A dislocation, once it has been reduced, is only a severe form of sprain. The historical treatment of these injuries is prolonged rest with absolute fixation. This treatment ignores two facts. First, that to repair injury done an efficient blood supply is essential: by absolute rest the circulation in the part is reduced to a minimum, and this is all the more pernicious on account of the vaso-motor disturbance due to the injury. Second, in all these injuries one or more joints have suffered, and the muscles which control the movement of the joints undergo a rapid wasting, due to a reflex set up in the joint which derives its nerve supply from the same source as do the muscles. By immobilisation nothing is done to counteract this wasting. Of recent years there has been a marked tendency to reduce the period of immobilisation considerably, and it is now no uncommon event for a case of dislocation to be recommended for mobilisation and massage from the outset.

The treatment of recent sprains and dislocations is very similar to that prescribed for any case of fracture in the vicinity, the only differences being that special muscle groups usually call for extra attention in devising treatment, and that treatment can progress more rapidly.

After dislocation there is always spasm of the muscles controlling the joint. This is a reflex attempt on the part of the muscles to prevent the bone slipping any further. In other words, it is nature's method of attempting to secure the immobilisation of a structure which is no longer in its normal position. Once the dislocation is reduced the need for this protective reflex is diminished, being now only necessary in so far as it is called for to prevent undue movement in a joint which is suffering from a severe traumatic arthritis. Thus the dislocation, when reduced, amounts to nothing more than a sprain of sufficient severity to tear one or more ligaments.

The masseur will never be called upon to treat a case of dislocation until it is reduced. Many medical men would be surprised at the ease with which some dislocations can be reduced spontaneously after massage has been performed for only a few minutes. This particularly applies to dislocations of the shoulder.

The general indications for treatment after dislocation will be plain from what has been said in the previous chapters, and all that is necessary is a short recapitulation.

For the relief of pain and of such spasm as may be present (after reduction in the case of dislocations, or after the ordinary manipulation performed for diagnostic purposes in the event of sprains) surface stroking is the one thing needful. The limb must be maintained in a position of perfect ease and comfort, and therefore in one which does not tend to recurrence of dislocation, or to the stretching of any ligaments that may have been injured.

The stroking also tends to counteract any inimical stimuli set up by the injury, and so helps to restore the vaso-motor tone and to prevent muscle wasting. How far these two results are interdependent it is impossible to say.

Deep stroking may be used at once as a further aid to the circulation, and any form of compression massage may be added for local treatment wherever it seems to be indicated, as an aid to the removal of local effusion before it has had time to organise. It will be remembered that this is the first care of the masseur if immediate treatment of a sprain is demanded, and then it is given with the additional motive of stopping haemorrhage from any vessel that may have been torn. The kneading in this event is to be followed by pressure by means of a thick pad of wool and a bandage, before the remaining treatment is undertaken.

Mobilisation of all joints in the limb that have not sustained injury may be freely administered from the outset, and all relaxed and active movements that do not tend to lay any stress on the torn structures in the neighbourhood of the injured joint may be prescribed.

Dislocations of the clavicle, fortunately rare, are easy to reduce, but it is excessively difficult to maintain the reduction. Thus no movement must be administered or allowed to any part of the limb above the elbow until explicit instructions are given. Many surgeons elect to disregard the deformity. In this event mobilisation should proceed apace. Should it be decided to try to ensure the reduction of the acromio-clavicular joint, a very special technique is required. The treatment, though difficult to carry out and irksome to the patient, is one that is commonly crowned with success. If it fails the patient is little, if any, the worse, and he has been given a good chance of complete recovery. The essentials are as follows. Reduction, which is easy, is performed with the patient recumbent. A firm pad is placed just in front of, and a second just behind, the joint. A pressure ring is placed round the olecranon, and a loop of bandage is tied as firmly as possible over the two pads and round the olecranon. The knot rests between the pads. The hand rests so that the thumb and first finger embrace the front of the neck. A sling is then arranged as shown in Fig. 77, p. 151, but the elbow is brought further forward over the front of the chest. The difficulty is to ensure that the loop, on which the stability of the joint depends, remains in position. The free use of safety-pins, which fix accessory loops round the trunk and the arm to the primary loop, affords the only solution of the problem. The whole is then stabilised by the free use of flannel bandages to fix the sling to the trunk, the turns of which are fastened to the sling and to one another by safety-pins. This fixation must be continued for four weeks without relaxation other than for daily treatment. The use of a sling is required for six weeks. The position is one that is cramped and uncomfortable, and daily treatment is essential if undue stiffness throughout the limb is to be avoided. The surface bandages are removed, and then the patient is placed recumbent. Massage should include the whole of the neck, and the pectoral region in turn, and the whole of the upper limb. The area round the origin of the deltoid calls for special attention. Free movement may be given to the elbow and all joints distal to it, great care being taken to ensure that no portion of the weight of the upper extremity is allowed to exert a downward dropping influence on the point of the shoulder. Active movements should be prescribed for rotation of the forearm, for the wrist, and for all the joints of the hand. When movement of the injured joint is prescribed, treatment may proceed as if the injury had been only a sprain, but mobilisation must proceed rather more gradually. If the sterno-clavicular joint has been dislocated similar treatment should be devised, but the prospect of maintaining the reduction of the joint would be far more speculative, and it is usually best to ignore the displacement. Sprains of the clavicular joints are rare; if treatment is ordered it should proceed as for dislocations, but free movement may be administered to the shoulder. This must be limited in the earlier stages to elevating the arm through a range of movement that is just less than a right angle. Shrugging of the shoulders may be commenced in about three days, and then the elevation of the arm may proceed by slow stages. Ordinary underhand use of the arm may be allowed from the outset, but the elbow should be supported on a sling for the greater part of the day, and the lifting of weights is prohibited. The pectoralis major and the deltoid call for special care in devising exercises.