Perfect the Shoulder Positioning Process

Patient Safety Patient Experience Orthopedics

By: April Smith, MPH | Contributing Editor

Published: 9/20/2021

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Safety, access and comfort are critical factors in preparing patients for successful surgeries.


Proper patient positioning before shoulder surgery prevents painful nerve and pressure injuries, and gives surgeons critical access to hard-to-reach areas of the joint space. Although surgeons often debate the clinical benefits of the beach chair and lateral decubitus positions, they can agree on the important role positioning plays in their abilities to achieve positive surgical outcomes.

• Beach chair. When placing patients in this position, sit them upright at angles that vary from 30 degrees to 90 degrees above the horizonal plane, with the head secured to the appropriate head rest. Make sure you have the ability to maneuver the upper extremity in a way that will grant proper access to the shoulder joint. “The shoulder blade needs to be off the edge of the bed,” says Edward W. Kelly, MD, MBA, a shoulder, elbow and sports medicine orthopedic surgeon at Twin Cities Orthopedics in Minnesota and Wisconsin. “That provides full mobility of the shoulder during surgery, so you can adduct the elbow to get excellent exposure of the humeral head.”

Dr. Kelly also advises surgeons to focus on how easy it will be to get patients into and out of the position. “I make sure that I can come in and out of the Trendelenburg position smoothly, so I gain exposure to the glenoid as needed,” he says. “I also tilt the patient away from me slightly to help keep them centered on the bed.” Finally, for stability purposes, it’s worthwhile to consider wrapping a co-band or an ACE wrap around the patient’s chest while padding their contralateral arm to keep them secure on the bed, adds Dr. Kelly.

Grant Garrigues, MD, a shoulder specialist at Midwest Orthopaedics at Rush in Chicago, says the beach chair position is a more anatomical position that provides greater visualization of the entire joint. He also points out it’s a setup that requires surgeons to focus closely on posture, padding and stability. “It’s important that the patient is straight on the table, and pressure points are properly padded, comfortable and supported. I also find it helpful to use an articulating arm holder for this purpose.”

• Lateral decubitus. When the patient lies on their side in a non-anatomical position, surgeons are granted better visualization of and access to lateral pathology during procedures. However, you have to be careful to avoid nerve issues around the patient’s armpit — particularly for longer cases. “In the lateral position, the patient’s neck and spine need to be neutral,” says Dr. Garrigues. “You should pad the peroneal nerve and use an axillary roll to protect the nerves in the armpit, because they can experience nerve compressions.”

In addition to keeping patients safe and secure in lateral decubitus, focus on the surgeon’s maneuverability and proximity to the anesthesia provider. “Surgeons must have clear access to the head of the patient’s bed, so they can work in both the front and back of the shoulder,” says Dr. Kelly. “Make sure that the patient is far enough up on the bed and that the anesthesia provider is not in the way.”

Safety and access

ACCESS GRANTED During arthroscopic shoulder surgery, the patient must be positioned in a way that affords 360-degree access to the joint.  |  Pamela Bevelhymer

Regardless of whether you’re placing the patient in the beach chair or lateral decubitus position, everything starts with patient safety. “The most critical aspect of positioning for shoulder surgery is patient safety,” Dr. Garrigues says. “Make sure that the patient is padded, relaxed, comfortable and supported, since they may be in that position for several hours.”

For instance, it’s essential to position the patient’s head in a neutral posture so they don’t wake up after surgery with a stiff neck or pinched nerve. “They’re coming in with shoulder pain,” says Dr. Garrigues. “We don’t want them to wake up with new pain somewhere else in their body.”

Proper patient positioning also requires allowing for extra time to make sure bony prominences are padded, so that the patient doesn’t develop pressure sores or nerve palsies. While these problems are typically temporary, they can usually be avoided with proper positioning and a little padding, says Dr. Garrigues. When patients are in the lateral decubitus position, elevating their head and shoulder a bit above the heart level and placing a tourniquet near the shoulder can limit intraoperative blood loss, says Dr. Garrigues.

There are several positioning aids on the market specifically designed to protect patients from injury and post-op discomfort — particularly for vulnerable areas such as the head and neck. It’s good practice to opt for only the aids that are backed by evidence-based research. Also, take time to review the manufacturer’s instructions for use for pads and supports with all staff who are involved in the positioning process.

While patient comfort is certainly the priority, don’t overlook the importance of ensuring surgeons are satisfied with how patients are positioned — and how the positioning impacts how well they can operate. It’s important to make sure your surgeons are in an ergonomic position, especially if they’re going to be operating for a few hours, says Dr. Kelly.

“Once I’ve positioned the patient, I position myself as though I’m operating to make sure that the setup is comfortable and I have the access I need,” he says. “I make sure the arm holder isn’t in my way, and the bed’s position and the patient’s inclination are to my liking.” 

One of the best ways to ensure patients are safe and comfortable during shoulder surgery is to put yourself in their shoes and attempt to see every aspect of the procedure from their perspective. “Whenever you position a patient, ask yourself, ‘Would I be comfortable in this position for a couple of hours?’” If the answer is probably not, readjust the patient accordingly.

Of course, it doesn’t help to have patients positioned safely and comfortably if surgeons don’t have sufficient access to vital anatomy during procedures. “Every shoulder surgery is different,” says Dr. Kelly. “During open procedures, the ability to move the arm and elbow in a manner that allows surgeons to expose both the glenoid and the humerus is key.” 

During arthroscopic procedures, surgeons need 360-degree access to the shoulder so they can operate from the front and back of the joint, says Dr. Kelly. “It can be difficult during arthroscopic surgery to access the very inferior aspect of the glenoid because the humerus head gets in the way,” he explains. 

The most critical aspect of positioning for shoulder surgery is patient safety.
— Grant Garrigues, MD

Total shoulder replacements demand setting up the patient so that the glenoid is clearly exposed and visible — which is no easy task, according to Dr. Kelly. “The most difficult part of a total shoulder replacement is the ability to expose the glenoid to put in the glenoid component,” he says.

Clear and constant visibility is key for the surgeon. During arthroscopic procedures, Dr. Kelly positions a monitor on each side of the surgical table so his view of the surgery is always in a direct line of sight as he moves around the patient. The setup also allows his assistant to view the action at all times.

Prevent common pitfalls

Stay attuned to common patient positioning errors — and ensure your surgical team avoids making similar lapses in best practices. “The best way to learn is from the mistakes of others, and the most common mistake I’ve seen is delegating patient positioning to someone who’s not properly trained,” says Dr. Garrigues.

Ideally, he says, the surgeon operating on the patient should be directly involved or in charge of the positioning. At the very least, they should assign responsibility to a member of the clinical team whom they trust implicitly. 

Ultimately, proper patient positioning is a critical part of the surgical process — a process where surgeons must do their utmost to put the patients at ease and allay their fears and concerns. “It’s all about trust,” says Dr. Garrigues. “During shoulder surgery, the patient is in a vulnerable position, and they trust that the surgeon and surgical team will take care of them. By paying attention to every detail, including patient positioning, we honor that trust.” OSM

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