Your team was tasked with setting up an observation post in the Hindu Kush mountains. As you complete the mission and descend down a snow covered slope, one of your team members slips and slides. He is able to self-arrest using an ice axe. Unfortunately he sustains an injury to his right shoulder.
After recovering him to a safer position, you notice he is in a lot of pain, and he has poor range of motion in his right shoulder. He holds his right arm in slight abduction and external rotation. There are no neurovascular deficits. You pull out a lightweight ultrasound probe from your ruck and you hook it up to the screen of your smartphone. The images obtained confirm your clinical suspicion. You choose to apply the Cunningham technique for the treatment of his injury as it does not require any special accommodations. You confirm the procedural success using ultrasound.
- What kind of injury did the patient sustain and what procedure was applied to fix it?
- Describe the anatomical change before and after the procedure.
- What is Cunningham technique and why would you choose it in the austere settings?
Your patient self-arrested using his ice axe, and he did not fall. You would think he is more likely to have a tear, sprain, strain or a dislocation of his shoulder, rather than a fracture. You recover him to a safer position in the proximity of the incident site and perform a focused exam. He is in a lot of pain and has poor range of motion in his right shoulder. He is holding his right arm in slight abduction and external rotation. Based on the mechanism of injury and the appearance of his shoulder on inspection (which looks just like in this random Google image on the left), you suspect an anterior shoulder dislocation. You perform a focused neurovascular exam and you conclude he is intact from that standpoint. His arm is warm and well-perfused, and he has normal distal pulses. You remember that peripheral nerve injuries are common in this setting, because of the proximity of the brachial plexus, but no such issue is clinically apparent in your patient.
The analgesia you have provided is not cutting it! He is cursing and moaning quietly in pain. If this is a dislocation, you know he needs a reduction! And now what?
The exfil point is still rather far away, and you need to make it before sunrise. The last thing you want is carrying this guy and his gear in such a steep and rugged terrain. This would substantially delay your march, and potentially jeopardize the extraction. So what can you do?
SONOGRAPHiC MiSSiON SUPPORT
In order to confirm the diagnosis of anterior shoulder dislocation you place the ultrasound probe of your choice (linear or curvilinear would be best) posteriorly on the patient’s shoulder in transverse orientation. Here you can clearly see that the humeral head is displaced anteriorly in relation to the scapula (with glenoid). You scan the humerus as well & confirm there is NO associated fracture. You note:
- NO cortical disruption or step-offs
- NO cortical elevation (bump)
- NO angulation
- NO hematoma
Hindu Kush mountains at night are no place for procedural sedation before shoulder reduction. Performing even an ultrasound-guided joint injection would likely prove quite challenging as well. But you happen to know a great technique that does not require any special accommodations, namely the CUNNINGHAM TECHNIQUE.
You kneel in front of your patient and ask him to grab the shoulder strap of your ballistic vest – very handy SOF-modification of the Cunningham technique (Karol’s brilliant idea!). Just like in the video above, with one hand you apply steady downward traction onto the patient’s arm. With the other hand you massage the trapezius, deltoid and biceps muscle sequentially, repeating this process and concentrating on the biceps. You can generally see and feel it, when the humeral head relocates itself (see video after 50 sec). It’s a drug-free technique . In the reference article they talk about anterior dislocations, but we have successfully used it for posterior dislocations as well.
A quick follow-up scan to confirm reduction allows you to see that the humeral head is definitely back where it belongs – namely articulating with the glenoid fossa of scapula.
Multiple studies [2,3] have shown that ultrasound is a great tool in the management of shoulder dislocations. It turns out that this application can be easily taught even to non-medical trainees . Therefore it is yet another argument to augment POCUS training for the SOF medics!
- Cunningham N. A new drug free technique for reducing anterior shoulder dislocations. Emerg Med. 2003; 15: 521-4.
- Akyol C et al. Point-of-care ultrasonography for the management of shoulder dislocation in ED. Am J Emerg Med. 2016; 34: 866-70.
- Abbasi S et al. Diagnostic accuracy of ultrasonographic examination in the management of shoulder dislocation in the emergency department. Ann Emerg Med. 2013; 62: 170-5.
- Shadi L et al. Pilot Study to Determine Accuracy of Posterior Approach Ultrasound for Shoulder Dislocation by Novice Sonographers. West J Emerg Med. 2016; 17: 377–382.
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