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Shoulder provides the widest range of motion of any part of the body with small and shallow glenoid cavity which is only 1/4 to 1/3 of the joint surface of the humerus. Therefore, shoulder is relatively unstable, contributing over 40% of all dislocations. Isolated dislocated shoulders normally happen to the youth due to intense bone strength while fracture dislocations normally happen to the elderly.Dislocated shoulders include anterior shoulder dislocation which is more common and posterior shoulder dislocation.
肩关节是人体活动度最大的关节，组成该关节的肩盂小且浅，只占肱骨头关节面的1/4～1/3，因此肩关节也是相对不稳定的关节。肩关节脱位占全身关节脱位发生率的40%以上，由于年轻人骨质强度大，时常发生单纯性脱位，而老年人多发生骨折合并脱位。肩关节脱位分前脱位和后脱位，前脱位较多见。
Anterior shoulder dislocation, the commonest dislocated shoulders（Figure4-2-1）, is usually caused by sport injuries. Male patients are far more than female patients due to loosen articular capsule,muscles and ligaments. That is even slight shoulder sprain can lead to dislocation.
Figure4-2-1 Anterior shoulder dislocation (subcoracoid dislocation)
图4-2-1 肩关节前脱位（喙突下脱位）示意图
肩关节前脱位是最常见的肩关节脱位（图4-2-1），多见于运动损伤，男性多于女性。老年人尤其是老年女性，因组成肩关节的关节囊、肌肉及诸韧带松弛，简单的肩部扭伤即可引起脱位。
Both direct and indirect violence could induce anterior shoulder dislocation, but indirect violence is far more common.
间接或直接暴力均可引起肩关节前脱位，但以间接暴力引起者最为多见。
Clinically, it can be classified into the following types according to the displacement of the humerus.
临床根据肱骨头移位的情况分为：
Subglenoid: Over outreaching, extortion and stretching of the upper arm shall induce the neck or the greater tuberosity of the humerus against the shoulder peak, a balance point causing humerus gliding to subglenoid.
（1）盂下型：上臂过度外展外旋后伸，肱骨颈或肱骨大结节抵触了肩峰，构成杠杆的支点作用，使肱骨头向盂下滑脱。
Subcoracoid: Abducted arm lands on the ground first when falling down and dislocation is caused by breaking articular capsule through this violent strength.
（2）喙突下型：跌倒时上臂外展位着地，传导暴力致使肱骨头冲破关节囊形成脱位。
Subclavicular: It owns the same injury mechanism with that of subcoracoid but with stronger violent strength, causing subclavicular dislocation.
（3）锁骨下型：与喙突下型受伤机制相同，暴力继续作用则引起锁骨下脱位。
Intrathoracic: In very rare cases, strong violence acts on the humerus, leading to intrathoracic dislocation.
（4）胸腔内型：极个别强大暴力作用于肱骨头，可冲击胸腔形成胸腔内脱位。
Patients normally had traumatic history, swelling, pain in the shoulder, square shoulder with limited motion and positive in Duga’s test. Dislocated humerus can be palpated in the coracoid process,under the clavicle and armpit. And the upper arm is deformed in outreaching and intrusion position with flexible fastening. Anterior shoulder dislocation, with or without fracture, can be diagnosed by X-ray results（Figure4-2-2, Figure4-2-3, Figure4-2-4）.
有明显的外伤史，肩部肿胀疼痛，功能障碍，呈“方肩”畸形，搭肩试验阳性。在喙突、锁骨下或腋窝部可摸到前脱位的肱骨头，上臂外展内旋畸形，并呈弹性固定。X线片检查可以确诊肩关节前脱位（图4-2-2、图4-2-3、图4-2-4），并能检查有无合并骨折。
Figure4-2-2 X-ray of right shoulder dislocation-subglenoid
图4-2-2 右肩关节脱位盂下型X线片
Figure4-2-3 X-ray of left shoulder dislocation-subcoracoid
图4-2-3 左肩关节脱位喙突下型X线片
Figure4-2-4 X-ray of left shoulder dislocation-subclavicular
图4-2-4 左肩关节脱位锁骨下型X线片
Bone-setting manipulation is proven to be effective for fresh dislocations. However, surgery is recommended to patients with protracted dislocation, habitual dislocation, proximal humerus fracture combined with severe displacement or combined with glenoid labrum which shall influence the shoulder stability.
