We carried out a prospective randomised controlled clinical trial to compare the functional and radiological outcomes of casting with percutaneous pinning in treating extra-articular distal radial fracture in an elderly Chinese population. Sixty patients were randomly allocated by sealed envelopes to either a 'Cast' group (n = 30) or a 'K-wire' group (n = 30). All patients were available for final follow-up assessment. The radiological outcomes in terms of dorsal angulation, radial inclination and radial length were statistically significantly better in the K-wire group, whereas the Mayo wrist score and quality of life, healing rate, healing time, and complications were similar. The functional outcomes and quality of life were not affected by the treatments. Both treatments had a very low rate of complication and high healing rates.