A 4-year-old girl was brought to the emergency department after falling from a tree onto her outstretched hand. Physical examination revealed deformity of the elbow, with bruising and puckering of the skin proximal to the antecubital fossa and no open wound (Panel A). Sensation was intact, but she was unable to bring the tips of her thumb and index finger together. The radial pulse was not palpable, but manual traction applied to the elbow resulted in return of the radial pulse. A splint was applied for stability, and a radiograph showed a displaced supracondylar fracture (Panel B). The distinctive bruising and puckering of the skin result from the piercing of the brachialis muscle by a proximal fragment of the humerus, which can compromise the neurovascular structures as they pass through the cubital fossa. The patient was transferred to the operating room, and closed reduction under fluoroscopy with percutaneous pin fixation was performed. Weakness of the thumb and index finger remained unchanged on immediate postoperative examination. At follow-up 2 months later, the weakness had resolved, and the patient had a nearly full range of motion at the elbow.