单纯性新鲜脱位经手法整复多可复位，陈旧性脱位、习惯性脱位、合并严重移位的肱骨近端骨折或合并盂唇损伤影响肩关节稳定性的可手术治疗。
Bone-setting manipulation
1．整复方法
Tract-over-the-head reduction: The patient is in supine position while the practitioner grasps the wrist of the injured side, keeping pulling downward gradually and rotating outward until over the patient’s head. Then it can return to where used to be. If not, one assistant shall push humerus head with two thumbs into the glenoid cavity through armpit（Figure4-2-5）.
（1）牵引过头法：患者仰卧，术者紧握患肢腕部向下徐缓、持续不断牵引，并向外旋转，逐渐外展患肢过头，可使肱骨头自动复位。若不能复位，助手可用双手拇指经腋窝将肱骨头推入关节盂内（图4-2-5）。
Push-off reduction: Take the right shoulder as an example. The patient is in supine position while the practitioner stands next to the injured side. Then the practitioner holds the wrist of the injured side with right leg pushing off under the armpit, pulling for 1 to 3 minutes with outreaching first, extorsion and adduction and intorsion still after hearing a“click”sound.
Figure4-2-5 Traction over the head
图4-2-5 牵引过头法复位示意图
（2）手牵足蹬复位法：患者取仰卧位，以右肩为例，术者立于患侧，双手握住患肢腕部，右膝伸直用足蹬于患者腋下，顺势用力牵引患肢，持续1～3分钟，先外展、外旋，患肩有入臼声后内收内旋，即表明复位成功。
Rotate reduction: The patient is in sitting or supine position with anaesthesia. One assistant holds the patient’s shoulders and the practitioner stands at the injured side, using the right hand to hold the elbow of the injured side while the left hand grasping the wrist of the same side, bending the elbow to 90°and outreaching the upper arm. Then the practitioner pulls along the vertical direction of the upper arm gradually, beginning extorsion and adduction gradually and closing to the anterior lower chest wall.Reduction shall be finished after hearing a“click”sound or feeling the“springing”of the bone when upper arm is extorted and adducted. Then the practitioner acts intorsion on the upper arm and puts the hand of the injured side on the shoulder peak of the other side for maintaining the position.
（3）牵引回旋复位法：患者采用靠坐位或仰卧位，麻醉后，助手扶住患者双肩，术者立于患侧，右手握住患肢肘部，左手握住患肢腕部，并使患肢屈肘90°且上臂外展，徐徐沿上臂纵轴方向牵引，并外旋上臂，再逐渐内收，并使肘部与前下胸壁接触内收。在上臂牵引外旋及内收的情况下听到响声或感到骨传导弹动感即为关节已复位。再将上臂内旋，并将患肢手掌扶于健侧肩峰上保持复位。
Stretching reduction: The patient is in sitting position. Assistant A stands behind the patient, the health side of the shoulder, with hands encircling through the patient’s chest. And assistant B holds the elbow of the injured side with one hand, doing outward and inferior stretching, outreaching and extorsion with increasing strength for 2 to 3 minutes. The practitioner stands in the lateral side of the patient,pressing the shoulder peak with two thumbs while acting on the armpit with rest fingers. With the help of resistance, the practitioner stretches the humerus shaft up and outward while the assistant B adducts the injured arm at the same time, pulling in intorsion position until the humerus shaft suits where it should be.
