Muscle spasm is the enemy, and force feeds the spasm. Every modern technique is a different way of persuading the same muscles to relax long enough for the humeral head to slide home — slowly, and without anyone bracing a foot against the bed.
This page covers the anterior dislocation, which is nearly all of them. Posterior and inferior dislocations are a different conversation and a lower consult threshold.
Options range from nothing (habitual dislocators) through intra-articular injection to procedural sedation — agents and dosing per your institutional protocol. The technique below works best on a calm patient.
Supine for external rotation. Sitting upright for Cunningham. Prone with the arm hanging for Stimson if you have time.
Talk continuously, move only when the patient lets you, and stop when they guard. Every technique fails against active spasm.
Supine · elbow adducted and flexed 90° · rotate the forearm outward over 5–10 minutes
Keep the elbow tight against the patient's side, support the wrist, and let the forearm fall slowly outward (Fig. 1). Move only between waves of spasm; stop every time the patient tightens. Most shoulders reduce quietly before full external rotation — often without the dramatic clunk anyone was waiting for.
Patient sitting · arm at side, elbow flexed · massage trapezius, deltoid, biceps
Sit face to face. The patient rests their wrist on your shoulder; ask them to sit tall, pull the shoulder blades back, and relax. Massage the trapezius, deltoid, and biceps in turn. As the spasm melts, the head slides back in with no traction at all. Works best on the analgesia-naive, cooperative patient — and fails fast on the one who can't relax, which is your cue to switch techniques rather than push.
Prone or sitting · rotate the scapular tip medially while the arm hangs or is gently tracted
Reposition the socket instead of the ball. With the arm hanging (prone, Stimson-style, with a light weight) or held in gentle forward traction by an assistant, push the inferior tip of the scapula medially while stabilizing the superior border. High success, minimal force, and it combines naturally with either technique above.
Re-examine · post-reduction imaging · sling
Reduction usually announces itself: the shoulder contour rounds out, pain drops, and the patient can reach their opposite shoulder. Re-document the axillary nerve and distal exam, confirm with x-ray or POCUS (the posterior approach shows the head seated in the glenoid), and place a sling.
| Item | Plan | Notes |
|---|---|---|
| Immobilization | sling | Comfort-based duration, typically 1–3 weeks; prolonged strict immobilization has fallen out of favor |
| Follow-up | ortho / sports | Within ~1 week. Young first-time dislocators have high recurrence and may be surgical candidates |
| Age > 40 | cuff check | Rotator cuff tear accompanies a large share of older first dislocations — arrange examination once the pain settles |
| Post-reduction film | always | Confirms position and catches the Hill-Sachs or bony Bankart the first film missed |
| Failed bedside attempts | escalate | Two or three gentle failures means sedation or orthopedics, not more force |
A continuous, calm narration — "let it get heavy, I'll stop whenever you say" — relaxes muscle better than most drugs. The clinicians with the highest no-sedation success rates are the ones who never stop talking.
A posterior shoulder view confirms the dislocation before you start and the reduction after you finish, without waiting for radiology twice. Pair it with the exam, not instead of it.
Deltoid-patch numbness discovered after the reduction is now your complication unless you documented it before. Two exams, both in the chart, every time.
Force against a guarding patient produces fractures, cuff tears, and failed reductions. If nothing has moved in ten patient minutes, change the technique or the analgesia — not the effort.
The arm locked in internal rotation after a seizure or electric shock is posterior until proven otherwise — and it hides on a single AP film. Get the axillary or scapular-Y view; don't apply anterior techniques to it.
The patient who has done this eight times can often tell you which technique works, and may reduce with reassurance alone. Believe them, and spare them the full trauma workup their x-ray history doesn't need.
A starting template for the procedure note. Text in brackets [ ] and pick-lists in { } are fields to complete. Save it as a SmartPhrase, then edit every field to match the actual procedure.
PROCEDURE: CLOSED REDUCTION, SHOULDER DISLOCATION
Side: {right : left} Direction: {anterior : posterior}
Mechanism: [***] First dislocation: {yes : no, # prior ***}
Consent: {verbal : written} consent obtained; risks including
failure, fracture, and nerve injury discussed.
Timeout performed. Operator: @ME@
Pre-reduction: axillary nerve sensation {intact : ***},
deltoid function {intact : ***}, distal pulses {intact : ***}.
Imaging: {x-ray : POCUS : none} — {no fracture : ***}.
Analgesia/sedation: [per institutional protocol ***]
Technique: {external rotation : Cunningham : scapular
manipulation : ***}. Reduction achieved on attempt #***
{with palpable clunk : with return of contour and comfort}.
Post-reduction: axillary nerve {intact : ***}, distal
neurovascular {intact : ***}. {X-ray : POCUS} confirms
concentric reduction, {no new fracture : ***}.
Sling applied.
Complications: {none : ***}
Disposition: orthopedic follow-up in ~1 week; sling for
comfort; return precautions given.
Electronically signed: @ME@ @TD@ @NOW@
Sample template only — not a validated institutional SmartPhrase. Verify wording, consent, and attestation requirements against your department's documentation, coding, and compliance policies before clinical use.