The management of forearm exostoses in children with HME remains a challenging aspect of pediatric orthopedics due to the variety of deformities and the potential for recurrence [8]. Our case series demonstrates that tailored surgical approaches can lead to significant improvements in both function and appearance, highlighting the importance of individualized treatment plans for these complex cases.

In Case 1, the use of ulnar lengthening effectively addressed the relative ulnar shortening, a common feature in Masada type I deformities. The gradual distraction technique allowed for controlled correction and resulted in substantial improvement in forearm rotation. This aligns with previous studies that have shown the efficacy of ulnar lengthening in restoring forearm function. For instance, Akita et al. reported similar improvements in forearm rotation and ulnar variance in their long-term study of forearm deformity correction in HME patients [9].

The more complex scenario presented in Case 2, with radial head dislocation (Masada type IIb), required a multi-faceted approach. The combined technique of exostosis excision, ulnar lengthening, and radial head reduction proved effective in addressing multiple aspects of the deformity. The significant improvement in elbow range of motion and pain resolution underscores the importance of addressing radial head dislocation in these cases. This finding is consistent with the work of Cho and Jung, who demonstrated the benefits of gradual ulnar lengthening combined with radial head reduction in patients with similar deformities [10].

The management approach in Case 3, involving simple excision of prominent exostoses, demonstrates that less invasive interventions can be appropriate in cases with minimal functional impairment. This strategy aligns with the principle of minimizing surgical intervention in growing children when possible. However, the observed mild recurrence underscores the need for long-term follow-up in these patients, as highlighted by Woodside et al. in their study on the natural history of multiple osteochondromas in the hand [11].

Our results support the notion that early surgical intervention can prevent progression of deformities and improve functional outcomes [12]. The significant improvements in range of motion across all cases suggest that surgery can effectively address the functional limitations associated with forearm exostoses. This is particularly important in the pediatric population, where early intervention may prevent the development of secondary deformities and degenerative changes.

The radiographic outcomes, particularly the improvements in ulnar variance and radial articular angle, corroborate the clinical findings. The correction of these parameters is crucial in restoring normal forearm biomechanics and preventing long-term complications such as chronic pain and degenerative changes. Gottschalk et al. have previously demonstrated the correlation between radiographic parameters and functional outcomes in patients with multiple hereditary exostoses, further supporting the importance of achieving radiographic correction [13].

It’s important to note that despite the positive outcomes, the risk of recurrence remains a concern, particularly in skeletally immature patients [14]. This emphasizes the need for continued monitoring and potential repeated interventions as these patients grow. The mild recurrence observed in Case 3 is a testament to this ongoing challenge in managing HME.

The timing of surgical intervention in these cases remains a subject of debate. Our experience suggests that early intervention, when significant deformity or functional impairment is present, can lead to favorable outcomes. However, the decision to operate must be balanced against the risks of surgery and the potential need for repeated procedures. Jiya et al. have reported good long-term outcomes with early surgical intervention, but also noted the need for additional procedures in some patients as they continued to grow [15].

The choice of surgical technique is critical in achieving optimal outcomes. Our case series demonstrates the effectiveness of different approaches tailored to the specific deformity pattern. Ulnar lengthening, as used in Cases 1 and 2, has been shown to be particularly effective in addressing relative ulnar shortening and improving forearm rotation. The technique of gradual lengthening allows for controlled correction and minimizes the risk of neurovascular complications [16].

The management of radial head dislocation, as seen in Case 2, remains challenging. Our approach of combining ulnar lengthening with radial head reduction proved effective in this case. However, long-term follow-up is necessary to assess the stability of the reduction and the potential development of degenerative changes in the elbow joint [17].

The role of simple excision, as demonstrated in Case 3, should not be underestimated. In cases with minimal functional impairment, this less invasive approach can provide significant cosmetic improvement and potentially delay the need for more extensive surgery. However, patients and families should be counseled about the possibility of recurrence and the potential need for future interventions [18].

One of the strengths of our study is the comprehensive assessment of both functional and radiographic outcomes. The use of standardized measurements allows for objective evaluation of the surgical results. However, we acknowledge several limitations of this study. The small sample size limits the generalizability of our findings, and the relatively short follow-up period may not capture long-term outcomes or complications. Additionally, the lack of a control group makes it difficult to compare our results with the natural history of untreated forearm exostoses.

Future research directions should include larger, prospective studies with longer follow-up periods to better elucidate the long-term outcomes of different surgical approaches. The development of more refined classification systems that incorporate both radiographic and functional parameters could help guide treatment decisions. Additionally, investigation into the molecular mechanisms underlying exostosis formation and growth could potentially lead to novel therapeutic approaches to prevent recurrence [19].