ion of the sterno-clavicular
joint or a _separation of the clavicular epiphysis_. This last is a
rare accident, which may occur between the seventeenth and the
twenty-fifth years, and is usually the result of violent muscular
action. It differs from the other injuries in this region in being
more easily reduced and retained in position, the epiphysis lying
entirely within the limits of the articular capsule of the
sterno-clavicular joint.

_Simultaneous fracture of both clavicles_ usually results from a
severe transverse crush of the upper part of the thorax or from a fall
on the outstretched hands--for example, in hunting. The middle third
of the bone is implicated, and there is marked displacement and
overriding. The patient is rendered helpless, and from the extrinsic
muscles of respiration being thrown out of action and the weight of
the powerless limbs pressing on the chest, there is considerable
difficulty in breathing, and this is often increased by the fracture
being complicated by injuries of the lung or pleura.

The _prognosis_ as to union in all these injuries is good. Firm bony
union usually occurs within twenty-one days. Non-union, false-joint,
or fibrous union is but rarely met with. At the same time it is to be
borne in mind that, in spite of all precautions, some deformity and
shortening may result, without, however, interfering with the
usefulness of the limb.

_Treatment._--The displacement in complete fractures of the clavicle
is readily reduced by supporting the elbow, bracing back the
shoulders, and levering out the tip of the affected shoulder. In a few
cases the interposition of some fibres of the subclavius muscle
between the fragments has prevented perfect reduction.

In the greenstick variety the bone may be bent back into its normal
position, but no great force should be employed, as, in spite of
imperfect reduction, the clavicle usually straightens as it grows, and
although some deformity may persist, the function of the limb is not
interfered with.

_Recumbent Position._--There is little doubt that the most perfect
aesthetic results are obtained by treating the patient in the recumbent
position. In girls, therefore, in whom it is desired that the
shoulders should be perfectly symmetrical, the best results are
obtained from placing the patient on a firm mattress, with a narrow,
firm cushion between the shoulder-blades, so that the weight of the
shoulder may carry the acromial fragment