Objective To compare the clinical efficacy of minimally invasive surgery with preservation of palmar side of pronator quadratus versus traditional Henry approach in the treatment of distal radius fractures in the elderly. Methods A retrospective study was carried out on 46 elderly patients with distal radius fracture treated in our department from January 2016 to January 2019. The patients were divided into minimally invasive group and control group, with 23 cases in each group. The minimally invasive group was treated by internal fixation with locking plate and screw and preservation of pronator quadratus, while the control group was treated with traditional open Henry volar approach of pronator quadratus muscle combined with internal fixation of plate and screw. The length of incision, intraoperative bleeding volume, complications, length of hospital stay, reduction of fracture and wrist joint function in 3 months after operation were compared between the two groups. SPSS statistics 20.0 was used to perform the statistical analysis. Student′st test or Chi-square test was employed in intergroup comparison for different data types. Results Compared with the control group, the incision length [(2.4±0.3) vs (7.2±1.4)cm] and the intraoperative bleeding volume [(13.2±2.1) vs (31.2±4.1)ml] were significantly less, and postoperative length of hospital stay [(4.6±0.9) vs (7.5±1.2)d] was obviously shorter in the minimally invasive group (P<0.05). No postoperative complications occurred in both groups. The visual analogue scale (VAS) scores of the patients were notably lower in the minimally invasive group than the control group [(0.5±0.2) vs (2.2±0.4), P<0.05], while the rates of the patients with better Gartland-Werley scores (95.65% vs 73.91%) and the wrist pronation angles [(83.8°±10.8°)vs (74.6°±9.5°)] were significantly larger in the former group than the latter group (P<0.05). Conclusion Minimally invasive surgery with preservation of palmar side of pronator quadratus and internal fixation with locking plate and screw exerts good efficacy in the treatment of distal radius fractures in the elderly, with small incision, less intraoperative bleeding, and sound overall wrist function in 3 months after operation.