The Cunningham Technique for massaging a shoulder dislocation back into place
Resident Clinical Pearl (RCP) February 2019
Renee Amiro – PGY2 FMEM Dalhousie University, Saint John NB
Reviewed and edited by Dr. David Lewis.
Case
A 53-year-old man comes in to the emergency department after having fallen at work and “hurt his shoulder”. Clinically, it is assessed as an anterior shoulder dislocation and he is sent to x-ray which confirms your diagnosis.
Traditionally, the way to reduce a dislocated shoulder involves procedural sedation and some pulling on the arm. While it may save the patient some pain, procedural sedation is not without its risks to the patient and has high staffing needs. Learning some less risky techniques for shoulder reduction can make it safer for your patient and less time intensive for you and your staff!
Anatomy
The shoulder is an inherently unstable joint. The glenoid is shallow and only a small portion of the humeral head is articulating with the glenoid in any position. The rotator cuff provides additional support to the shoulder joint.
Mechanism of Injury for an Anterior Shoulder Dislocation
Most commonly it is a blow to the abducted, externally rotated, and extended arm.
Less commonly a blow to the posterior humerus or fall on an outstretched arm.
Clinical Exam
The arm will be slightly abducted and externally rotated. It will be lost of the normal rounded appearance of the shoulder.
Examination of the axillary nerve and peripheral pulses are essential when examining a patient with an anterior shoulder dislocation before and after reduction.
Imaging
On AP radiograph the head of the humerus will appear medial to the glenoid. On a lateral radiograph it will appear anteriorly displaced. Take care with posterior dislocations as these can appear in joint on the AP, and may only be apparent on the lateral Y view.
Figure 2. radiograph of an anterior shoulder dislocation.2
Don’t forget you can use PoCUS to triage shoulder injuries too:
PoCUS Triage Shoulder Dislocation
Based on your clinical examination and imaging, you have determined that this patient indeed has an anterior shoulder dislocation. You have decided to avoid procedural sedation if you can and attempt reduction with the Cunningham technique!
The Cunningham Technique
Step 1
- Inform the patient of what you are going to attempt. Tell them that their cooperation is necessary for success. Try and relax the patient by getting them to do deep, slow breathing.
Step 2
- Sit the patient up with the back straight and shoulder blades pulled back. You can use a bed or a chair, whatever is easiest and most comfortable for both you and the patient.
Step 3
- Get the patient to support the arm and bring it in to the best position to facilitate reduction. That location is typically with the arm abducted and pointing down with the elbow flexed at 90 degrees with the forearm pointing horizontally and anteriorly.
Step 4
- Sit opposite the patient and place your hand on their elbow in between their body and their arm. Rest their forearm and hand on your arm.
Step 5
- Apply steady downward traction with the weight of your forearm. Keep the gentle weight on the arm through out. Should now be causing pain as this will cause the muscles to spasm.
Step 6
- Massage the trapezius, deltoid, and biceps muscles in sequential order. Repeat this process over and over. Your thumb should be anterior with four fingers posterior as your massaging these muscles. Most times you will not get the traditional “clunk” sound so frequent reassessments are necessary to see if the shoulder has been relocated.
YouTube Video Link of Cunningham Technique
The Bottom Line
The Cunningham technique can be used as a safe, successful and less resource intensive procedure to relocate an anterior shoulder dislocation. Patient engagement and cooperation is essential in its success.
Similar Alternative to the Cunningham Technique (The Sool’s Method):
References
- Cunningham N. A new drug free technique for reducing anterior shoulder dislocations. Emerg Med (Fremantle). 2003 Oct-Dec;15(5-6):521-4. PMID: 14992071.
- Sherman, S. (2018, August). Shoulder dislocation. Retrieved March 01, 2019, from UTD
