb resting on a
2) An antero-posterior view as described by B#{246}hler(1929). sandbag, presenting its lateral aspect to the operator.
This view is not always easy to achieve when the patient Exposure-The skin incision passes from the calcaneo-
is in pain, but it gives information about the degree of cuboid joint to a point a little below the lateral malleolus.
displacement and number of fragments of the thalamic It runs above the peroneal tendons along the line of the
portion (Figs. 7 to 9). 3) Anthonsen’s oblique projection sinus tarsi. The branches of the sural nerve are defined
which allows confirmation of information found in the by blunt dissection and retracted gently to avoid damage
previous views. 4) An antero-posterior view of the to them, which might otherwise give rise to a painful
midtarsal joint to define fracture lines running into the neuroma. The peroneal tendons are retracted downwards,
calcaneo-cuboid joint through the anterior part of the avoiding, if possible, opening their sheaths. The main
calcaneus. calcaneo-fibular portion of the lateral ligament of the
Tomography has been attempted in a number of ankle is preserved and may not even be exposed.
cases but has not proved helpful ; its use is not recom- The sinus tarsi is then exposed. Blood clot, fat,
mended. Comparison with radiographs of the normal ligamentous debris and small pieces of bone are removed
side is often very helpful. to obtain a clear view of the operative field. Sometimes
visibility may be aided by slight retraction of bone of the
lateral wall of the calcaneus.
TREATMENT
It is then possible to assess the condition of the
Whereas first degree, undisplaced fractures have been fracture. The lateral process of the talus appears first
treated by a walking plaster, all fractures of second or and may show evidence of its impact with the calcaneus.
third degree have been treated by operation (Figs. 10 Below it, the semilunar fragment is inspected in the
to 24). Immediately after arrival, as soon as radiographs cancellous bone and only shows the posterior part of its
have been taken, the foot and leg are bandaged to prevent articular surface. This surface is either intact or divided
blistering and the limb is elevated on a Braun’s frame. into two or three fragments displaced to varying degree

FIG. 10 FIG. II FIG. 12

Figure 10-Second degree thalamic fracture in a North African aged 48 years who sustained a fall of 3 metres (10 feet). The semilunar
fragment has rotated 80 degrees. Figure 1 I-A metal spatula is introduced into the primary fracture line and engages the semilunar
fragment. Figure 12-The spatula rotates the semilunar fragment to reduce it. The tuber-joint angle is restored.

....yI

7’,,.,

FIG. 13 FIG. 14 FIG. 15

The same case as in Figures 10 to 12. Figure 13-A transverse Kirschner wire fixes the semilunar fragment in place and a longitudinal
wire fixes the posterior main fragment to the anterior main fragment. There is a space in the cancellous bone beneath the semilunar
fragment. Figure 14-Twenty-eight days later. The cancellous space has filled in spontaneously without the need for bone grafting.
Figure 15-Six months later. The wires have been removed. The subtalarjoint is well restored.

VOL. 57-B, No. 4. NOVEMBER 1975

418 R. SOEUR AND R. REMY

and partially covered by bony fragments derived from lateral surface it should be properly aligned with the
crushing ofthe lateral wall. In the distal part ofthe wound medial fragment or an intermediate fragment if this is
damage to the anterior part of the calcaneus and the present, which should itself have been correctly reduced.
calcaneo-cuboid joint can be observed. At this point the subtalar joint should have been reduced

FIG. 16 Fin. 17 FIG. 18

The same case as in Figures 10 to IS-antero-posterior views. Figure 16-Before treatment. Figure 17-After fIxation.
Figure 18-At the end of treatment. The patient resumed work at the ninth month; five years later he was still doing his
normal work as a chimney sweeper.

.5,

FIGs. 19 AND 20
Second degree bilateral thalamic fractures with
comet-shaped fragments in a prison warder aged
53 years who fell from a scaffolding. Figure 19-
Lateral radiographs. Figure 20-Antero-posterior
radiographs.

