Anterior Shoulder Dislocation

– An Approach to Reduction

by Dr Anand Senthi

First published 10/11/26

The flowchart below illustrates an approach to anterior shoulder dislocation reduction. This represents a simplified adaptation of the excellent algorithmic approach provided by an expert in the field, and creator of the Cunningham technique, Dr Neil Cunningham, Specialist Emergency Physician.

The flowchart design intends for clinicians to proceed down along the flowchart if not achieving successful reduction.

Positions & Techniques described in the Flowchart

• Adduction Techniques
  • Cunningham description and video
    • Includes description of Analgesic Position 1
  • Kocher’s description and video
• Abduction Techniques
  • Zero Position (aka “Modified Milch) description  and video
    • Includes description of Analgesic Position 2
  • Scapular Rotation description in seated position and video in prone position
    • With preceding Stimson (video)

Numerical notes to pathway:

1. Depending on the sub-type of anterior shoulder dislocation, the patient will either be able to comfortably adduct their humerus or not, and the choice of first reduction techniques can be rationally based around this. Usually either no analgesia or minimal analgesia/sedation (e.g. nitrous oxide or methoxyflurane) are required when commencing the pathway assuming the appropriate positioning and techniques are used.
2. For the patient that CAN adduct:
   1. Analgesic Position 1 is essentially the first stage of the Cunningham technique.
   2. The Cunningham technique generally requires no analgesia and positions the patient perfectly to attempt Kocher’s technique if it fails.
   3. Consequently the represented linear sequence is most practical.
3. For the patient that CAN’T adduct:
   1. Either technique – Zero or Scapular Rotation – can be used first and if unsuccessful try the other.
   2. The Analgesic Position 2 is most useful as a prelude to the Zero position, though can be used as a prelude to Scapular Rotation, if the latter is performed in the seated position.
   3. Practically the Scapular Rotation technique tends to be easier to execute in the prone position, in part due to greater ease palpating and rotating the tip of the scapular and because the Stimson technique can be used as prelude. In this case, skip Analgesic Position 2. However the prone position may not be possible in some patients (e.g. elderly, obese, distressed).
4. The optimal time to perform an Xray is unknown
   1. Where the diagnosis is very likely based on history, examination and experience of the treating clinician, it is generally reasonable to commence the pathway without an xray.
   2. Alternatively where the diagnosis is in question due to atypical history,  non-confirmatory examination (e.g. lack of acromial step) or risk factors for fracture (e.g. elderly, osteroporosis, metastases) an early xray before reduction may be preferred.
   3. The recommended techniques, if performed as described with minimal or no analgesia, are very low force techniques that are unlikely to cause harm in the event the diagnosis is incorrect or complicated (e.g. humeral fracture).
   4. However if the flowchart has been followed, and the first 2 recommended techniques have failed an xray should be performed to confirm the diagnosis and rule out fractures.
5. Analgesia/sedation
   1. The degree to which analgesia/sedation can be increased will depend on clinical resources, skill set and the patient’s clinical state and co-morbidities
6. Retry and/or change techniques
   1. With additional analgesia/sedation, the previously attempted techniques may now be successful and the techniques of the opposite arm of the flowchart may also be possible.
   2. Alternatively, Dr Cunnigham advocates choosing further techniques based on specific measurements taken on the xray in his Algorithmic approach.
   3. If in doubt or struggling, seek expert help.

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