le; even
when the displacement is permanent, however, the usefulness of the arm
is not necessarily impaired.

Treatment is similar to that for fracture of the clavicle by sling and
body bandage. Another plan is to place a pad over the acromial end of
the clavicle, and fix it in this position by a few turns of elastic
bandage carried over the shoulder and under the elbow. The forearm is
placed in a sling with the elbow well supported, and the arm is bound
to the side by a circular bandage. When the bone cannot be kept in
position and the usefulness of the limb is impaired, the joint
surfaces may be rawed and the bones wired, with a view to obtaining
ankylosis.

#The sternal end# may be dislocated forwards, backwards, or upwards.

_Forward_ dislocation is the most common; the end of the clavicle lies
on the front of the sternum, somewhat below the level of the
sterno-clavicular joint, and its articular surface can be distinctly
palpated (Fig. 16). The inter-articular cartilage sometimes remains
attached to one bone, sometimes to the other; the rhomboid ligament is
usually intact.

In the _backward_ dislocation the end of the clavicle lies behind the
manubrium sterni and the muscles attached to it; there is a marked
hollow in the position of the joint, and the facet on the sternum can
be felt. In a comparatively small number of cases the bone exerts
pressure upon the trachea and oesophagus, producing difficulty in
breathing and swallowing. It has also been known to press upon the
subclavian artery and on other important structures at the root of the
neck.

[Illustration: FIG. 16.--Forward Dislocation of Sternal End of Right
Clavicle. From a fall on a polished floor, in a man aet. 40.]

In rare cases the rhomboid ligament is torn, and the end of the
clavicle passes _upwards_, and rests in the episternal notch behind
the sterno-mastoid muscle.

The bone may be retained in position by keeping the shoulders braced
back by a figure-of-eight bandage, or by padded handkerchiefs, and
making pressure over the displaced end of the bone with a pad. The
forearm is supported by a sling, and the arm fixed to the side.
Massage is employed from the first, and the patient is allowed to move
the arm by the end of a week. Imperfect reduction interferes so little
with the functions of the limb that operative measures are seldom
required except for aesthetic reasons.

Dislocation of #both ends# of the clavicle has occasionally occur