（4）拔伸托入法：患者取坐位，第一助手立于患者健侧肩后，两手斜形环抱固定患者胸部，第二助手一手握患肢肘部，外展外旋患肢，向外下方牵引，用力由轻而重，持续2～3分钟，术者立于患肩外侧，两手拇指压其肩峰，其余手指插入腋窝内，在助手对抗牵引下，术者将肱骨头向外上方钩托，同时第二助手逐渐将患肢向内收，内旋位牵拉，直至肱骨头有回纳感，复位即告完成。
Chair-back reduction: The patient sits in a chair with the injured side out of it. Cotton pads shall be put under patient’s armpit to protect vessels and nerves. Then the practitioner holds the injured side, pulling extorsion, outreaching and doing adduction gradually after hearing a“click”sound. Then the practitioner intorts patient’s elbow and the reduction shall be finished successfully.This method is recommended to patients with dislocated shoulders and weak muscle strength (Figure4-2-6).
（5）椅背复位法：患者坐在靠椅上，将患肢放在椅背外侧，腋肋紧靠椅背，用棉垫至于腋部以保护腋下血管、神经。术者握住患肢，先外展、外旋牵引，听到入臼声后再逐渐内收，然后内旋屈肘，即可复位成功。此法适用于肌力较弱的肩关节脱位者（图4-2-6）。
Figure4-2-6 Chair-back reduction
图4-2-6 椅背复位示意图
Suspension reduction: The patient is in prone position with the injured side suspending beside the bed, weighting 2kg to 5kg objects in the wrist（not in the hand）of the injured side according various muscularity for about 15 minutes in natural position.
（6）悬吊复位法：患者俯卧床上，患肢悬吊于床旁，根据患者肌肉发达程度，在患肢腕部系布带并悬挂2～5kg重物（不可以手提重物），以其自然位持续牵引15分钟左右，多可自动复位。
Note: X-ray of anterior shoulder dislocation before and after bone-setting manipulation（Figure4-2-7, Figure4-2-8）.
附：肩关节前脱位手法整复前后X线片对照图（图4-2-7、图4-2-8）。
Figure4-2-7 X-ray of anterior shoulder dislocation (subcoracoid) before and after bone-setting manipulation
图4-2-7 左肩关节喙突下型脱位复位前后X线片对照
Figure4-2-8 X-ray of anterior shoulder dislocation (subclavicular) before and after bone-setting manipulation
图4-2-8 左肩关节锁骨下型前脱位复位前后X线片对照
Fixation
2．固定方法
To avoid recurrent dislocation and help the recovery of soft tissues and articular capsule, triangular bandage shall be used for 2 to 3 weeks. It can be properly prolonged if it is fresh isolated dislocation.
采用患肢三角巾悬吊固定2～3周即可，新鲜脱位固定时限应适当延长，以使损伤的关节囊等软组织完全修复避免形成习惯性脱位。
See Appendix: Recommended TCM Prescriptions during Different Stages of Fractures.
骨折早、中、晚三期辨证用药。
Do the same as that of proximal humerus fracture.
同肱骨上端骨折。
Posterior shoulder dislocation is very rare which may be easily misdiagnosed or missed diagnosis due to clinical presentation not so obvious as that of anterior shoulder dislocation.
肩关节后脱位极为罕见，临床症状不如肩关节前脱位明显，常被误诊或漏诊。
Direct violence hits the humeral head from front to back, breaking the humeral head through the posterior wall of the articular capsule and the labrum cartilage and sliding into the scapula, which often accompanied by depressed fracture of anterior humeral head or scapular fracture. This dislocation shall also be the result of indirect violence, for example, the upper arm rests on the palm of the hand with a strong internal rotation when falling down. This conducted violence leads to humeral head dislocated backward. Small posterior tuberosity fractures are more common due to the distraction of the subscapular muscle during posterior dislocation.
