Distal radius fractures (DRFs) are among the most common orthopaedic injuries encountered in clinical practice, representing a significant portion of all extremity fractures [1]. The incidence of DRFs is particularly high in the elderly population, where reduced bone mineral density and osteoporosis dramatically increase the risk of fracture following a low-energy trauma, such as a fall on an outstretched hand [2]. Conversely, in younger cohorts, these fractures are typically the result of high-energy mechanisms [3]. Regardless of the etiology, the overarching goal of DRF management is the restoration of normal anatomy to ensure a pain-free, mobile, and functional wrist. The management of DRFs involves a spectrum of treatment modalities, ranging from conservative cast immobilization and percutaneous K-wire fixation to open reduction and internal fixation utilizing volar locking plates [4]. The choice of treatment is heavily influenced by the fracture pattern, patient age, and functional demands. However, regardless of the chosen method, obtaining and maintaining an anatomical reduction is paramount. Studies indicate that failure to preserve anatomical parameters—such as radial inclination, volar tilt, and ulnar variance—directly correlates with poor functional outcomes, including diminished grip strength, limited range of motion, and the early onset of post-traumatic osteoarthritis [4, 5]. Despite advances in surgical techniques and fixation devices, loss of reduction (LOR)—defined as the secondary displacement of fracture fragments after initial satisfactory alignment—remains a major clinical challenge [6, 7]. LOR often occurs within the first few weeks following the injury and can insidiously compromise treatment success. Clinical variables, including advanced chronological age and the severity of the initial displacement, have been identified as primary contributors to late collapse [8]. Notably, fractures with extension into the distal radioulnar joint (DRUJ) or those complicated by ulnar styloid process fractures demonstrate a pronounced propensity for secondary displacement, highlighting the delicate biomechanical interplay required for wrist stability [8]. Consequently, identifying reliable radiological predictors of LOR is critical for preoperative planning and early postoperative monitoring. Radiographic parameters such as the degree of initial dorsal comminution, excessive radial shortening, and a loss of volar tilt are foundational metrics used to gauge the intrinsic stability of the fracture [2]. Moreover, DRUJ instability, which is frequently associated with DRFs, can be inferred from specific radiographic clues, such as widened radioulnar distance or marked positive ulnar variance [9]. Recognizing these subtle radiological deviations allows orthopedic surgeons to proactively modify their treatment strategy, perhaps opting for more rigid volar plate fixation in patients demonstrating high-risk radiographic profiles. While the literature extensively covers general risk factors for DRF malunion, there remains a continued need for targeted observational data specifically analyzing early radiological parameters as independent predictors of reduction failure following initial fixation. We hypothesized that “one or more radiographic parameters, particularly articular step-off, TPI, cast index, and PAD index, are significantly associated with and predictive of loss of reduction during conservative treatment, and patients with loss of reduction have different 6-month functional outcomes compared with those without loss of reduction.” The study aims to determine the radiographic parameters that predict maintenance or loss of reduction during conservative treatment of distal radius fractures; to evaluate the predictive value of radial inclination, radial height, articular step-off, TPI, cast index, and PAD index for loss of reduction; to assess whether the predictive value of these parameters differs according to fracture extension into the distal radial articular surface; and to compare 6-month functional outcomes, including pain assessed by VAS, upper-extremity function assessed by QuickDASH, and wrist function assessed by the Mayo wrist score, between patients with and without loss of reduction..

