A pediatric supracondylar humeral fracture with a pulseless, poorly perfused hand requires emergency operative reduction. If the limb remains pulseless and poorly perfused after fracture fixation, vascular exploration and possible reconstruction is necessary. A pediatric supracondylar humeral fracture with a pulseless, well-perfused hand should be treated urgently with operative fixation of the fracture and subsequent reassessment of the vascular status. Controversy exists regarding the optimal management of pediatric supracondylar humeral fractures with a pulseless, well-perfused hand following anatomic reduction and fixation. Options include immediate vascular exploration or twenty-four to forty-eight hours of inpatient observation. If perfusion is compromised during this period of observation, an emergency return to the operating room for vascular exploration and possible reconstruction is indicated.