Background <p>Different approaches have been proposed to treat patients with pulseless supracondylar humeral fractures (SHF). We aim to analyze the current outcomes of patients who have undergone different treatment options for pulseless SHF, namely watchful waiting versus urgent surgical exploration.</p> Methods <p>Electronic databases including PubMed, Embase, and Cochrane Library were explored. Our study included patients from all age groups but only included English-language articles. Single case reports and case studies with adequate description of patient population, injury, and outcomes were included. An individual patient data meta-analysis was done to evaluate key outcomes of surgical exploration versus no surgical exploration in pulseless patients with SHF.</p> Results <p>Overall, the data for 1070 individual patients from a total of 48 studies were included.</p> <p>Patients with pulseless SHF with open fractures have a higher probability of requiring vascular intervention (<i>p</i> &lt; 0.001) as they are more likely to have disrupted arteries (<i>p</i> = 0.050) and more likely to require vascular repairs (<i>p</i> &lt; 0.001) than patients with closed fractures. Similarly, patients with pulseless SHF with pucker sign (<i>p</i> = 0.003) and ecchymosis (<i>p</i> = 0.002) were more likely to undergo surgical exploration. However, the neurological status had no relation to them undergoing surgical exploration (<i>p</i> = 0.382), and also does not affect complication outcomes (<i>p</i> = 0.326) nor the need for vascular intervention (<i>p</i> = 1.00).</p> <p>However, patients with pale pulseless SHFs were more likely to undergo surgical exploration (<i>p</i> &lt; 0.001), were more likely to have disrupted arteries (<i>p</i> &lt; 0.001), required more vascular intervention (<i>p</i> &lt; 0.001), and had a higher likelihood of complications (<i>p</i> &lt; 0.001).</p> <p>Notably, there is no significant difference in overall complications between those who underwent exploration of arteries and those who did not among patients with pink pulseless SHF (<i>p</i> = 0.230).</p> Conclusions <p>Significant predictors for arterial injury requiring intervention include a pale pulseless limb, open fracture, pucker sign, and ecchymosis; expedient surgical exploration is recommended in these scenarios. However, for patients with pink pulseless SHF, watchful waiting is a viable strategy. Our meta-analysis found no significant difference in overall complication rates between patients with pink pulseless who underwent exploration and those who did not.</p> Level of evidence <p>Level II.</p> Registration <p>The review process was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines CRD.</p>