Two-hundred and fourteen elderly patients (75+ years old) with dorsally displaced distal radius fractures were randomized to receive cast immobilization (n=107) or open reduction and internal fixation with anterior plating (n=107). The primary outcome of interest was the patient-rated wrist evaluation (PRWE) score at 12 months. Secondary outcomes of interest included quality of life (Short-Form 12 [SF-12]), the Quick Disability of the Arm, Shoulder and Hand (qDASH) score, Mayo wrist score, grip strength, and range of motion. Tertiary outcomes included adverse events and radiological alignment outcomes. Outcomes were assessed at 3 and 12 months follow-up. Results revealed no significant differences between the two groups in all primary and secondary outcomes at 12 months follow up. However, at 3 months, range of motion in extension and Mayo wrist scores were in favour of the casting group, and qDASH scores were in favour of the anterior plating group. Radiological alignment outcomes were superior in the anterior plating group at 3 and 12 months. As well, a lower rate of malunion and complex regional pain syndrome was observed in the anterior plating group.