Post by Graham Walker from the Central Line Blog
I, sir, am a convert.
I had read about Dr. Cunninghams technique at his website, shoulderdislocation.net. I was amazed at his videos, but honestly didnt believe them. Painless? No pulling? And no procedural sedation? I didnt think it was possible.
Until last week.
A 16 year-old boy came into our busy Peds ED after having been pushed, and had fallen onto the shoulder; he was neurovascularly intact but clearly out. He was in pain as I unwrapped the EMS triangle gauze wrap and placed him in a shoulder sling, but was very calm, not screaming or tearful, and I thought, todays the day to try this. I gave him a shot of subcutaneous morphine, and by the time he was back from x-ray, he was resting comfortably. I explained my two options like this: I have one technique that I can try right now, it will have no pain, and can try to get your shoulder back in in about 5 minutes. And if that doesnt work, we will put in an IV, and give you some medicines to make you sleepy, and then put it in that way. Wanting no needle for the line, he wanted to try the Cunningham technique. Literally 3 minutes later, it was reduced.
Dr. Cunningham does a much better job of explaining his technique at his site than I would, so Ill recommend everyone to head over there and read through it, but after it worked last night, I was on Cloud 9. None of my colleagues believed me. Painless? No sedation? No way. (This was especially satisfying and helpful, as I was also managing a little girl with a spiral tibia fracture that needed procedural sedation for some reduction; it would have been nursing suicide to tie up two nurses for two procedural sedations. We were being triaged a good 7 patients an hour at the time.)
I do want to share several tips and suggestions on this technique:
- Read through Dr. Cunninghams analgesic positions. There are essentially two positions in which a patient will hold their arm if its dislocated, and these are positions that are pain-free for the patient. More on position 1 and position 2.
- Watch the videos a couple times. They really are amazing.
- You have to have a calm, compliant patient, and they have to trust you. The technique truly is painless, but if they dont trust that you arent going to hurt them, or theyre anxious or tense, its not going to work. I tried this technique a few weeks ago with an obese, very tense woman (despite narcotics) and it didnt work. I had to sedate her with a tiny touch of Fentanyl/Versed, and it popped in immediately with 30 seconds of the FARES technique.
- Ive emailed back and forth with Dr. Cunningham for some clarifications that I wanted to share with you about his technique. The most common mistakes?
Patient position shoulder slumped forwards or to the side (abduction). You can massage all you like, the humeral head wont slide laterally in this position. Again sit straight up, lift your head up, chest out, shoulders back, relax as much as you can.Your position sat/knelt too far forwards or to the side, pulling patients humerus into anterior flexion or abduction.Traction the more you pull, the more the patient will pull against it, stopping relocation.Spasm at point of reduction prep your patient that the actual relocation might feel a bit strange (whatever technique you use) and that if they feel the shoulder move and it feels strange to just relax and let it move, if they spasm at this point it might hurt and abort the reduction (OK as long as you can explain this to them, take your time and go again).
What does shrug your shoulders mean to him? (I described this to my patient as When your teachers tell you youre slouching, and they ask you to sit up straight and fix your posture.)
Shrug I use the term shrug as the simplest way to describe to a patient what Im actually aiming for. Most patients will be starting with the shoulder slumped forwards, this has the effect of placing the scapula in an anterior position (rotated and anteverted). In this position the humeral head has to move a long way anteriorly past the glenoid rim before it can move laterally and reduce this basically means that it will not reduce in any of the humerus in adduction manoeuvres (mine, Kochers, external rotation etc). The scapular position you are aiming for is retroversion and a posterior position (glenoid rim moves back, little anterior humeral head movement required, can just slide laterally). Possibly a better way to word this is (to patient) sit straight up, lift your head up, chest out, shoulders back, relax as much as you can. (Try this on yourself, youll feel your own back, scapulae and shoulders moving where you want them). You definitely dont want them actively shrugging or nothing will move.
Dr. Cunningham also admits that we should always be tailoring our technique to our patient: If you find yourself spending >5 mins on massage (and happy that patient as relaxed as can be) then the problem is almost certainly positioning, try and visualise yourself and your patient from a few steps back to see what you can improve, or try a different technique.
- Update: A few more pointers from Dr. Cunningham. On my obese patient I had tried it with and failed:
It can be difficult/impossible to perform Kochers or Cunningham manoeuvre on obese patients simply because they cant adduct the humerus enough. This means that the articular surface of the humeral head is not opposed to the labrum (for an easy slide) and the anterior joint is under more tension. I normally prefer either a Milch or a scapular manipulation manoeuvre for the obese.
And on Analgesic Position 1:
this is the easiest way to get the patient into the position but the key is the relationship between the humeral head and the scapular glenoid rim. So in fact you can get this position with the patient on a chair, trolley or Ive done it with patient supine standing next to bed with one hand around mid humerus and the other holding the wrist keeping the elbow at 90 degrees and the wrist supinated. Asking the patient to put chest out and shoulders back at this point while massaging biceps does the trick. I have used this a couple of times with trauma awake patient with a cspine collar on who you really dont want to manipulate neck/shoulder or sedate.
A big thanks to Dr. Cunningham for his technique, for helping my patient (and of course, making me look like a total baller in the department). In the right patient, it works like a charm, and the 3 minutes you invest in talking calmly to the patient, gaining their trust, and helping them relax is worth the 20-30 minutes you save filling out sedation paperwork, hooking them up to the monitor, having the nurse draw up the meds, sedate the person, reduce the person, and then wait for them to wake up before they can get post-reduction films.
Dr. Cunningham is working on putting together some more videos shortly that provide tips and troubleshooting. I look forward to them!
Levitan on Incrementilization