Background <p>Insufficient reduction of intra-articular fractures can lead to posttraumatic arthritis. An accurate intraoperative assessment of the articular surface is essential to guide surgical decision-making. This study aims to compare the sensitivity of 2D and 3D fluoroscopy for detecting intra-articular gaps and step-offs in distal radius fractures.</p> Methods <p>Intra-articular distal radius fractures were induced in 6 cadaveric forearms and intra-articular incongruities (gap/step-off) of 0, 1 and 2&#xa0;mm were created using 3D-printed repositioning guides. Images were acquired by 2D and 3D fluoroscopy for each step and evaluated by 3 blinded observers. Sensitivity and specificity for the detection of intra-articular incongruities were analyzed. Additionally, the inter-rater agreement for the decision to perform revision surgery and dose area product (DAP) were evaluated.</p> Results <p>The overall sensitivity of 3D&#xa0;fluoroscopy for the detection of intra-articular incongruities was 90.28% compared to 55.56% for 2D&#xa0;fluoroscopy. Sensitivities for the detection of 2&#xa0;mm incongruities were higher than for 1&#xa0;mm especially in 2D&#xa0;fluoroscopy (1&#xa0;mm: 38.89%; 2&#xa0;mm: 74.72%). In 41.67% of cases with 1&#xa0;mm incongruities where no revision was deemed necessary in 2D&#xa0;fluoroscopy, 3D&#xa0;imaging prompted a change in decision to perform revision. The dose area product was significantly higher for 3D&#xa0;fluoroscopy (41.87&#xa0;cGycm²) compared to 2D&#xa0;fluoroscopy (3.13&#xa0;cGycm²) (<i>p</i> &lt; 0.0001).</p> Conclusion <p>The results suggest that 3D&#xa0;fluoroscopy can facilitate the detection of intra-articular incongruities in distal radius fractures and may prompt intra-operative revisions. Further clinical studies are needed to determine the effect on surgical outcomes.</p>