直接暴力系从前方向后直接打击肱骨头，使肱骨头冲破关节囊后壁和盂唇软骨而滑入肩胛盂后，常伴肱骨头前侧凹陷骨折或肩胛冈骨折。间接暴力引起者，系上臂强力内旋跌倒时手掌撑地，传导暴力使肱骨头向后脱位，后脱位时由于肩胛下肌的牵拉，小结节骨折较常见。
The anterior side of the shoulder is empty and the protruded humerus head can be touched behind the shoulder joint. As the posterior margin of the scapula is pressed into the sunken humeral head to form a false joint, the affected shoulder can be extended without significant limitations. Functions such as forward lifting and abduction are only partially compromised but internal and external rotation are more obvious. The square shoulder deformity, elastic fixation and positive in Duga’s test were not typical. The X-ray（anteroposterior）shows that the glenohumeral relationship is generally normal. But by reviewing it carefully,the humeral head is in the internal rotation position, the large nodules disappeared, and the semilunar shadow of the humeral head on the scapula disappeared. The X-ray（axial plane）shows posterior displacement of the humeral head, indicating flattened or sunken humeral head in anteromedial side or scapular fracture（Figure4-2-9）.
Figure4-2-9 X-ray of right shoulder posterior dislocation beforebone-setting manipulation
图4-2-9 右肩关节后脱位复位前X线片
肩部前侧空虚，在肩关节后方可触及脱出的肱骨头，肩峰异常凸出。由于肩盂后缘压入肱骨头凹陷处形成假关节，患肩后伸活动可无明显受限，前举、外展仅有部分受限，以内、外旋活动受限较为明显。方肩畸形、弹性固定和搭肩试验阳性不典型。X线正位片显示盂肱关系大致正常，但仔细研究可发现肱骨头呈内旋位，大结节消失，肱骨头于肩胛盂的半月形阴影消失。X线轴位片可显示肱骨头后移位，提示肱骨头的前内侧变平、凹陷或肩胛冈骨折（图4-2-9）。
Bone-setting manipulation
1．整复方法
A patient with fresh shoulder dislocations is in sitting or prone position. One assistant presses the shoulder blade of the patient backwards with one hand as fixation, and pushes the patient’s humerus head forward and downward with the other hand. The longitudinal axis is slightly forward flexed and the patient’s upper arm shall be reset by external rotation. In the late stage, shoulder functional exercises shall be started as soon as possible（Figure4-2-10）.
新鲜肩关节后脱位患者采用坐位或俯卧位，助手一手向后压住患者肩胛骨作为固定，另一手用拇指向前下推压患者肱骨头；术者两手握住患者患肢腕部，沿患者肱骨纵轴轻度前屈牵引，并外旋患者上臂即可复位。后期嘱咐患者加强肩关节功能活动锻炼（图4-2-10）。
Figure4-2-10X-ray of right posterior shoulder dislocation after bone-setting manipulation: well-aligned
图4-2-10 右肩关节后脱位复位后X线片，关节对合良好
Fixation
2．固定方法
Triangular bandage shall be used in the injured side for 2 to 3 weeks.
采用患肢二角巾悬吊固定2～3周。
See Appendix: Recommended TCM Prescriptions during Different Stages of Fractures.
骨折三期辨证用药。
Do the same as that of proximal humerus fracture.
同肱骨上端骨折。
A 33-year-old man came to Guangzhou Orthopaedic Hospital 3 hours after an accident fall during exercise and injured his left palm and the left shoulder joint at the same time, causing swelling,deformity, and limited movement of the left shoulder joint. Physical examination present-ed swelling,pain, deformity in the left shoulder, tenderness in the left humerus head, and compromised functions of shoulder flexion and extension. X-ray shows posterior dislocation of left shoulder with proximal humerus fracture（Figure4-2-11）, being managed with bone-setting manipulation and fixed by splints. Reviewed X-ray shows well-aligned left shoulder and corrected displacement（Figure4-2-12）. External fixation was removed after one month, and be treated as usual.The fracture healed and the shoulder was back to normal in 6-week follow-up（Figure4-2-13）.
