[Illustration: FIG. 22.--Kocher's Method--Third Movement; Rotation of Arm towards Middle Line.]
A method of reduction has been formulated by A. G. Miller, which we have found to be quite as successful as Kocher's method. The limb is grasped above the wrist and elbow, the forearm flexed to a right angle, and the upper arm abducted to the horizontal (Fig. 23). While an assistant makes counter-extension and fixes the scapula, the surgeon gradually draws the arm away from the body till the head of the humerus is felt to pass laterally. The humerus is then rotated medially by dropping the hand (Fig. 24), and the bone gradually glides into the socket.
[Illustration: FIG. 23.--Miller's Method of reducing Sub-coracoid Dislocation--First Movement.]
[Illustration: FIG. 24.--Miller's Method of reducing Sub-coracoid Dislocation--Second Movement.]
In a certain number of cases reduction can be effected by _hyper-abduction_ of the shoulder with traction. The patient is laid upon a firm mattress, and the surgeon, seated behind him while an assistant fixes the acromion, slowly and steadily extends the arm until it is raised well above the head. In some cases the head of the humerus spontaneously slips into its socket; in others it may be manipulated into position by pressure from the axilla. This method is restricted to recent cases, as in those of long standing the axillary vessels are liable to be stretched or torn.
The method of reduction by traction on the arm with the heel in the axilla is only to be used when other measures have failed, as it depends for its success on sheer force.
_After-Treatment._--After reduction, the part is gently massaged for ten or fifteen minutes, a layer of wool is placed in the axilla, the forearm is supported by a sling, and the arm fixed to the side by a circular bandage. Massage is carried out from the first, and movement of the shoulder in every direction except that of abduction may be commenced on the first or second day. The circular bandage may be dispensed with at the end of a week, and abduction movements commenced, and by the end of a month the patient should be advised to use the arm freely.
The #sub-clavicular dislocation# (Fig. 17) is to be looked upon as an exaggerated degree of the sub-coracoid rather than as a separate variety. It is produced by the same mechanism, but the violence is greater, and the damage to the soft parts more severe. The head passes farther upwards and towards the middle line under cover of the pectoralis minor, resting under the clavicle against the serratus anterior and chest wall. The symptoms are usually so marked that they leave no doubt as to the diagnosis. The outline of the head of the humerus in its abnormal position is visible through the skin, and the shortening of the limb is more marked than in the sub-coracoid variety. The treatment is the same as for sub-coracoid dislocation.