There are literally dozens of methods emergency physicians can use to reduce a dislocated shoulder, but they all have one thing in common: they hurt. Some are less painful than others, but in most emergency departments, the majority of patients undergoing closed shoulder reduction need at least some level of sedation to help them manage their pain during the procedure.
That's why Graham Walker, MD, was so skeptical when he saw an online video in which Australian physician Neil Cunningham, MBBS, reduced a dislocated shoulder in less than two minutes, using only massage.
“I didn't believe it,” said Dr. Walker, the chief resident in emergency medicine at St. Luke's-Roosevelt Hospital in New York City. “A painless shoulder reduction with no pulling and no sedation?”
Impossible — or so he thought until early March, when he got the chance to try the technique for himself. The pediatric emergency room at St. Luke's-Roosevelt was swamped, and when a 16-year-old boy came in after having been pushed and fallen onto his shoulder, Dr. Walker decided to give the Cunningham technique a try to avoid tying up a nurse with a procedural sedation.
Within three minutes, the patient's shoulder was back in place. “I was amazed,” he said.
Dr. Cunningham's technique works like this: Seat the patient comfortably, as upright as possible, with shoulders relaxed. Supporting the affected arm, slowly and gently move the humerus into full adduction. Gently massage the trapezius and deltoids; this helps to relax the patient and reassures them that the doctor is not going to do anything painful.
Then, move on to gently massaging the biceps at the mid-humeral level. Ask the patient to shrug her shoulders, continuing the biceps massage. Wait for the patient to relax fully, and the humeral head will slip back into place. (Warn the patient that it may feel strange as this happens and not to fight against the movement.)
Dr. Cunningham, now a staff specialist in the emergency department at St. Vincent's Hospital in Melbourne, Australia, developed the technique while working in a busy ED that was often so full that he would see patients on gurneys in the ambulance bay and sitting in corridors. “While holding patients' arms waiting for analgesia to be drawn up, I found that I could relieve their pain with positioning and by encouraging them to relax the spasming muscles with a combination of talking and massaging the muscles,” he explains. “After shoulders started reducing faster than the analgesia could be drawn up, I returned to the anatomy books to work out both the different positions of structures, and the different forces resulting from overstretched ligaments, joint capsules, and spasming muscles.”
As Dr. Walker found, the technique is not difficult to learn. “The combination of humerus and scapular positioning and specific muscle massage is fairly straightforward to grasp,” Dr. Cunningham said. “I have seen emergency physicians surprise themselves with this technique when they find the correct position and reduce a shoulder in less than five minutes on a patient twice their size.”
Because the technique is so simple, painless, and requires no sedation, should it be used for all shoulder dislocations? Absolutely not, Dr. Cunningham said. He doesn't even always use it himself (although he starts with it in about 70% of cases). If the patient can't relax enough to cooperate, or the arm can't be adducted, for example, the approach won't work. “The technique should match the patient, not the other way round,” Dr. Cunningham said.
To maximize the chance of success, Dr. Cunningham takes time to prepare the patient before laying a hand on him. “Explaining to a patient what you are going to do and that you are not going to pull their arm at any point is really important to reduce anxiety,” he says.
Instead of supporting underneath the affected limb, he grips the forearm or elbow with gentle but steady pressure, which moves the humeral head back slightly toward its usual position, which reduces the patient's pain. ”Encouraging the patient to relax verbally and with massage, followed by slow, gentle movements will allow you to get to your starting position,” he said.
With some patients, you'll never get to this point — they're simply too agitated to attempt a technique like this. For them, analgesia and sedation is a must. “Using drugs in these patients is a recognition that muscle relaxation is going to be impossible otherwise, meaning that either your chosen technique will not work, or you will hurt your patient as they fight any movement you attempt,” Dr. Cunningham said. “Once you have sedated your patient, it is then important to use a technique suitable for your patient, not just pulling hard.”
In Dr. Walker's ED, the other residents and attendings are now looking for shoulder dislocations, eager to try the Cunningham technique for themselves. “I've had a patient for whom it didn't work,” he said. “She was obese and very tense, and just not a good candidate. But with the right patient, it's so simple and a great alternative to techniques that require sedation.”
The hardest part of the technique, Dr. Cunningham said, has been convincing others that it works. “There has been such a reliance on drugs and traction techniques that it can be difficult to persuade some people to change their thinking. But anyone who has reduced a shoulder within a couple of minutes with no drugs and no pain will certainly see the benefits of a non-traction technique.”
To view videos of the technique in action and read detailed instructions, visit Dr. Cunningham's website at www.shoulderdislocation.net.
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