Figure4-2-11 X-ray: Left posterior shoulderdislocation with proximal humerus fracture
图4-2-11 X线片示左肩关节后脱位合并肱骨近端骨折
患者男，33岁，锻炼时不慎跌倒，左手掌撑地致伤，同时撞击左肩关节处，引起左肩关节处肿胀、畸形及活动受限，伤后3小时来广州市正骨医院就诊，检查发现：左肩关节处肿胀、疼痛、畸形，左肱骨头部压痛明显，肩关节屈伸功能障碍。X线片示：左肩关节后脱位合并肱骨近端骨折（图4-2-11）。治疗上行手法整复，夹板固定。复查X线片示：左肩关节对位良好，骨折移位已复位（图4-2-12）。一个月后拆除外固定，按术后常规处理。一个半月后复查：骨折已经愈合，肩关节活动度已恢复正常（图4-2-13）
Figure4-2-12 X-ray after bone-settingmanipulation : well-aligned left shoulder
图4-2-12 复位后X线片示左肩关节对位良好
Figure4-2-13 CT 3D reconstruction of left shoulderdislocation after bone-setting manipulation
图4-2-13 左肩关节脱位复位后CT三维重建图
Posterior shoulder dislocation is an injury which can be most likely to be missed diagnosed in all major joints. Main reasons are listed as follows.
1．Most dislocated shoulders are subacromial dislocation with little clinical presentations, no obvious deformity and interlocking of the anterior dislocation .
2．Multiple negative findings could be found on the anterior and posterior X-rays of the shoulder.Furthermore, over-reliance on X-rays also accounts for one of the main reasons.
3．Nevertheless,the practitioner may lack of consideration during the diagnostic process or the examination is not careful enough and thoroughly. Symptoms and signs of the shoulder are thought as the result of a small fracture such as a small nodule or a rim of the pelvis on the plain film. Lack of indepth examination or further examination both can lead to misdiagnosis. Therefore, after inquiring about injury conditions, a careful examination should be carried out. And the patient’s should be compared and checked thoroughly, including anterior, posterior and lateral sides. Considering posterior shoulder dislocation, X-rays of the anterior and posterior, axial, dynamic, or scapular tangent position of the shoulder could be ordered for further diagnosis. By observing the X-ray of patient’s shoulder carefully to identify whether there are changes in X-rays（both anterior and posterior）of the patient’s shoulder space and the shadow of the humeral head and glenoid overlap or in the image relationship between the anterior edge of the glenoid and the humeral head articular surface.
肩关节后脱位是所有大关节中最容易漏诊的一种损伤，主要原因有：①肩关节后脱位大部分为肩峰下脱位，体征不典型，没有肩关节前脱位明显的畸形及交锁现象；②在肩关节前后位X线片上多阴性表现，这也是过分依赖X线片影像成为造成漏诊的主要原因；③诊断过程中缺乏考虑，查体欠仔细彻底，以为肩部的症状体征是因X线平片上显示有小的骨折如小结节或盂缘骨折所致，缺乏深入查体或进一步检查而造成误诊。所以在询问受伤时情况后要仔细认真检查，对患者双侧从前、后、侧3个方位进行对比检查。在考虑有肩关节后脱位时，可摄肩关节前后位、轴位、动力位或肩胛骨切线位X线片。应仔细观察患者肩关节前后位X线片肩关节间隙及肱骨头与肩盂重叠阴影是否改变，关节盂前缘与肱骨头关节面影像关系是否改变。
Acromioclavicular dislocation is a common shoulder injury in the clinic（Figure4-2-14）,accounting for 3.2% of all joint dislocations and 12% of the shoulder injury.
肩锁关节脱位是临床上常见的肩部运动损伤（图4-2-14），占全身关节脱位发生率的3.2%，占肩部损伤发生率的12%。
Figure4-2-14 Anatomy of acromioclavicular joint dislocation
图4-2-14 肩锁关节脱位解剖示意图
Acromioclavicular joint dislocation is mostly caused by direct violence. For example, when the shoulder is in the abduction and internal rotation position, the violence hits the top of the shoulder or the shoulder touches the ground when falling down.
肩锁关节脱位多为直接暴力引起，如肩关节处于外展内旋位时，暴力冲击于肩的顶部或跌倒时肩部着地，可引起肩锁关节脱位。
Three types of acromioclavicular dislocation are as follows.
肩锁关节脱位分型有3型。
Type Ⅰ：Articular capsule and acromioclavicular ligament are not completely ruptured with complete coracoclavicular ligament and mild displaced clavicle.
