Cunningham Shoulder Technique

Just as Jimmy Page couldn’t have enough strings to his guitar, the emergency physician can’t have enough strings to his shoulder relocation bow.

Great analogy, eh.

I was an instant convert to the FARES method for reducing anterior shoulder dislocations. Now I’ve learned of another method — the Cunningham method:

**I’ve been informed that the video actually shows the inadvertent Fennessy modification of the Cunningham technique. Hence the Kiwi accent and subtitles…See comments below!

This is the description of the technique:

• Inform the patient of the procedure and the fact that it will be painless. It is important to relax the patient and confident reassurance is the first step towards this.
• Sit the patient up with the back vertical. This can be done on a bed, chair or trolley, but preferably seated on a non-wheeled chair without arm rests.
• Carefully support the arm while it is moved into the correct position, allowing the patient to help with the other arm. The correct position is with the arm adducted (next to the body) and pointing vertically down, the elbow is flexed at 90 degrees so that the forearm points horizontally and anteriorly.
• The operator then squats/kneels to the side of the patient and facing the opposite direction to the patient. The operator then slips the hand between the patients forearm and body so that the patient’s wrist/hand is resting on the operator’s upper arm. Do not make pulling movements at any time as this will elicit pain and result in spasm.
• Apply steady, very gentle traction (the weight of the operators forearm is quite enough) directly downwards once the patient is settled and pain free. Keep this gentle weight on the arm throughout, stop if any spasm or pain. Usually resting with the patients arm in this position will start to reduce the pain of spasm.
• With the other hand, the operator then massages the trapezius, deltoid and biceps muscle sequentially, repeating this process and concentrating on the biceps brachii until the muscles are fully relaxed. A strong kneading of the biceps with the thumb anterior and the four fingers of the operator posterior to the arm is recommended. At this point the humeral head will relocate usually without any clear indication that the shoulder has reduced (no sound or ‘clunk’ feeling). This means that the shoulder must be observed/checked regularly to confirm when relocation has occurred (with shoulder exposed movement can be seen as the ‘step’ disappears.)

Further Reading

• The therapeutic clunk
• FARES method (shoulder reduction)
• Spaso technique (shoulder reduction)
• Spaso breaks his silence (Immobilization and reduction)
  

Reference

• Cunningham N. A new drug free technique for reducing anterior shoulder dislocations. Emerg Med (Fremantle). 2003 Oct-Dec;15(5-6):521-4.

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Chris Nickson

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of three amazing children.

On Twitter, he is @precordialthump.

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