Modified Cunningham Technique for Anterior Shoulder Dislocation

Comparison of the Standard Cunningham Technique and the Modified Cunningham Technique in Terms of Reduction Success and Emergency Department Discharge Time in Patients With Anterior Shoulder Dislocation: A Two-Center Prospective Randomized Study

Anterior shoulder dislocation is a common emergency condition that usually requires closed reduction in the emergency department. Several reduction techniques are used in clinical practice, and the ideal method should be effective, fast, easy to perform, well tolerated by the patient, and associated with a low need for sedation.

This two-center prospective randomized study compares the standard Cunningham technique with a modified Cunningham technique in adult patients presenting to the emergency department with anterior shoulder dislocation. Eligible patients were randomly assigned to one of two groups: standard Cunningham technique or modified Cunningham technique.

The main aim of the study is to compare the success rate of shoulder reduction between the two techniques. Secondary aims include comparing reduction time, pain level measured by the Visual Analog Scale, need for additional reduction maneuvers, need for sedation, emergency department discharge time, and procedure-related complications.

The study is designed to determine whether the modified Cunningham technique can provide faster and more successful shoulder reduction without increasing patient discomfort or complication risk.

Anterior shoulder dislocation is one of the most common joint dislocations encountered in emergency departments. Closed reduction is the standard initial treatment in suitable patients. Although several reduction techniques are available, many methods require traction, patient tolerance, analgesia, or procedural sedation. These factors may prolong the reduction process, increase emergency department workload, and expose patients to sedation-related risks.

The Cunningham technique is a seated, patient-cooperation-based shoulder reduction method that aims to facilitate reduction by relaxation of the shoulder girdle muscles and massage of the biceps, deltoid, and trapezius muscles. The modified Cunningham technique used in this study preserves the basic principles of the standard technique but adds a controlled positioning maneuver. In the modified technique, the patient's affected hand is placed on the volar aspect of the physician's elbow, while the physician supports the patient's elbow and applies gentle downward pressure to the antecubital region together with muscle massage. This modification is intended to provide better control of the extremity, facilitate muscle relaxation, and support reduction without forceful traction.

This was a two-center, prospective, randomized, open-label, parallel-group study conducted in emergency department settings. Adult patients presenting with acute anterior shoulder dislocation were evaluated for eligibility. Patients meeting the inclusion criteria were randomly assigned to undergo closed reduction using either the standard Cunningham technique or the modified Cunningham technique.

The reduction procedure was performed by emergency physicians according to the assigned technique. Reduction success was assessed clinically and confirmed by post-reduction radiographic imaging when clinically appropriate. In patients in whom the assigned initial technique was unsuccessful, further management, including additional reduction maneuvers, procedural sedation, or orthopedic consultation, was performed according to routine clinical practice.

The study was designed to evaluate whether the modified Cunningham technique improves the clinical efficiency of anterior shoulder dislocation reduction in the emergency department without increasing pain or procedure-related complications. No investigational drug, biological product, or medical device was used in this study.

Inclusion Criteria:

• Age 18 years or older
• Presentation to the emergency department with acute anterior shoulder dislocation
• Diagnosis of anterior shoulder dislocation confirmed by clinical examination and radiographic imaging
• Conscious and cooperative patients who are able to comply with the seated reduction procedure
• No associated mechanical pathology such as fracture, open wound, laceration, foreign body, or other traumatic condition preventing closed reduction
• Ability to provide written informed consent for participation in the study

Exclusion Criteria:

• Refusal to participate in the study
• Missing or unavailable study data
• Posterior or inferior shoulder dislocation
• Fracture-dislocation or associated fracture
• Open shoulder injury or significant laceration
• Foreign body or other mechanical pathology involving the affected shoulder
• Neurovascular deficit requiring urgent surgical or orthopedic evaluation
• Multiple trauma
• Altered mental status or inability to cooperate during the procedure
• Previous surgery on the affected shoulder
• Unsuitability for reduction in the seated position
• Requirement for immediate procedural sedation before the first reduction attempt