（1）Ⅰ型：关节囊及肩锁韧带不完全破裂，喙锁韧带完整，锁骨只有轻度移位。
Type Ⅱ: Articular capsule and acromioclavicular ligament are completely broken with stretched coracoclavicular ligament and half of the diameter of the clavicle beyond the shoulder peak.
（2）Ⅱ型：关节囊及肩锁韧带完全断裂，喙锁韧带牵拉伤，锁骨外端直径的一半上翘突出超过肩峰。
Type Ⅲ：Articular capsule, acromioclavicular ligament and coracoclavicular ligament are completely broken and the distal clavicle is completely displaced.
（3）Ⅲ型：关节囊、肩锁韧带及喙锁韧带完全断裂，锁骨远端完全移位。
Patients had traumatic history, visible localized protrusion, deformity, pain, swelling, tenderness;compromised shoulder functions, such as abduction, uplift, forward flexion and extension; severely displaced acromioclavicular joint where may be presented sunken and loosen acromioclavicular joint and positive result in Piano sign. X-ray shall be paid attention to the bilateral contrast（Figure4-2-15）.
此脱位均有外伤史。局部可见突起畸形，疼痛，肿胀，压痛。肩关节外展、上举、前屈后伸运动均受限。移位严重肩锁关节处可有凹陷，肩锁关节松动，琴键征阳性。X线检查应注意双侧对比（图4-2-15）。
Patients of Type Ⅰ and Ⅱ dislocations are generally managed with conservative treatment.
As articular structure is severely damaged in patients of Type Ⅲ dislocations with poor stability, surgery is recommended due to the difficulty in maintaining external fixation after succeed bone-setting manipulation.
Ⅰ、Ⅱ型脱位一般采取保守治疗，Ⅲ型脱位关节结构损伤严重，关节稳定性差，即使手法复位成功外固定也难以维持，建议手术治疗。
Figure4-2-15 X-ray of acromioclavicularjoint dislocation
图4-2-15 肩锁关节脱位X线片
Bone-setting manipulation
1．整复方法
The patient sits with his/her hands on his/her hips and the injured side abducted, and the practitioner shall press the outer end of the raised clavicle with one thumb to reset.
患者双手叉腰坐立，维持患肢外展位，术者用拇指向下按压凸起的锁骨外端即可复位。
Fixation
2．固定方法
Modified eight-shaped bandage combines with clavicle support shall be used for fixation（Figure4-2-16）.
采用改良单“8”字绷带配合锁骨固定带固定（图4-2-16）。
Figure4-2-16 Fixed and bandaged with modified eight-shaped bandage
图4-2-16 改良单“8”字绷带固定包扎示意图
A 32-year-old man came to Guangzhou Orthopaedics Hospital 1 hour after this injury, complaining limited right shoulder pain due to a fall while playing. Physical examination present-ed swelling in the right shoulder, obvious localized tenderness and positive in Piano sign, and X-ray shows acromioclavicular joint dislocation（Figure4-2-17）. Reviewed X-ray shows fully recovery after bone-setting manipulation and fixation（Figure4-2-18）. External fixation was removed after 6 weeks and the function of right shoulder is back to normal after 8-week follow-up without any deformities left（Figure4-2-19）.
李某，32岁，男，因打球时跌倒致右肩部疼痛活动受限后1小时来诊，就诊时见右肩部肿胀，局部压痛明显，琴键征阳性，予完善X线片检查提示右肩锁关节脱位（图4-2-17），予复位固定后复查X线片提示右肩锁关节位置良好（图4-2-18），6周后拆除固定，8周后右肩功能基本恢复正常，未遗留外观畸形（图4-2-19）。
Figure4-2-17 X-ray of rightacromioclavicular joint dislocation beforebone-setting manipulation
图4-2-17 右肩锁关节脱位复位前X线片
Figure4-2-18 X-ray after bone-settingmanipulation
图4-2-18 复位后X线片
Figure4-2-19 Fully recovered after 8 weeks
图4-2-19 右肩锁关节脱位8周后功能恢复情况
Sternoclavicular joint dislocation is rare, accounting for only 3% of the incidence of shoulder injuries. However, it is difficult to treat because of the leverage of plane joints and the weight of shoulder arms.
