To determine the effect of experience of the operator and the effect of type of anaesthesia used on re-manipulation rates of fracture distal radius manipulated in A& E, a retrospective review of distal radius fractures manipulated in A& E between January 2000 and January 2001. Operators were divided into two categories: junior (SHO grade) and senior (higher grade) doctor.

54 patients with fracture distal radius had manipulation in A& E. 15 male and 39 female patients with mean age of 61 years (52 for males and 63 for females) were included.

42 (78%) fractures were manipulated under haematoma block (18 by junior, 23 by senior doctor) and 12 (22%) fractures were manipulated under Bier block (1 by junior, 11 by senior doctor). Operator’s grade was not clearly mentioned in one case. 13 out of 54 patients (24%) needed fracture re-manipulation under general anaesthesia. 12 out of 42 fractures manipulated under haematoma block (30%) needed re-manipulation compared to only one out of 12 fractures (8%) manipulated under Bier block (p=0.25). 9 out of 19 fractures manipulated by junior doctors needed re-manipulation compared to only 4 out of 34 fractures manipulated by senior doctors (p=0.007). Haematoma block was used for 18 out of 19 cases by junior doctors and for 23 out of 34 cases by senior doctors (p=0.038). Average number of fracture clinic follow-ups was 4 (range 2 to 8).

Junior doctors had significantly higher preference for haematoma block and significantly higher re-manipulation rate. Re-manipulation rates were higher with fractures manipulated under haematoma block compared to Bier block.

Adequate training and supervision should be provided for SHOs while performing such procedures in A& E. Use of Bier block as a regional anaesthesia for manipulation of distal radius fractures in A& E should be encouraged.