This observational study was conducted at a tertiary care hospital in Bihar, India, over 6 months in 2026 to identify radiological parameters associated with loss of reduction (LOR) following treatment of distal radius fractures (DRFs). LOR was considered as secondary displacement or deterioration of fracture alignment after an initially satisfactory reduction. Study Population The study population comprised adult patients presenting with radiographically confirmed distal radius fractures who underwent initial reduction followed by fixation as part of their treatment. Patients were evaluated clinically and radiologically from the time of initial treatment through the follow-up period. Patients with adequate baseline and follow-up radiographs were included. Patients with incomplete radiological records, pathological fractures, previous fracture or surgery involving the affected wrist, associated injuries that significantly affected wrist function, or inadequate follow-up were excluded. Fractures were assessed for intra-articular extension and other radiological characteristics relevant to fracture stability. Sampling Method & Sample Size Patients were recruited using consecutive sampling during the study period. The sample size was calculated using the proportion of LOR reported by Cengiz et al. (2026) [10], in which 21.2% patients developed LOR. Using the formula n=Z^2 pq/d^2, with a 95% confidence level, expected proportion of 21.2%, complementary proportion of 78.8%, and absolute precision of 10%, the calculated sample size was approximately 65 participants. Allowing for approximately 15% attrition or incomplete follow-up, the final required sample size was rounded to 80 patients. Outcome Parameters The primary outcome was occurrence of loss of reduction during follow-up. Radiological parameters included radial inclination, radial height, volar/dorsal tilt, articular step-off, Three-Point Index (TPI), Cast Index, and Padding Index (PAD index) [11-13]. The relationship of these parameters with subsequent LOR was assessed. Fractures were additionally categorized according to extension into the distal radial articular surface. Secondary outcomes included functional status at 6 months, assessed using the Visual Analogue Scale for pain, QuickDASH score for upper-extremity disability, and Mayo Wrist Score for wrist function [14, 15]. These outcomes corresponded to the predefined objectives of the study. Methodology After obtaining consent, demographic and clinical information was recorded, including age, sex, mechanism of injury, affected side, fracture characteristics, and relevant treatment details. Standard radiographs of the injured wrist were obtained at baseline and after initial reduction/fixation according to institutional practice. Radiographs were evaluated for radial height, radial inclination, volar or dorsal tilt, articular step-off, and other indicators of fracture alignment. Cast Index, TPI, and PAD index were calculated from the appropriate post-reduction radiographs using established radiographic measurements. Particular attention was given to dorsal comminution, radial shortening, intra-articular extension, and residual displacement because these features had previously been associated with fracture instability. Follow-up radiographs were obtained at predefined postoperative intervals to identify secondary displacement or deterioration of alignment. LOR was recorded when predefined radiographic criteria demonstrated clinically relevant secondary displacement from the initial satisfactory reduction. Patients were subsequently categorized into LOR and maintained-reduction groups. At 6 months, pain and functional outcomes were assessed using VAS, QuickDASH, and Mayo Wrist Score. Radiological measurements were performed systematically using the same measurement protocol, and measurements were recorded independently before statistical analysis. The study framework was based on previous evidence showing that parameters such as articular incongruity, radial shortening, dorsal angulation, and radiographic indices could be associated with secondary displacement or functional outcome. Statistical Analysis Data were entered into a computerized database and analysed using GraphPad Prism version 11. Continuous variables were expressed as mean ± standard deviation, whereas categorical variables were expressed as frequencies and percentages. Continuous variables between groups were compared using the independent-samples t-test, while categorical variables were compared using the chi-square test or Fisher's exact test. Variables demonstrating clinically relevant or statistically significant associations were entered into multivariable logistic regression to identify independent predictors of LOR. Odds ratios with 95% confidence intervals were reported. A two-sided p-value <0.05 was considered statistically significant. Ethical Consideration The study was conducted after obtaining approval from the Institutional Ethics Committee. Written informed consent was obtained from eligible participants before enrolment. Patient confidentiality was maintained throughout the study by using coded identification rather than personal identifiers in the study database. The collected information and radiographs were used exclusively for research purposes, and participants were informed about the study procedures, follow-up assessments, potential benefits, and their right to withdraw from the study without affecting their treatment.

