Shoulder Dislocation: Cunningham Technique. Carlo Arrigo, MD, M. Fanelli e F. Sguaizer, EN - Montichiari ED

Shoulder dislocation is one of the most common clinical situations in the emergency department. Emergency physician approach varies according to experience. There are various approaches in relocating the joint, which includes scapular rotation, Snowbird, and Kocher maneuvers.  During the last year, I stumbled upon the Cunningham technique after discovering it thanks to internet.
 
There are some amazing videos from the site ShoulderDislocation.net which illustrate how the maneuever works. MedEmIt also published a comment which had great success. (LUSSAZIONE DI SPALLA. PRIMA DI CHIAMARE L'ORTOPEDICO CON LE SUE MANONE TIRA E TIRA: PROVA LA MANOVRA DI CUNNINGHAM!)
 
To be honest, when I heard about this non invasive technique and watched the videos for the first time, I was so fascinated that I was convinced to try it as soon as possible. And now, the first tip:
If you are not sure you have understood how the maneuver works, do not try it. It will not work
 
Looking for scientific literature, it is possible to find a clear article published in 2005 by Dr. Cunningham (Techniques for reduction of anteroinferior shoulder dislocation - Emergency Medicine Australasia (2005)17, 463–471), an Australian emergency physician.
 
There are various kinds of shoulder dislocation.  The most common is anterior or subcoracoid dislocation Fig. 1 (70%) which is associated with subglenoid dislocation Fig. 2 (30%). Other types are more rare, caused by fracture and violent forces, and  we do not consider them in this report.
 
 

The technique

 
This technique addresses static obstruction by posteriorly directed shrugging of the shoulder. This uses the rhomboids to retrovert the scapula reducing the obstruction of the glenoid rim and labrum to the returning humeral head.
Some tips for better understanding how it works:
  • The patient sits without slouching in a hard backed chair, the affected arm adducted to the body and the elbow fully flexed.
  • The operator kneels next to the patient and places his wrist onto the patient’s forearm, the patient’s hand resting on the operator’s shoulder.
  • The trick is to be able to induce shrugging of the shoulders superiorly and posteriorly, which ‘squares off’ the angle of the shoulder (reducing scapular anteversion and the static obstruction of the glenoid rim).
  • The dynamic obstruction of the spasming biceps is actively reduced by massaging the muscle at the mid-humeral level.
  • No hurry, please. Be patient.
  • The biceps is massaged at mid-humeral level to specifically relax the muscle (removing dynamic obstruction). The head reduces quickly, without traction.
  • Alert the patient that when humeral head starts to move, he will feel pain which lasts few seconds. In that moment He needs to be concentrated so as to be more cooperative.
 

In conclusion

 
  • Choose the most appropriate patient.
  • Anterior dislocation (most common) and the cooperative patient make the maneuver effective.
  • Inform your patient clearly before, and help him during the technique.
  • If you have Entonox (Kalinox), USE IT!! It will help the patient to be more relaxed.
  • At the end you will feel a very good Doctor!!! (clap-clap-clap)
 
To demonstrate the technique we recorded a video of this maneuver. Go to the link below: 
 
 

Carlo Arrigo, Associate Editor MedEmIt - Senior Consultant in Emergency Medicine - Montichiari Emergency Department (Spedali Civili di Brescia) Italy

Morena Fanelli e Fabiana Sguaizer, Emergency Nurse - Montichiari Emergency Department (Spedali Civili di Brescia) Italy

 
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