Management of the Pediatric Pulseless Supracondylar Humeral Fracture: A Systematic Review and Comparison Study of "Watchful Expectancy Strategy" Versus Surgical Exploration of the Brachial Artery.

BACKGROUND: Pulseless hand after a supracondylar humeral fracture (SHF) in children is well known in the bibliography. Although things are clearer in the management of a "pale pulseless hand," controversy still exists about the "pink pulseless hand" (PPH). METHODS: We reviewed the literature from the electronic database PubMed for studies with main object the vascular injuries after SHF in children and especially the pulseless hand. The primary search terms were "supracondylar humeral fracture" and "vascular injuries". In our final study, 16 articles were gathered and analyzed. RESULTS: We collected 608 pulseless SHFs, regardless of the vascular status, 203 PPHs, and 109 pale pulseless hands. We compared two different strategy methods when the hand remained pulseless after the reduction and fixation of the fracture: (1) the close observation strategy and (2) the surgical exploration of the artery. The close observation strategy was the treatment of choice in PPH, whereas the surgical exploration of the brachial artery was mostly performed in pale pulseless hands. CONCLUSIONS: Closed reduction and fixation of the fracture should be the priority in all pulseless SHFs, both pink and pale. In poorly perfused pale hands, after the reduction and fixation of the fracture, there is a chance that radial pulse may return (we found that this chance is approximately 30%). If not, immediate surgical exploration of the artery is strongly indicated. In well-perfused pink hands, the traditional dogma of "watchful waiting" should not be revisited as long as no signs of deterioration of the vascular status appear. LEVEL OF EVIDENCE: Level I-Systematic review of level I studies.

Critical shoulder angle is intrinsically associated with the development of degenerative shoulder diseases: A systematic review.

Aim of this study was to investigate the potential influence of Critical Shoulder Angle (CSA) as a predisposing factor for the development of degenerative full-thickness rotator cuff tears (DRCT) or primary glenohumeral osteoarthritis (PGOA). A systematic review of the Pubmed, Scopus, Mendeley, ScienceDirect and the Cochrane Central Register of Controlled Trials online databases was performed for literature regarding CSA and its association with DRCT and PGOA. In order to evaluate solely the relationship between CSA as a predisposing factor for the development of the aforementioned degenerative shoulder diseases (DSDs), we precluded any study in which traumatic cases were not clearly excluded. Our search strategy identified 289 studies in total, nine of which were eligible for inclusion based on our pre-established criteria. Quality assessment contacted using the Newcastle Ottawa Scale for case-control studies. There were a total of 998 patients with DRCT and 285 patients with PGOA. The control groups consisted of a total of 538 patients. The mean CSA ranged from 33.9° to 41.01° for the DRCT group, from 27.3° to 29.8° for the PGOA group and from 30.2° to 37.28° for the control group. All studies reported statistically significant differences between the DRCT and PGOA groups and the respective control groups. Our study results showed that there is moderate evidence in the literature supporting an intrinsic role of CSA in the development of DSDs. Level of evidence: IV. Systematic review of diagnostic studies, Level II-IV.