Beethoven was the soloist in the public premiere as part of the concert on 22 December 1808 at Vienna's Theater an der Wien.

It is scored for solo piano and an orchestra consisting of a flute, two oboes, two soprano clarinets, two bassoons, two French horns, two trumpets, timpani, and strings.

The marathon concert saw Beethoven's last appearance as a soloist with orchestra, as well as the premieres of the Choral Fantasy and the Fifth and Sixth symphonies.

A very strong cadence in the tonic, withering away within one bar, introduces a transitional, modulatory theme with restless triplet accompaniment, also containing hints of stretto.

Through a rising bass line and sequential harmonies, the music regains the tonic key (on a dominant pedal) with a new theme derived from bars 3, 4, and 5.

The second movement, known for its prominent and frequent use of a motif from the Dies Irae chant, has been associated with the imagery of Orpheus taming the Furies (represented, respectively, by the piano and unison strings) at the gates to Hades, a suggestion of Beethoven's 1859 biographer Adolf Bernhard Marx.

Cadenzas for the Fourth Piano Concerto have been written by a number of pianists and composers throughout its history; these include Beethoven himself (two separate sets of cadenzas), Johannes Brahms, Clara Schumann, Ferruccio Busoni, Hans von Bülow, Ignaz Moscheles, Camille Saint-Saëns, Anton Rubinstein, Wilhelm Kempff, Nikolai Medtner, Eugen d'Albert, Leopold Godowsky, Wilhelm Backhaus, Samuil Feinberg, Manuel M. Ponce, etc.