Purpose <p>Minimally invasive plate osteosynthesis (MIPO) has been introduced as an alternative technique for distal radius fracture fixation, aiming to minimize surgical trauma while preserving soft tissue integrity. The Wide-Awake Local Anesthesia No Tourniquet (WALANT) method enables intraoperative functional assessment and early active wrist motion. Comparative evidence between MIPO and conventional volar plate fixation performed under WALANT remains limited.</p> Methods <p>A single-center, assessor-blinded, randomized controlled trial was conducted between October 2021 and February 2023. Sixty-six patients with isolated closed distal radius fractures were randomized to MIPO (<i>n</i> = 33) or conventional open volar locking plate fixation via a modified Henry approach (<i>n</i> = 33) under WALANT. The primary outcome was first postoperative day pain measured by the visual analogue scale (VAS). Secondary outcomes included morphine usage, QuickDASH score, grip and pinch strength, range of motion, operative time, aesthetic score, radiographic parameters, and complications. Minimum follow-up was six months.</p> Results <p>The MIPO group showed a statistically lower POD1 VAS pain score than the conventional group that was below the minimal clinically important difference and therefore not clinically significant (mean 3.4 [SD 0.96] vs. 4.2 [SD 1.51]; mean difference 0.8, 95% CI 0.2–1.4; <i>p</i> = 0.012). Cosmetic outcomes were higher in the MIPO group (mean aesthetic score 3.3 vs. 2.8). Morphine consumption, QuickDASH scores, grip and pinch strength, range of motion, operative duration, and radiographic outcomes were similar between groups, whereas intraoperative fluoroscopy use was higher in the MIPO group. All patients achieved bone union within three months, and no major complications were reported.</p> Conclusion <p>In this randomized controlled trial, MIPO under WALANT achieved functional, radiographic, and safety outcomes equivalent to conventional volar plate fixation. The statistically lower POD1 pain score in the MIPO group fell below the minimal clinically important difference, indicating no clinically significant difference in early postoperative pain between the two techniques; the only consistent advantages were smaller incisions and better cosmetic scores. MIPO under WALANT is therefore a safe and viable alternative—chosen for its cosmetic benefit and at the cost of greater fluoroscopy use and a steeper learning curve—rather than a clinically superior technique.</p> Level of evidence II <p>Randomized controlled trial, Therapeutic study.</p>