In the absence of reliable evidence, the opinion of the work group is that emergent closed reduction of displaced pediatric supracondylar humerus fractures be performed in patients with decreased perfusion of the hand.

Rationale
Ischemic injury with contracture and/or permanent muscle and nerve damage is a disastrous outcome of the displaced pediatric supracondylar fracture with vascular compromise. The precise incidence of these complications is not accurately reported but they do occur. Only 7 studies related to the recommendation were found and all were excluded based on their poor quality. This recommendation is based on expert opinion because the displaced pediatric supracondylar fracture with reduced perfusion jeopardizes the function and viability of the limb.

Several factors may impact decisions in this clinical scenario. The degree of vascular compromise can vary from absent pulses at the wrist with some perfusion to the hand, to a completely pale hand with concomitant nerve deficits. Additional factors include the skill level of the practitioners, the time from injury, and the availability of consultants such as vascular surgeons. In the absence of high level evidence related to these factors, the practitioner’s judgment will be important. In the case of a pale hand without wrist pulses, the potential benefit of manipulating the fracture may be greater than splinting and sending the patient to a center that is hours away. Conversely, if an unsuccessful reduction fails to improve blood flow, there may be trade-offs including worsening the condition by delaying access to specialized centers. This consensus recommendation allows for the discretion and judgment of the practitioner to determine who does the emergent reduction, where it is done, and what technique (open versus closed) is used. This recommendation is consistent with common medical practice.