The Montecranon classification-a comprehensive treatment strategy for complex proximal ulna fracture dislocations

Area of Science:

• Orthopedic Surgery
• Trauma Surgery
• Elbow Biomechanics

Background:

• Complex proximal ulna fractures, including Monteggia-like and transolecranon fracture dislocations, require structured management.
• A novel Montecranon classification (MC) was developed in 2011, integrating ligamentous structures, coronoid process, and radial head assessment.
• The MC provides a systematic approach to classifying and treating these complex elbow injuries.

Purpose of the Study:

• To evaluate the clinical outcomes and reliability of the Montecranon classification (MC) for complex proximal ulna fracture dislocations.
• To assess the effectiveness of the MC in guiding treatment and predicting patient outcomes.
• To validate the MC across different experience levels of orthopedic surgeons.

Main Methods:

• Retrospective analysis of consecutive patients treated for complex proximal ulna fracture dislocations between 2011 and 2022.
• Classification of fractures using established systems (Bado, Jupiter, Mayo) and the new MC.
• Clinical and radiographic assessment at minimum one-year follow-up, including range of motion, patient-reported outcomes (EQ-5D-5L, Quick DASH, MEPS), and complication analysis.
• Interobserver and intraobserver reliability testing of the MC among elbow experts, young consultants, and novice doctors.

Main Results:

• Thirty of 43 patients met inclusion criteria, with 87% Monteggia-like fractures and 13% transolecranon dislocations.
• Mean follow-up was 4.2 years, with good functional outcomes (e.g., mean MEPS 93, mean arc 126°).
• Seventy percent of patients required secondary surgery, primarily for hardware removal; however, 90% achieved good to excellent final results.
• Interobserver reliability for MC was moderate to poor, while intraobserver reliability was moderate to good; novice surgeons benefited more than experts.

Conclusions:

• The MC, focusing on ligamentous structures, coronoid process, and radial head, is valuable for managing complex proximal ulna fracture dislocations.
• Despite a high rate of secondary surgeries, the MC-guided management leads to favorable clinical outcomes.
• The MC classification system appears more beneficial for surgeons with less experience in managing complex elbow fractures.