The management of pink pulseless hands in paediatric supracondylar humerus fractures: A systematic review and meta-analysis.

Abstract

The management of the pink pulseless hand (PPH) following paediatric supracondylar humerus fractures remains controversial, with no clear consensus between orthopaedic management and early neurovascular surgical exploration. This study aimed to compare outcomes of these strategies through systematic review and meta-analysis. A systematic review was conducted in accordance with PRISMA guidelines. Multiple electronic databases were searched up to December 2024. Retrospective cohort studies evaluating management of PPH in paediatric supracondylar fractures were included. Primary outcomes were return of radial pulse within 24 h following (1) closed reduction and percutaneous pinning (CRPP) without neurovascular exploration and (2) surgical exploration of the brachial artery. Secondary outcomes included comparative pulse return, conversion to neurovascular exploration, and long-term functional outcomes. Data were analysed using a random-effects model. Twenty-five studies comprising 591 patients were included. Following CRPP alone, the pooled proportion of pulse return within 24 h was 0.61 (95% CI 0.48-0.74), with substantial heterogeneity (I² = 82.7%). In contrast, neurovascular exploration demonstrated a higher pooled pulse return rate of 0.94 (95% CI 0.89-0.99) with minimal heterogeneity (I² = 0%). Comparative analysis showed lower odds of immediate pulse return with nonoperative neurovascular management (OR 0.36, 95% CI 0.14-0.97). The pooled conversion rate from nonoperarvie management to surgery was 24.8% (95% CI 16.7-33.0%). Long-term functional outcomes were comparable between groups (OR 2.46, 95% CI 0.46-13.10). Operative exploration is associated with higher rates of immediate pulse restoration compared with nonoperative management. However, long-term functional outcomes appear similar between strategies. Initial conservative management may be appropriate in selected cases, but a low threshold for surgical exploration is warranted when pulse does not return or clinical concern persists. Further prospective studies are required to define optimal management pathways.