In the absence of reliable evidence, the opinion of the work group is that open exploration of the antecubital fossa be performed in patients who have absent wrist pulses and are underperfused after reduction and pinning of displaced pediatric supracondylar humerus fractures.

Rationale
In a majority of patients with displaced fractures and vascular compromise, limb perfusion improves after reduction.  In the absence of improvement, surgical exploration of the antecubital fossa is indicated for patients with absent wrist pulses and a cold, pale hand. The work group issued this consensus recommendation, despite the paucity of evidence and the rarity of this occurrence, because of the risk of limb loss.

Benefits of immediate exploration outweigh the potential harms. The catastrophic risks of persistent inadequate perfusion include loss of limb, ischemic muscle contracture, nerve injury, and functional deficit. Risks of exploratory surgery include infection, neurovascular injury, and stiffness.

The orthopaedic surgeon will need to use clinical judgment. Consultation regarding vascular injury may be necessary. Treatment decisions should be made in light of all circumstances presented by the patient. This recommendation is consistent with common medical practice.