Among 80 patients, the mean age was 45.86 ± 13.23 years, with males comprising 57.5%. The right side was affected in 53.8%, and fall on an outstretched hand was the commonest mechanism (63.8%). Intra-articular fractures accounted for 47.5%, dorsal comminution for 38.8%, and ulnar styloid fracture for 30.0%. Loss of reduction occurred in 17 (21.3%) patients [Table 1]. Table 1. Baseline demographic and clinical characteristics of the study participants (N = 80) Variable Category n (%) / Mean ± SD Age (years) Overall 45.86 ± 13.23 Sex Male 46 (57.5) Female 34 (42.5) Affected side Right 43 (53.8) Left 37 (46.2) Mechanism of injury Fall on outstretched hand 51 (63.8) Road traffic injury 21 (26.2) Other trauma 8 (10.0) Fracture extension Intra-articular 38 (47.5) Extra-articular 42 (52.5) Dorsal comminution Present 31 (38.8) Absent 49 (61.2) Ulnar styloid fracture Present 24 (30.0) Absent 56 (70.0) Loss of reduction Present 17 (21.3) Absent 63 (78.7) Patients with LOR had significantly lower radial height (8.17 ± 2.36 vs. 10.24 ± 1.86 mm, p=0.0002) and radial inclination (15.82 ± 4.71° vs. 20.15 ± 3.98°, p=0.0003), with greater articular step-off (1.93 ± 0.74 vs. 0.98 ± 0.51 mm, p<0.0001). TPI, Cast Index, and PAD Index were also significantly higher in the LOR group (all p<0.0001), indicating poorer radiological alignment and greater fracture instability [Table 2]. Table 2. Comparison of baseline/post-reduction radiological parameters between patients with and without loss of reduction Radiological parameter LOR group (n=17) Mean ± SD Maintained reduction (n=63) Mean ± SD p-value (Unpaired t test) Radial height (mm) 8.17 ± 2.36 10.24 ± 1.86 0.0002 Radial inclination (°) 15.82 ± 4.71 20.15 ± 3.98 0.0003 Volar/dorsal tilt (°) −3.84 ± 7.29 5.47 ± 5.90 <0.0001 Articular step-off (mm) 1.93 ± 0.74 0.98 ± 0.51 <0.0001 Three-Point Index (TPI) 1.01 ± 0.09 0.91 ± 0.08 <0.0001 Cast Index 0.90 ± 0.07 0.81 ± 0.06 <0.0001 Padding Index (PAD index) 0.98 ± 0.12 0.82 ± 0.10 <0.0001 Several radiological factors were significantly associated with LOR, including articular step-off >2 mm (OR 7.79, p=0.0006), radial shortening >3 mm (OR 8.57, p=0.0004), dorsal tilt >10° (OR 7.73, p=0.0009), TPI >1.0 (OR 9.23, p=0.0003), Cast Index >0.84 (OR 9.55, p=0.0004), and PAD Index >0.90 (OR 5.87, p=0.0026). Dorsal comminution was not significantly associated with LOR (OR 2.86, p=0.0611) [Table 3]. Table 3. Association of radiological risk factors with loss of reduction Radiological risk factor LOR present n (%) LOR absent n (%) Odds Ratio 95% CI p-value Articular step-off >2 mm 11 (64.7) 12 (19.0) 7.79 2.40–25.28 0.0006 Radial shortening >3 mm 10 (58.8) 9 (14.3) 8.57 2.59–28.35 0.0004 Dorsal tilt >10° 9 (52.9) 8 (12.7) 7.73 2.31–25.86 0.0009 TPI >1.0 12 (70.6) 13 (20.6) 9.23 2.76–30.91 0.0003 Cast Index >0.84 13 (76.5) 16 (25.4) 9.55 2.71–33.52 0.0004 PAD Index >0.90 11 (64.7) 15 (23.8) 5.87 1.86–18.55 0.0026 Dorsal comminution 10 (58.8) 21 (33.3) 2.86 0.95–8.57 0.0611 On multivariable analysis, significant independent predictors of LOR were articular step-off >2 mm (adjusted OR 4.14, p=0.018), radial shortening >3 mm (adjusted OR 4.53, p=0.013), TPI >1.0 (adjusted OR 5.81, p=0.005), Cast Index >0.84 (adjusted OR 6.62, p=0.003), and PAD Index >0.90 (adjusted OR 3.20, p=0.048). Dorsal comminution and intra-articular extension were not significant independent predictors (p=0.177 and 0.112, respectively) [Table 4]. Table 4. Multivariable logistic regression analysis of independent predictors of loss of reduction Predictor Regression coefficient (β) Adjusted OR 95% CI p-value Articular step-off >2 mm 1.42 4.14 1.28–13.39 0.018 Radial shortening >3 mm 1.51 4.53 1.38–14.85 0.013 TPI >1.0 1.76 5.81 1.69–19.98 0.005 Cast Index >0.84 1.89 6.62 1.92–22.82 0.003 PAD Index >0.90 1.16 3.20 1.01–10.14 0.048 Dorsal comminution 0.72 2.05 0.72–5.86 0.177 Intra-articular extension 0.83 2.30 0.82–6.44 0.112 At 6 months, patients with LOR had significantly higher VAS pain scores (4.26 ± 1.13 vs. 1.91 ± 1.04, p<0.0001) and QuickDASH scores (15.87 ± 5.24 vs. 10.72 ± 3.73, p<0.0001), while Mayo Wrist Scores were lower (88.11 ± 6.84 vs. 92.41 ± 5.54, p=0.0085). Radial height and inclination also remained significantly lower in the LOR group (both p≤0.0001), indicating poorer radiological and functional outcomes [Table 5]. Table 5. Comparison of 6-month functional outcomes between patients with and without loss of reduction Outcome at 6 months LOR group (n=17) Mean ± SD Maintained reduction (n=63) Mean ± SD p-value VAS pain score 4.26 ± 1.13 1.91 ± 1.04 <0.0001 QuickDASH score 15.87 ± 5.24 10.72 ± 3.73 <0.0001 Mayo Wrist Score 88.11 ± 6.84 92.41 ± 5.54 0.0085 Radial height (mm) 7.91 ± 2.23 10.05 ± 1.73 <0.0001 Radial inclination (°) 15.45 ± 4.69 19.84 ± 3.82 0.0001

The present study evaluated radiological predictors of loss of reduction (LOR) following distal radius fracture treatment in 80 patients. Patients with LOR demonstrated significantly lower radial height and radial inclination, altered volar/dorsal tilt, greater articular step-off, and higher TPI, Cast Index, and PAD Index values. On univariable analysis, articular step-off >2 mm, radial shortening >3 mm, dorsal tilt >10°, TPI >1.0, Cast Index >0.84, and PAD Index >0.90 were significantly associated with LOR. Multivariable analysis identified articular step-off, radial shortening, TPI, Cast Index, and PAD Index as independent predictors. At 6 months, patients with LOR had significantly higher pain and QuickDASH scores and lower Mayo Wrist Scores, indicating poorer functional outcomes. The 21.3% incidence of LOR in the present study was very similar to that reported by Cengiz et al. (2026), who observed LOR in 21.2% (31/146) of adults with distal radius fractures treated conservatively [10]. Their study also found significant differences between patients with and without LOR for articular step-off, TPI, and Cast Index, supporting the importance of these radiological parameters in predicting fracture instability. However, their multivariable analysis showed that TPI was particularly important in intra-articular fractures, whereas Cast Index was the strongest predictor in extra-articular fractures [10]. The present finding that articular incongruity and radial shortening were associated with LOR is consistent with the findings of Khaionjittavakul et al. (2025) [16]. In their cohort of 244 adults, intra-articular fracture stepping and ulnar variance >3 mm were significant predictors of fracture instability, along with pre-reduction dorsal angulation and inadequate restoration of volar cortex [16]. Similarly, the present study found that articular step-off >2 mm was significantly associated with LOR (OR 7.79, p=0.0006) and remained an independent predictor after adjustment (adjusted OR 4.14, p=0.018). The importance of post-reduction alignment observed in the present study is also supported by Shah et al. (2025), although their population consisted of children. They reported that pre-reduction translation ≥51% of radial shaft width and non-anatomic post-reduction alignment with residual translation were independent predictors of LOR [6]. The present findings similarly demonstrate that inadequate restoration of anatomical parameters, particularly radial height, inclination, articular congruity and tilt, is associated with subsequent displacement. The difference in population should, however, be considered when comparing the magnitude of these associations [17, 18]. The present results particularly support the predictive value of Cast Index, TPI, and PAD Index. Cast Index >0.84 showed the highest adjusted association with LOR (adjusted OR 6.62, p=0.003), followed by TPI >1.0 (adjusted OR 5.81, p=0.005). These findings are comparable with Pavone et al. (2020), who found significantly higher Cast Index, Padding Index, Canterbury Index, and TPI values among pediatric patients who developed secondary displacement; Cast Index showed the highest sensitivity (78.3%) and negative predictive value (89.8%) [19]. Hang et al. (2011) also reported significant associations of Padding Index, Canterbury Index, and TPI with redisplacement [20]. Thus, across different populations, cast-related and geometric radiological indices appear useful for