Easy ways to resist change in medicine.

(Hippocrates, Stimson) leverage techniques (Kocher, Milch), and scapular manipulation. Kocher’s manoeuvre was originally described in 1870. The affected arm is flexed at the elbow and adducted against the side of the body. The forearm is rotated externally and the upper arm lifted in a sagittal plane as far as possible and finally internally rotated. There have been many adjustments to this widely used technique, especially as the additional torque resulting from adduction and internal rotation have been associated with humeral shaft fractures in elderly people. 9 To perform Kocher’s manoeuvre the surgeon must abduct and externally rotate his own arm, this means the fibres of the sternocostal head of his pectoralis major are maximally stretched. If a patient is not well sedated or has not received adequate analgesia he or she is more likely forcefully to resist the reduction. This results in a sudden uncoordinated eccentric contraction of the surgeon’s pectoralis major muscle, which in our case resulted in a pectoralis major rupture. If adequate sedation and pain relief are not possible, reduction under general anaesthetic may be necessary to minimise the risk of complications for both the patient and the doctor.