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To determine if intravenous regional anesthesia (Bier block) is safe and efficacious for the management of children's extremity fractures in the emergency department (ED).Retrospective review of 470 ED records of children presenting with extremity fractures reduced with intravenous regional anesthesia from 1989 through 1994.ED of a 256-bed teriary care children's hospital.Four hundred seventy children treated in the ED from 1989 through 1994 for extremity fractures reduced with Bier block anesthesia. Three hundred eleven boys and 159 girls with a mean age of 9.4 years (range two-19 years) were included in the review.Utilization of intravenous regional anesthesia for fracture reduction of affected extremity.ED records and orthopaedic consultation notes were reviewed for adequacy of reduction, number of reduction attempts, efficacy of anesthesia, and any associated untoward effects or complications, and review of operative notes of any children who required a subsequent procedure in the operating room (OR) under general anesthesia.Ninety-nine percent (467) had adequate anesthesia for fracture reduction. There were no complications noted. Specifically, there were no incidents of hypotension, tachycardia, seizures, or arrhythmia. Bier block anesthesia was aborted in three patients because venous access could not be obtained in the affected extremity. Less than 2% (8) required a general anesthetic in the OR for further treatment. All of the children taken to the OR underwent internal fixation of the fracture.Intravenous regional anesthesia (Bier block) is safe and efficacious in the treatment of children's extremity fractures in the ED.