The purpose of this study was to evaluate surgeon, patient, and radiographic factors influencing the recommendation for operative treatment in distal radius fractures. In a web-based study 252 orthopaedic surgeons from a variety of countries reviewed 30 consecutive sets of radiographs of patients that presented to our emergency department with a fracture of the distal radius. Surgeons were randomly assigned to receive either 'Radiographs only' or 'Radiographs and clinical information'. Surgery was recommended on average 52% of the time whether or not surgeons received clinical information. Female surgeons, surgeons with less than 21 years of experience, and hand surgeons were more likely to recommend operative treatment, but these factors explained only 1% of the variation. Radiographic criteria (intra-articular fractures, ulnar styloid fractures, dorsal comminution, dorsal tilt, and ulnar variance) explained 49% of the variation. The overall agreement on treatment was moderate and slightly higher among surgeons that received radiographs alone. Level of Evidence: Level II, therapeutic; not a clinical study.