Reduction-This is performed carefully and without haste. and the tuber-joint angle restored to normal. If not, the
A metal spatula introduced into the primary fracture line manoeuvre is repeated and correction obtained.
engages the semilunar fragment and reduces it by rotating Fixation-The semilunar fragment is fixed to the medial
it in the opposite direction (Figs. 10 to 12). On its deep fragment by a transverse Kirschner wire of 2 millimetres

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 FRACTURES OF THE CALCANEUS WITH DISPLACEMENT OF THE THALAMIC PORTION 419

FIGS. 2 1 AND 22
Same patient as in Figures 19 and 20 seven months
after operation. Kirschner wires have maintained
the position of the fragments which have united in
good alignment. Plasters were used for one month,
walking plastersfor two months and a supporting
bandage for one month. Work was resumed after
four months.
FIG. 22

(12 inch) diameter. It should enter the fragment 5 The limb is elevated on a Braun’s frame for four
millimetres U inch) from its articular border and 10 weeks. The plaster is then changed, sutures are removed
millimetres ( inch) from its anterior border. The shape and a walking plaster is applied. The last is retained for
of the posterior part of the calcaneus having been restored, a further eight weeks. Walking ability is restored rapidly
it is now possible to reduce the anterior main fragment and sticks need not be used. When the plaster is removed,
on the posterior with restoration, as far as is possible, of oedema is prevented by an Unna’s paste bandage.
the lateral wall. The small cortical fragment which forms The wires were removed, on average, seven months
the lateral edge of the floor of the sinus tarsi can be fixed after operation, the longest period being four years and
as a wedge between the anterior part of the calcaneus the shortest three months. In six patients, union was
and the thalamic portion. An antero-posterior wire sound with
the wires in situ and they were not seen again.
passing slightly obliquely from the lateral to the medial Removal of the wires presents no difficulty provided that
side completes the fixation. A third wire is rarely the branches of the sural nerve are avoided.
necessary. In the first ten cases it was thought that it
might be useful to fill the space resulting from the
elevation of the thalamic fragment with bone chips from COMPLICATIONS
the tibial metaphysis. This was later abandoned as
unnecessary because the cancellous bone reconstitutes No bone sepsis was encountered. In fifty-eight operations
itself so rapidly (Figs. 10 to 15). there were six minor complications. Failure of superficial
Radiographs are taken to confirm reduction, the skin skin healing required skin grafting in five cases, and in
is sutured with interrupted steel sutures and a plaster one case a neuroma in the scar was relieved by infiltration
cast is applied. with local anaesthetic.

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420 R. SOEUR AND R. REMY

FIG. 23

FIGs. 23 AND 24
Same patient as in Figures 19 to 22, five years
later. He has no complaints and is able to do his
work without symptoms. There is no limp. There
is full movement of the ankle and midtarsal joints
but some limitation of movements of the subtalar
joints.

