We commonly see patients with shoulder dislocations in the Emergency Department. There are a myriad of approaches in relocating the joint, which includes scapular rotation, Snowbird, and Kocher maneuvers.
I recently stumbled upon the Cunningham technique after hearing about it from Dr. Graham Walker (of MDCalc fame) on TheCentralLine.org. There are some amazing videos from the ShoulderDislocation.net which illustrate how the maneuever works.
The underlying concept of the Cunningham technique is that lengthening and relaxing the spasmed biceps muscle allows for the humeral head to spontaneously slide just over the glenoid rim and back into the glenohumeral joint socket.
I was a little skeptical when reading this technique, but the videos are quite convincing.
Tips:
- Build trust with the patient that you won't hurt them.
- Start with the patient's elbow to his/her side.
- The trick is to adequately position the scapula before you start. Move the anteverted scapula posteriorly by having the patient sit up straight, puff out chest, pull shoulders back, and relax as much as possible in that position.
- Go slow.
- Points of maximal massage: Trapezius, Deltoid and Biceps muscle along mid-shaft of humerus.
- Warn the patient that when the humerus starts to move, it may feel odd but try to not to resist it.
While I haven't used this technique before, I'll be sure to give it a try. Physiologically, the procedure makes sense.
Great! Only emergency physicians can speak to the patient, and massage his shoulder, and perfom a non-painful procedure. I cannot image our orthopedics doing this!
ReplyDeleteFunny! Maybe there will be a more kindle, gentler generation of orthopedists, if we can make all relocations go in just by massaging the spasmed muscles.
ReplyDeleteThe second video features the Kiwi accent of LITFL's own shoulder whisperer Gerrard "Junior" Fennessy. Nice work, eh.
ReplyDeleteChris
Hello,
ReplyDeleteCould someone tell the success rate on unselected patients ?
Serious data or even rule of thumb estimate ?
I could not find any reference with numerous data.
Thank you
Axel Ellrodt, France
Based on NO literature or data whatsoever. Just "experiential data". I haven't had much luck on this yet (n=1). Good luck!
ReplyDeleteTo : Axel Ellrodt, France
ReplyDeleteHi Axel, the success rate is hard to estimate. Experienced practitioners may get the shoulder in about 90% of the time (there are so many confounders - environment, fractures, patient anxiety etc).
The key to non-analgesic techniques (such as the Cunningham or Kocher's) is to reassure the patient and to engage them - slowly, carefully, calmly.
If you have a look at shoulderdislocation.net, Dr Cunningham presents a case series of 5. His advice to me was "there is no single BEST technique - it depends on the patient (especially position)".
Hi Gerarrd: Thanks for commenting. I agree that it's patient (and user-) dependent. Keep up the great work at www.ShoulderDislocation.net!
ReplyDeleteUn metodo molto interessante. Ottimo.Lo faro' conoscere ai miei colleghi.ciao
ReplyDeletegaetano
Declaration of interest first up: Dr Cunningham is one of my bosses.
ReplyDeleteI have observed the technique being performed by him on several occasions with success and had a good look at his website.
I have tried on four or five patients now, unselected and have not achieved success with the technique alone, but I have found it has assisted me to move into a gentle external rotation as part of Kocher's and this has then reduced the dislocation without the need for medication and with good patient satisfaction in terms of comfort.
The strength of the technique is most definitely in the ability to win the confidence of your patient, including those who will have had previous dislocations and a variety of different experiences of attempted reductions.
Hi Mark: I too have had very little success with this technique. There really is no downside in trying carefully while building patient rapport. Concurrently, I order up the propofol in anticipation of traditional relocation techniques. I'll try your modification idea. Seems to make sense. Thanks!
ReplyDelete