OBJECTIVE Many outcome studies of various surgical techniques for unstable fractures of the distal radius have been published but applicability of the results remains limited because the majority of these trials were not done in a prospective and/or randomized manner. In this study we evaluated 2 common surgical techniques used in the treatment of unstable distal radius fractures in a randomized prospective fashion with a 1-year radiographic and clinical follow-up period. Our hypothesis was that external fixation with augmentation would provide superior results compared with percutaneous pinning and casting. METHODS Fifty patients younger than 65 years of age with unstable fractures of the distal radius were randomized into 1 of 2 surgical treatment groups: percutaneous pins with casting or augmented external fixation. All surgery was performed by 1 of 3 surgeons within 10 days of injury. Over 80% of the fractures were classified as AO-ASIF C2 or C3 and there was a similar distribution of fracture types in each group. RESULTS The use of augmented external fixation did not improve the mean radiographic parameters of radial length, radial angulation, or volar tilt. Restoration of volar tilt of highly comminuted fractures was difficult to achieve regardless of the technique. Improved articular surface reduction was realized with the use of an external fixator but overall only 3 patients were noted to have steps or gaps greater than 2 mm. No significant differences in mean Disabilities of the Arm, Shoulder, and Hand scores, total range of motion, grip strength, or health-related quality of life were observed between the groups. All 3 patients diagnosed with sympathetic dystrophy had had external fixation. CONCLUSIONS Although augmented external fixation represents a popular first line treatment for unstable fractures of the distal radius this study suggests that for fractures with minimal articular displacement similar clinical results can be obtained with percutaneous pinning and casting.