identifying fractures at increased risk of secondary displacement. In the present study, dorsal comminution was not independently associated with LOR (adjusted OR 2.05, p=0.177), although it showed a nonsignificant association on univariable analysis (OR 2.86, p=0.0611). This finding differs from Leone et al. (2004), who reported a trend toward greater dorsal comminution among early failures and identified radial shortening, dorsal tilt, and loss of radial inclination as important predictors of instability [21]. The difference may relate to variations in patient age, fracture characteristics, treatment methods, and definitions or timing of failure. The present study also demonstrated significant differences in 6-month functional outcomes. Patients with LOR had higher VAS pain and QuickDASH scores, while Mayo Wrist Scores were lower. These findings are consistent with Mulders et al. (2018), whose systematic review and meta-analysis demonstrated that unacceptable radiological reduction was associated with worse patient-reported outcomes, particularly with unacceptable dorsal angulation and ulnar variance [18]. They also agree with Ng and McQueen (2011), who highlighted radial shortening, loss of radial inclination, and persistent articular step-off as important determinants of functional outcome [22]. However, not all previous studies have demonstrated a direct relationship between radiological parameters and functional outcomes. Ranjeet and Estrella (2012) found no significant correlation between radiologically acceptable reduction and functional scores at follow-up [17], while Jaremko et al. (2007) similarly reported that radiographic deformity was not significantly correlated with patient-reported outcomes at 6 months [23]. Conversely, Chung et al. (2007) found that articular incongruity predicted poorer short-term hand function at 3 months, although radiographic parameters were no longer predictive at 1 year [24]. These differences suggest that the relationship between radiological alignment and functional recovery may vary according to follow-up duration, outcome instrument, patient characteristics, and fracture/treatment characteristics. Finally, Kwon et al. (2012) demonstrated that radiographic evidence of positive ulnar variance was associated with distal radioulnar joint instability, while the present study identified radial shortening and other alignment indices as predictors of LOR [9]. Together, these findings emphasize the biomechanical importance of maintaining radial length and anatomical alignment during treatment. Overall, the present study supports the use of articular step-off, radial shortening, TPI, Cast Index, and PAD Index as clinically relevant radiological markers for identifying patients at increased risk of loss of reduction and highlights the association between secondary displacement and poorer 6-month pain and functional outcomes. The study was limited by its single-centre observational design, relatively small sample size, and short 6-month follow-up, which may limit generalizability and assessment of long-term functional outcomes.

In conclusion, loss of reduction occurred in nearly one-fifth of patients with distal radius fractures and was significantly associated with poor radiological parameters, including reduced radial height and inclination, abnormal volar/dorsal tilt, greater articular step-off, and increased TPI, Cast Index, and PAD Index. Articular step-off >2 mm, radial shortening >3 mm, TPI >1.0, Cast Index >0.84, and PAD Index >0.90 were independent predictors of loss of reduction, whereas dorsal comminution and intra-articular extension were not independent predictors. Patients who developed loss of reduction also had significantly greater pain, higher QuickDASH scores, and lower Mayo Wrist Scores at 6 months. These findings highlight the importance of careful assessment of early post-reduction radiographs and close follow-up of patients demonstrating high-risk radiological parameters to identify those at increased risk of secondary displacement and poorer functional outcomes.

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