Acute elbow dislocations: current concepts

After shoulder, elbow is the second most frequently dislocated joint: it is mandatory for clinicians to know the correct approach for the best management of these patients. Falls and traumatic sports are the mean cause of acute elbow disloca-tions, and the second decade of life is the most affected. The elbow presents two group of important stabilizers, essential for its stability: in particular, the highly congruent ulno-humeral joint, the lateral ulnar collateral ligament and the ante-rior bundle of the medial collateral ligament are the primary static constraints responsible for elbow stability. Two main pathological mechanisms have been described in literature, the "Circle of Horii" and the "Ladder Concept," but further investigations are needed to better understand every pattern of elbow dislocation. Simple dislocation, without associated fractures, can be grouped by the direction of the forearm dislocation. Complex dislocations are often difficult to classify: the use of specific classification systems for each fracture may lose the whole instability picture, so in the last years has been developed the "Three-Column Concept." Its practical application led to the description of the Wrightington clas-sification, useful diagnostic and preoperative planning tool. When recognized in the Emergency Department, an elbow dislocation needs an accurate neuro-vascular assessment, standard X-rays views and eventual CT-scan evaluation avoid to under-estimate limb or life-threating conditions. Then, the best setting for the reduction maneuvers requires the patient sedation or narcosis and a dynamic fluoroscopic control to immediately evaluate the residual elbow instability. In a stable elbow, an articulated bracing system allow the prompt mobilization controlling the eventual degrees of flexion or prono-supination with residual instability. In an unstable elbow, an appropriate assessment of the instability direction and the classification of the associated bone fractures lead the treatment choice: the recent "Three-Column Concept" and its de-rived Wrightington Classification, helps to better understand the relationships between fractures, pattern of instability and required surgical procedures. Both bone and soft tissues structures may be the object of repair, reconstruction, or stabili-zation to achieve the treatment goal for the best outcomes: an early mobilization with the less possible residual instability.