胸锁关节脱位少见，仅占肩部损伤发生率的3%，因为平面关节及肩臂重量的杠杆作用，治疗较为困难。
Most of them are caused by indirect violence, for example, removed inner end of the clavicle by lifting the front of the sternum due to leverage, rupturing the articular capsule and the anterior ligament of the sternocleidomine. As the protrusion is located above the sternum, anterior dislocation of sternocleidomes is thus formed. When the violence acts on the posterolateral of the shoulder, the clavicle is displaced behind the sternum, forming a posterior sternoclavicular joint dislocation.
多为间接暴力所致，当暴力作用于第1肋骨，因杠杆作用，将锁骨内端向胸骨前方撬起，撕破关节囊及胸锁前韧带，突出移位于胸骨前上方，形成胸锁关节前脱位。当暴力作用于肩部后外侧，而锁骨移位到胸骨后方，形成胸锁关节后脱位。
The anterior sternoclavicular dislocation presents obvious swelling and deformity. Tenderness and protrusion in the medial end of the clavicle could be touched. Patients often lean their heads and shoulders to the injured side and hold the affected limb with their hands for pain-relieving. The posterior sternoclavicular dislocation does not present obvious deformity. Emptiness could be touched near the sternoclavicular joint. As the inner end of the clavicle is moved behind the sternal bone, the scapula is pulled inwardly, and the patient’s shoulder cannot fully lie down in supine position. Mediastinal vessels could lead to dyspnea, pharyngeal dysphagia, and obstruction of blood circulation. Clinically, there may be compression symptoms such as angulation of the superficial neck veins. X-ray (coronal plane) is easy to be missed diagnosis, and extra oblique or lateral X-rays shall be ordered for further diagnosis（Figure4-2-20）.
胸锁关节前脱位肿胀畸形较为明显，触诊压痛，明显可触及凸起的锁骨内侧端。患者常以头肩倾向伤侧、健侧手托住患肢以减轻疼痛。胸锁关节后脱位一般畸形不明显，触摸胸锁关节前侧空虚。由于锁骨内端移位于胸骨后方，肩胛骨被牵拉呈内旋，患者平卧位肩部不能接触床面；胸锁关节后脱位有的锁骨内端移于肋骨后方还可压迫气管、食管或纵隔血管引起呼吸困难、吞咽困难及血循环受阻，临床上可有颈部浅静脉怒张等压迫症状。胸部正位X线片常漏诊，需加摄胸部斜位或侧位X线片（图4-2-20）。
Figure4-2-20 X-ray of right sternoclavicular dislocation
图4-2-20 右胸锁关节脱位X线片
Preferred treatments are bone-setting manipulation and external fixation. Surgery shall be considered if a patient presents tracheal, esophageal, or mediastinal vascular compression caused by breathing difficulties, dysphagia or impaired blood circulation.
胸锁关节脱位首选手法复位加外固定，合并气管、食管或纵隔血管压迫引起呼吸困难、吞咽困难及血循环受阻者则需手术治疗。
Bone-setting manipulation
1．整复方法
The patient leans back on his/her back with upper limbs on his/her hips. And the practitioner pushes the chest wall of the injured side with one hand and pulls the upper end of the patient’s upper arm outwards with the other hand.
患者背靠坐位，上肢叉腰，术者一手推顶患者伤侧胸壁，一手握住患者上臂上端向外侧牵引，即可使关节脱位整复。
Fixation
2．固定方法
Cotton pads shall be put in the anterior side of the sternoclavicular joint and anterior eight-shaped bandages shall be used for compression and fixation.（Please refer to the fixation for the medial clavicle fracture.）
于胸锁关节前侧加棉垫，并用前“8”字绷带局部加压固定，可参照锁骨内侧骨折的固定方法。
See Appendix: Recommended TCM Prescriptions during Different Stages of Fractures.
骨折三期辨证用药。
Do the same as that of clavicle fracture.
同锁骨骨折后的锻炼方法。