Restoring rotational balance of the paediatric forearm: lessons from post-traumatic malunion.

INTRODUCTION: Post-traumatic malunion of paediatric forearm fractures may lead to impairment of pronation and supination. Treatment decisions are traditionally based on radiographic alignment, although functional limitations do not always correlate with deformity on plain radiographs. Understanding the interaction between bony deformity, soft tissue contracture and growth related remodelling is essential for restoring rotational balance of the forearm.Current concepts:Impaired forearm rotation may result from angular or rotational malalignment, loss of the radial bow or soft tissue contracture. Two-dimensional radiographic measurements do not accurately predict functional impairment. Growth-related remodelling can substantially improve both alignment and rotation over time, particularly in younger children and fractures near active growth plates. Physiotherapy and splinting may address soft tissue restrictions. In persistent cases, three-dimensional analysis and patient-specific instrumentation allow more accurate correction of deformity and improved restoration of forearm rotation. Increasing evidence suggests that functional improvement depends not only on anatomical correction but also on restoring the balance between radius, ulna and interosseous membrane.

CLINICAL IMPLICATIONS: Management of post-traumatic forearm malunion should focus on restoring rotational balance rather than correcting deformity alone. Patient-specific evaluation that considers both anatomical deformity and soft tissue constraints may help guide treatment and optimize functional outcomes.