Introduction: Ultrasound-guided manipulation and reduction (M&R) of the distal radius fractures (DRF) is believed to improve radiographic indices due to real-time feedback of fracture alignment. The objective of this trial was to compare volar tilt, radial inclination, and radial height on radiographs between Ultrasound guided and conventional (landmark-guided) M&R. Materials and methods: A total of 79 distal radius extraarticular fractures in adults were randomised to Ultrasound guided and conventional (landmark-guided) M&R. The radiograph parameters described above were compared before and after M&R in both groups. Results: Except for volar tilt (P=0.05 difference in difference), there was no difference in both the groups on radiograph parameters i.e. radial inclination and radial height. We estimated a reduction in the incidence of malreduction by 49% (Risk ratio 0.51) and an absolute risk reduction of 22% through USG-guided reduction. We evaluated a number needed to treat 4 through USG-directed M&R of DRF to prevent one unacceptable reduction. There were 9 (22%) and 18 (46%) (P=0.70) unacceptable reductions in USG-guided and landmark-guided M&R. Conclusion: Adding USG guidance to conventional landmark-based closed reduction methods is not beneficial for the accuracy of fracture reduction in Colle’s fracture. However, improved volar tilt in sonographic-directed M&R needs further studies to determine the clinical significance.