Fracture surgery of the extremities using 2D fluoroscopy frequently fails to detect the suboptimal positioning of implants and joint incongruities. The use of intraoperative 3D-rotational X-ray (3D-RX) imaging with a new X-ray device potentially reveals these failures. We compared 50 intraoperative (2D) results of surgery and certainty about the effectiveness of different aspects of fracture reduction as interpreted from conventional (2D) methods versus intraoperative 3D-RX in 42 distal extremity fractures by means of a surgery questionnaire. In addition, we investigated the need for revision surgery based on postoperative radiological findings in 81 patients. After fracture reduction, just before a 3D-RX scan, the surgeon preoperatively assessed the result of surgery. Three months after surgery, the 3D-RX scan was judged by three experienced surgeons independently. Intraoperative 3D-RX showed significantly more information as to screw positioning and rotation of the fracture reduction than the conventional method (p < 0.005). None of the 81 patients in whom 3D-RX was performed needed surgical revision based on postoperative radiological examinations. Intraoperative 3D-RX with this new device scanning offers additional information about extremity fracture reduction as compared to conventional intraoperative 2D imaging, and may reduce the need for revision surgery. The value of 3D-RX on functional outcomes still needs to be assessed.