Background <p>Ultrasound (US) is a promising alternative to fluoroscopy (FL) for guiding percutaneous leverage reduction of displaced radial neck fractures in children. However, few studies have compared these modalities. This study aims to compare both the accuracy and efficacy of FL-guided versus US-guided percutaneous pinning in the treatment of radial neck fracture.</p> Methods <p>Seventy-three children with displaced radial neck fractures were consecutively enrolled and assigned to the US or FL group. In all the patients, fractures were reduced with the percutaneous pin leverage technique. The patients were divided into two groups: the FL-guided group and the US-guided group. Baseline information, radiographs, and clinical results according to the criteria suggested by Metaizeau and complications were analyzed. Final Metaizeau criteria were categorized into excellent, good, fair, and poor.</p> Results <p>The success rates for closed reduction were 100% for the US group and 91.2% for the FL group. The US group exhibited a significantly shorter operation time compared to the FL group (24.77 ± 8.00&#xa0;min vs. 42.21 ± 15.18&#xa0;min; <i>P</i> &lt; 0.01). Additionally, the US group had a significantly lower number of FL images and radiation dose (3.59 ± 1.57 times, 9.56 ± 6.08 mGy) than the FL group (22.26 ± 8.07 times, 69.68 ± 34.70 mGy; <i>P</i> &lt; 0.001). Reduction quality did not significantly differ between the groups according to the Metaizeau reduction classification (<i>P</i> = 0.130). According to the Metaizeau classification criteria, there was no significant difference between the two groups, including post-operative complications.</p> Conclusion <p>Ultrasound-guided techniques offer a viable alternative for the treatment of displaced radial neck fractures in paediatric patients by minimising radiation exposure, expediting operative time and facilitating reduction.</p> Level of evidence <p>Therapeutic Level III.</p>