Cunningham Technique for dislocated shoulder reduction: A Resident Clinical Pearl

Rebecca Fournier, PGY1 

Family Medicine, Dalhousie University

Reviewed by Dr. Chris Doiron

Copyedited by Dr. Mandy Peach

Case

38yo woman presenting with right shoulder pain after falling on ice. Unable to adduct right arm across body. Pain is minimal when resting quietly. Xray confirms anterior dislocation. You recently read about a sedation sparing technique to reduce her shoulder and decide to attempt it.

The Cunningham technique has been shown to be an effective and simple method to reduce a dislocated shoulder. The technique is based on the theory that the humeral head remains outside the glenoid fossa due to tension in the muscles surrounding the shoulder, primarily the biceps. Without the use of sedation or analgesia, the Cunningham technique relaxes the muscles to encourage self reduction. When used as the first technique of choice, Puha et al (2016) found a success rate of 76.9 compared to more traditional methods at 87%+. However, attempting Cunningham technique first allowed avoidance of sedation and was not found to increase pain or duration of hospital stay.

Cunningham Technique

A. Patient Selection and Preparation

1. Ideal patient is calm, in minimal pain, able to take direction, understands and willing to participate in procedure.
2. May consider Ativan 0.5 to 1 mg prior to procedure with goal for calm, thoughtful patient able to participate in the reduction. In most cases, Ativan is not required for a successful reduction

B. Patient position

1. Performed with awake, seated patient. Encourage good posture to maximize success
2. Patient and examiner sit opposite one another eye to eye
3. Patients arm position

a. Held adducted at side: critical to success, may be limiting if patient uncomfortable in this position or body habitus restricts adduction at the side.
b. Elbow flexed to 90 degrees

4. Examiner position
a. Examiner rests one hand firmly on top of the patient’s dorsal forearm, applying downward pressure
b. Opposite hand will perform massage aspect of technique

C. Technique
1. Examiner applies gentle, steady pressure downward on dorsal forearm
2. With free hand, examiner massages upper extremity proximal muscles

a. Start at deltoid and trapezius
b. Move distally to biceps and triceps

3. As the patient’s musculature begins to relax, some may experience apprehension.

a. Patient positioning: an awake, seated patient. Encourage good posture with shoulders up and back + chest pushed forward to maximize success.

b. Gently reassure patient that this sensation indicates progress and continued relaxation is key to success
c. Premedication with Ativan prior to procedure may additionally facilitate this transition

4. Anticipate Shoulder to spontaneously relocate

a. May take as long as 15 minutes to relocate
b. Often times an audible “clunk” is not heard, check often to verify if reduction has been successful

5. Confirm reduction with post procedure xray

Take away points:

– Requires no sedation (requires awake patient!) or analgesia
– Pick the right patient! Must be calm, able to take direction, willing to participate, and trust provider
– Attempting Cunningham procedure first avoids risks of sedation and analgesia without increasing length of stay
– Cunningham method is all about positioning and relaxation; let the humeral head find its way back to the glenoid. Check out the videos for a step by step by visual.
– Confirm reduction with post procedure xray

References

Gudmundsson TH, Bjornsson HM. [Reduction of shoulder dislocation with the Cunningham method]. Laeknabladid. 2017 Sep;103(9):373-376. Icelandic. doi: 10.17992/lbl.2017.09.150. PMID: 29044033.

Puha B, Gheorghevici TS, Veliceasa B, Popescu D, Alexa O. CLASIC VERSUS NOVEL IN REDUCTION OF ACUTE ANTERIOR DISLOCATION OF THE SHOULDER: A COMPARISON OF FOUR REDUCTION TECHNIQUES. Rev Med Chir Soc Med Nat Iasi. 2016 Apr-Jun;120(2):311-5. PMID: 27483710