RESULTS Functional results-Some patients complained of fatigue

at the end of a working day, of swelling behind the
Duration of incapacity-For industrial cases, complete
malleoli, of pain along the outer border of the foot or of
incapacity averaged six months. Three patients did not
discomfort related to change in the weather. Movement
resume work after six months because of other complica-
of the ankle was full and there was no shortening of the
tions such as multiple fractures or other causes. Five
tendo calcaneus. Movements of the subtalar joint were
patients were only partially employed at the time of
normal in twenty cases, diminished in thirteen and absent
completion of management. In non-industrial cases, the
in twelve, one having had an arthrodesis. Joint movement
duration of incapacity was considerably less, usually
was painless except in one case. The midtarsal joint was
three to three and a half months.
normal in twenty-three cases, limited in movements in
Anatomical results-The articular surfaces of the subtalar
nine, and completely ankylosed in four cases, one of
joint were restored in every case and the semilunar or
which had been fused by operation. (This was the patient
comet-shaped fragments, which had rotated, on average,
mentioned previously who had had a subtalar arthrodesis.)
58 degrees, were restored to their normal position (Figs.
Permanent disability-Two patients have no permanent
I 3 to 1 5 and 23 and 24). The reduction was maintained:
disability at all. Except for those with concomitant
in only two cases was there a minor degree of secondary
injuries, the degree of permanent disability was slight or
displacement. The tuber-joint angle before operation
mild. All except eight patients have resumed their normal
measured between -25 and +22 degrees with a mean of
work. Most have to climb ladders or scaffolding, to work
10 degrees. After operation, normal values up to +38
on trucks or lifts and to stand on beams.
degrees were obtained, with a mean of +27 degrees.
Valgus deformity of the calcaneus was absent or slight.
DISCUSSION
Studies offootprints did not show the characteristic image
associated with traumatic flat foot (Fig. 25). There was Previous authors have described the displaced fragment
no instance of severe osteoporosis, such as is sometimes of the thalamic portion of the calcaneus (Judet, Judet and
seen after other methods of treatment. La Grange 1954; Sanchis Olmos 1963), but have failed

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 IRACTURES OF TIlL CALCANLUS WITh DISPLACEMENT OF THU THALAMIC PORTION 421

a modification in the approach to treatment. Previous

attempts at reduction had concentrated on depressing the
posterior end of the calcaneus and lateral compression
by means of a B#{246}hler
clamp, followed by an attempt to
correct the displacement of the thalamic fragment by
means of a punch (Belenger, Vander Elst and Lorthioir
1951; Gosset 1949, 1953; Decoulx, Razemont and
Ducloux 1956). The method described here aims, as in
other articular fractures, to reduce the fragment by open
operation. Reduction of the displaced fragment re-
establishes the tuber-joint angle, and it only remains to
restore the alignment of the main posterior and anterior
fragments. The gap in the cancellous bone that is formed
when the fragment is reduced fills in in a few weeks;
packing with bone chips is unnecessary and may endanger
a good reduction.
: Fixation with heavy materials such as screws, bolts
or staples is inappropriate in such fragile fragments ; it

can only be achieved by thin wire and a well applied

plaster cast.

CONCLUSIONS

.,,..‘ Fractures involving the thalamic portion of the calcaneus

are rarely due to direct vertical compression. They are
more usually due to a shearing stress combined with
compression in a rotary direction. The first stress divides
the bone into two main fragments, anterior and posterior.
The second stress causes further fragmentation, especially
FIG. 25 at the posterior articular surface where a semilunar or
Same patient as in Figures 19 to 24 to show normal footprints. comet-shaped piece of bone is rotated downwards and
backwards. By rotation of the fragment in the opposite
to appreciate that it should be reduced by rotating it into direction, the fundamental deformity is corrected and the
position and not simply by elevating it. It had previously tuber-joint angle restored. Fixation of the thalamic
been thought that the displacement of the fragments was fragment is maintained by a transverse Kirschner wire
due to the upward pull of the tendo calcaneus and of the and of the two main fragments by a longitudinal wire,
muscles of the sole (B#{246}hler1929; Soeur 1935). A more with plaster casts, not bearing weight for four weeks and
precise knowledge of the role of the thalamic fragment weight-bearing for eight weeks. The results have been
led to a rejection of this mechanism and, consequently, satisfactory in fifty-six cases.

The authors wish to thank Mr W. J. W. Sharrard for his advice concerning the publication and the translation of this paper.

REFERENCES
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B#{246}hler,L. (1929) Behandlung der FersenbeinbrfIche. Archly f#{252}rKlinische Chirurgie, 157, 723-732.
Decoulx, P., Razemon, J. P., and Ducloux, M. (1956) Les fractures du calcan#{233}um. A propos de 59 observations. Indications op#{233}ratoires
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VOL. 57-B, No. 4, NOVEMBER 1975