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Thirty-four patients were enrolled in a prospective randomized study comparing cast immobilization alone versus percutaneous pin fixation following closed reduction of distal radial metaphyseal fractures. Patients older than 10 years of age with greater than 30 degrees of dorsal angulation or with complete fracture displacement were eligible for enrollment. Average follow-up was 10.5 weeks. All fractures healed uneventfully without deformity, growth arrest, or functional limitations. Overall complication rates were similar between groups. Thirty-nine percent of patients treated with casting had subsequent loss of reduction requiring remanipulation; there were no cases of loss of reduction in patients treated with pin fixation. Thirty-eight percent of patients treated with pin fixation had pin-related complications; all resolved following pin removal without long-term sequelae. Cost analysis showed no significant difference in treatment charges between groups. Treating surgeons should be aware of the potential short-term complications of each treatment method and adjust their postoperative care appropriately.