Predictors of loss of alignment after emergency department reduction and casting of distal radius fractures in adults: A Systematic Review

Background: Loss of alignment after closed reduction and casting of distal radius fractures is a frequent reason for repeat imaging, delayed surgery, and malunion. Early recognition of fractures at greatest risk of redisplacement is important after emergency department management. In this study we aimed to analyze adult original articles on patient, fracture, radiographic, reduction, and casting factors associated with loss of alignment after closed reduction and immobilization. Methods: A PRISMA-aligned review framework covered PubMed, Scopus, Web of Science Core Collection, and Cochrane CENTRAL from inception to August 2026. Eligible studies enrolled adults with acute distal radius fractures managed nonoperatively after closed reduction and reported serial radiographic alignment or redisplacement. Pediatric studies, operative cohorts, case reports, and studies lacking post-reduction follow-up were excluded. Results: We include 18 adult original studies. Increasing age, radial shortening or positive ulnar variance, severe initial displacement, comminution, and failure to restore the volar cortex were the most recurrent predictors. Post-reduction alignment carried a prognostic value. Loss of alignment occurred frequently in cohorts, although definitions, radiographic thresholds, fracture patterns, and timing of follow-up varied substantially among individual studies. Traditional composite rules showed limited external discrimination. Conclusion: Risk prediction is strongest when baseline fracture severity is combined with immediate post-reduction radiographic quality rather than relying on a single historical criterion.