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The open approach to a supracondylar humerus fracture may be needed for open fractures, vascular compromise, and most commonly, irreducible fractures refractory to closed management. Gartland types III and IV fractures as well as flexion-type fractures are more likely to require an open technique. Vascular compromise can be overt as is the case of a white, pulseless extremity or more subtle as with the “pink, pulseless” extremity. The use of Doppler signals intraoperatively can be helpful to distinguish which “pink, pulseless” cases warrant open exploration. Intraoperative signs of irreducibility include persistent gapping at the fracture site, loss of Baumann’s angle, and discontinuous columns on oblique views. In the scenario an open technique may be necessary, our recommended setup involves positioning of the patient supine on an operating table with a radiolucent hand table attached. An anterior approach to the antecubital fossa is both cosmetic and extensile. This is our preferred approach for rreducible extension-type fractures, suspected interposition brachialis muscle and fascia, median nerve sensory deficits, and vascular exploration. The medial approach is best for flexion-type fractures, ulnar nerve entrapment, extension-type fractures with posterolateral displacement, and oblique or unstable fractures necessitating medial pinning. Postoperative treatment is similar after open technique as for closed pinning of a supracondylar humerus fracture.