From the Blogosphere
The Cunningham Technique
Erin Brumley, MD
3
2-year-old male with history of psychiatric illness and seizures presents with
left arm pain after a fall. Patient thinks
he slipped on ice, but is unsure. He reports
no LOC, no head pain, no neck pain. Does
not believe he had a seizure. No urinary incontinence, no tongue
biting. Has severe pain in left shoulder. Physical exam shows small
forehead abrasion, no c-spine tenderness, and decreased ROM to
left shoulder. He holds his arm internally rotated and adducted.
There is an obvious deformity to the left shoulder with a hollow
palpated anteriorly.
Three view x-rays ordered in triage read as negative for fracture
or dislocation, but limited by poor patient positioning.
I was pretty sure that it was dislocated, so I went ahead and ordered the definitive axillary view that they stress as all-important
during your orthopedic rotation.
As I was charting on another patient, the x-ray tech came over,
looking slightly embarrassed, and said that she was pretty sure she
had just reduced my patient’s shoulder as she was trying to get
him in the proper position for the axillary view. She said, “It was
amazing, he couldn’t move it, then pop, and he has full ROM now.”
Nice.
Two minutes later, got a phone call from radiology…Might have
missed a posterior dislocation…Looks great in the axillary view
now…Would recommend getting repeat normal films to be sure
that there was no fracture missed while it was not in proper position.
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LOUISVILLE MEDICINE
Ordered the repeat 3 view x-rays and went to make sure he was still
reduced. Found my patient still internally rotated, in pain, not able
to move, and still with the hollow anteriorly. Gently held his hand
and arm and before he realized what I had done, pulled slightly and
externally rotated and put it back in place. As I called for the sling,
he went to take his gown off and it slid back out as he extended his
arm and moved it anteriorly. Tried again to gently externally rotate
it, but he was now on to me and was tense and pulling against me.
Asked for suggestions other than sedation and got one from the one
and only Dr. Martin Huecker: “Try the Cunningham Technique.”
I went back in his room. He was looking a little wary. I told him
it’s not going to hurt; I was just going to massage his arm a little bit
to see if it will go back in. I held his left forearm in my left hand at
the elbow and, using my right hand, massaged first his trapezius,
then his deltoid, then his biceps, then his deltoid, then his trapezius,
then his deltoid….annnnnnnnnnnnd…..slid back in place. Patient
looked as surprised as I did. Immediately put him in a sling and
swathe. Got repeat x-rays in the sling.
He was in the department for about 30 minutes after that while
awaiting x-ray reads and his arm stayed reduced while in the splint.
No fractures on x-ray. He was discharged with Orthopedic followup
in the sling.
One can find a formal description of The Cunningham Technique on the blog “Life in the Fast Lane.” lifeinthefastlane.com/
cunninghams-shoulder-relocation/ LM
Note: Dr. Brumley is a second-year resident in Emergency Medicine
at the University of Louisville.