Purpose <p>Early postoperative x-rays are frequently ordered after fracture fixation surgery without clear indication. The purpose of this study was to investigate the utility of early formal x-rays compared to intraoperative fluoroscopy in patients undergoing surgical fixation of pelvic and acetabular fractures.</p> Methods <p>Adult patients undergoing surgical fixation of pelvic and acetabular fractures at a Level 1 Trauma Center were identified. Early postoperative x-rays were defined as x-rays ordered within 48&#xa0;h of surgery without clear indication. Two blinded orthopedic surgeons assessed x-rays and fluoroscopic imaging for reduction quality (within 2&#xa0;mm of anatomic) and accuracy of implant placement. Accuracy of implant placement was categorized as safe, suspicious, or definite implant malposition.</p> Results <p>Patients received early postoperative x-rays in 117 cases (53.9%) and fluoroscopy only in 100 cases (46.1%). Among patients undergoing postoperative x-ray, 100% of reductions deemed to have imperfect reduction quality were also deemed to be imperfect on intraoperative fluoroscopy. Similarly, 100% of implants deemed to be of inconclusive safety on postoperative x-ray were also deemed inconclusive on intraoperative fluoroscopy. Considering all patients, 4/117 (3.4%) in the postoperative x-ray group experienced an unplanned change of care within 1&#xa0;week of surgery vs. 1/100 (1.0%) in the fluoroscopy only group (<i>p</i> = 0.38).</p> Conclusion <p>The acquisition of early postoperative x-rays and implant placement accuracy are not reliable predictors of change in care among patients with pelvic and acetabular fractures. Early postoperative x-rays may be unnecessary and should only be ordered with clear clinical indications to improve cost-effectiveness and reduce radiation exposure.</p> Level of evidence <p>&#xa0;Retrospective cohort study; III.</p>