A total of 304 patients with isolated, unstable distal radius fractures who received either receive surgical care (n=187) or casting (n=117) were included in this study. Patients who opted for surgical treatment were randomized to receive either internal fixation with volar plate, external fixation, or percutaneous pinning. Patients who preferred conservative management received casting. The primary outcome of interest included the 24-month Michigan Hand Outcomes Questionnaire (MHQ) Summary score. Secondary outcomes of interest included MHQ domain scores. Outcomes were measured up to 24 months post-treatment. In all patients, the mean MHQ Summary score at 24 months was 86 [95%CI 83, 88] and the mean MHQ ADL score at 24 months was 88 [95%CI 80,88], representing good hand function and return to activities of daily living. No statistically significant differences in any of the MHQ domains at 24 months post-treatment. Internal fixation with volar plate had statistically significantly higher MHQ ADL and satisfaction domain scores compared to the other 3 interventions (p<0.0001) at 6 weeks post-treatment. Patients who underwent external fixation scored significantly lower in these 2 domains compared to the casting and internal fixation with volar plate groups. The external fixation group reported worse MHQ ADL scores compared to the other groups until 12 months post-treatment.