Nonsurgical and Surgical Management of Forearm Pronation Deformity in Patients 21 Years of Age or Younger with Cerebral Palsy: A Systematic Review.

PURPOSE: To identify clinical criteria guiding surgical versus nonsurgical treatment, compare functional outcomes, assess complication rates, and evaluate the ability of each approach to enhance supination in children with cerebral palsy (CP).

METHODS

MEDLINE, Embase, and Cochrane Library were systematically searched to identify studies evaluating the treatment of forearm pronation deformity in pediatric patients with CP through June 2025. Inclusion criteria were clinical studies (RCTs, cohorts, case-controls) involving CP patients <21 years undergoing surgical or nonsurgical intervention for pronation deformity and reporting relevant outcomes. Studies were assessed using PRISMA guidelines. Data were extracted on demographics, intervention type, outcome measures, supination/pronation range, and complications.

RESULTS

Twenty-eight studies met the inclusion criteria. Treatment selection is guided by deformity severity, passive and active supination, functional impairment, and prior response to nonsurgical interventions (botulinum toxin A injections and therapy). Nonsurgical treatments are used in younger children with dynamic deformities and retained motor control, and are associated with short-term improvements that typically diminish over time. Surgical procedures are reserved for patients with static or progressive deformities or failed conservative care and consistently result in greater, more durable improvements in supination and function compared with nonsurgical methods. Pronator teres-based procedures demonstrated the most reliable enhancement of supination while largely preserving residual pronation. Complication rates were low across both nonsurgical and surgical interventions.

CONCLUSIONS

Management of forearm pronation deformity in patients under 21 years old with CP should be individualized based on deformity characteristics, functional goals, and prior response to therapy. While nonsurgical options may provide early or adjunctive benefit, surgical intervention offers more reliable and sustained improvements in supination and function, particularly when preservation of pronation is a priority. When maximal restoration of active supination is desired, and full passive supination is present, pronator teres rerouting appears to offer a modest but consistent advantage over alternative surgical techniques.

LEVEL OF EVIDENCE: Level IV: Systematic review of level I to IV studies.