One hundred thirty-eight patients with displaced intra-articular distal radius fractures with non-acceptable fracture characteristics were randomized to receive either cast treatment (n=70) or surgical treatment with open reduction and locking plate fixation (n=68). The primary outcome of interest was the Patient Rated Wrist Evaluation (PRWE) score at one-year follow-up. Secondary outcomes included the Disability of the Arm, Shoulder, and Hand (DASH) score, quality of life (measured by the EQ-5D), range of motion, grip strength, and complications. Outcomes were assessed up to 12 months. Overall, the results of the study revealed that the primary intention-to-treat analysis was inconclusive regarding the non-inferiority of cast treatment compared to surgery. However, a secondary analysis demonstrated non-inferiority after adjusting for baseline covariates. In conclusion, surgery may provide short-term benefits, particularly in physiologically young patients.