Distal radius fractures are one of the most commonly seen fractures in the emergency department (ED), often among elderly females with osteoporosis [1]. The majority of these patients tend to be managed in the outpatient setting, although around 20 % require hospital admission. Typically, this includes elderly patients or younger patients following high energy trauma [2,3].

Displacement of fracture fragments is common and often managed by closed manipulation and plaster cast application. Manipulation of displaced distal radius fractures is generally carried out in ED or orthopaedic fracture clinic [4]. They can be performed under a variety of anaesthetic techniques including haematoma block (HB), peripheral regional anaesthesia (RA), intravenous regional anaesthesia (IVRA), general anaesthetic, or sedation with or without supplementation with Entonox. This is a widely used 50:50 premix of nitrous oxide and oxygen, delivered by inhalation for short-term analgesia. There is limited evidence to determine the most efficient anaesthetic [[5], [6], [7]].

The British Orthopaedic Association (2017) released new standards on the management of distal radius fractures. The standards for practice in BOAST state that if manipulation is indicated, it should be undertaken using regional anaesthesia (as opposed to local haematoma block) and performed by a suitably qualified and trained practitioner [8]. NICE guidelines (2016) recommend considering regional anaesthesia for the manipulation of distal radius fractures and do not mention haematoma blocks. They also raise the question of whether real-time image guidance during manipulation might offer greater clinical and cost-effectiveness compared to manipulation without such guidance, highlighting the need for further high-quality research in this area [9].

Evidence from Cochrane reviews has shown that intravenous regional anaesthesia (Bier’s block) provides superior analgesia and facilitates better fracture reduction compared with haematoma block [5]. More recently, Oakley et al. reported that Bier’s block achieved lower pain scores and better restoration of alignment than haematoma block in a multicentre study [7]. Peripheral brachial plexus blocks have also been reported to provide reliable anaesthesia and excellent patient tolerance, although comparative data against haematoma block remains sparse [5,6]. These findings, alongside national guidelines, support the rationale for introducing a regional anaesthesia service.

At the investigating trust, manipulation of distal radius fractures was traditionally undertaken with a haematoma block in the trauma clinic or the emergency department. Patients not requiring emergency manipulation were seen in a virtual fracture clinic and the consultant brought suitable patients the following day for manipulation under haematoma block. The analgesia provided by this was often felt to be inadequate and required supplementation with Entonox. To comply with the standards above, the decision was made to introduce a ‘regional anaesthesia list’ (block list) for the management of distal radius fractures in the trust. Prior to the introduction of this service, data was collected on patients managed with haematoma blocks to allow a comparison of outcomes between the two types of anaesthetics.