These displacements are sometimes so easily reduced by mere pressure as to make it almost impossible to retain them. At other times anesthesia with firm pressure, accompanied by flexion of the trunk backward or forward, may be required; reduction has been possible sometimes only through incision and by the use of instruments applied as levers, or by the use of a screw driven into one of the fragments, thus affording a handle by which to manage it. Serious dislocations are frequently accompanied by fractures of the ribs or of the sternum. The same fixation of the thorax is required as in fractures of these parts, and should be conducted in the simplest manner possible.
DISLOCATIONS OF THE RIBS.
To displace a rib from its sternal connections requires actual fracture of bone or cartilage. Forward dislocation at its posterior and spinal connection, especially of the eleventh and twelfth ribs, has been described. Considerable effort is necessary for its production, and the case should be treated on its individual merits.
DISLOCATIONS OF THE CLAVICLE.
Either end or both ends of the clavicle may be dislocated. Its sternal end may be thrown in any direction but downward; its acromial end in any direction, although usually upward. Dislocations of the sternal end can only occur in consequence of serious damage to the sternoclavicular ligaments, because of which, and in the absence of a socket, it is extremely difficult to maintain the parts when restored to position. Violent backward traction upon the shoulder permits anterior displacement when the joint is thus weakened. Backward displacement is usually the result of indirect violence when the shoulder is forced forward and inward, while upward displacement is the result of tilting which occurs when the shoulder is violently depressed. Respiration is generally more or less disturbed, while in backward luxations deglutition may be made difficult and painful.
Reduction is not difficult to effect, but extremely difficult to maintain. Pressure in the proper direction, accompanied by traction upon the shoulder, suffices for the former. For the latter there should be a combination of fixation of the shoulder and arm with proper traction, and at the same time pressure upon the end of the clavicle. For all of the clavicular dislocations the dressing and position advised by Dr. Moore, of Rochester, and referred to in the chapter on Fractures as his double figure-of-eight, serves admirably for maintaining the proper position of the shoulder, while pressure can be made by a pad, retained either by adhesive plaster or by some further addition to the dressing itself. (See [p. 494].) Acromial dislocation is usually in the upward direction, and is produced by violence upon the shoulder, which has expended itself in rupturing ligaments rather than in fracturing the acromion process. The indication here is to keep the shoulder elevated by any dressing which will accomplish the purpose and the clavicle bound down.
Fig. 340
Position of clavicle in dislocation of sternal end upward.
Dislocation of both ends, i. e., complete loosening of the bone, occurs occasionally, in which case the indications already given are reinforced, while the difficulties of treatment are considerably aggravated. Here the shoulder should be kept upward, outward, and backward, and the clavicle retained by pressure or some other means.