185 elderly patients with an intra-articular distal radius fracture were randomly allocated to either surgical treatment with volar locking plate fixation or closed reduction and 6-week cast immobilization. This study aimed to determine whether operative treatment was more effective than cast immobilization for elderly patients with an intra-articular distal radius fracture. Follow-up was performed at 3 and 12 months. Results from the intention-to-treat analysis revealed better early recovery of wrist range of motion and better radiographic outcome with volar plating, although no differences in functional or clinical outcome at 1 year between groups. Per-protocol analysis demonstrated similar results to ITT analysis.