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To compare closed intramedullary nailing with open plate and screw fixation and set the indications for each treatment modality in distal metaphyseal fractures of tibia, 64 consecutive cases of fractures that had been randomly treated with either method were prospectively followed up.Thirty-four patients were in the group treated with closed intramedullary nailing (Group I) and 30 patients were treated with open reduction and internal fixation with anatomic plates and screws (Group II). They were observed for 2 years, and the end results were compared between the two groups.The duration of operation was 72 minutes in Group I and 89 minutes in Group II (p = 0.02). The period of time before radiologic union was 18 weeks in Group I and 20 weeks in Group II (p = 0.89). There was one superficial infection in Group I and six superficial infections and one deep infection in Group II (p = 0.03). The average angulation was 2.8 degrees in Group I and 0.9 degrees in Group II (p = 0.01). The ankle dorsiflexion at the final follow-up was 14 degrees in Group I and 7 degrees in Group II (p = 0.001). The Olerud and Molander functional ankle score was 88.5% of normal side in Group I and 88.2% in Group II (p = 0.71).Our results have shown that locked intramedullary nails have an advantage in the duration of operation, restoration of motion, and reduced wound problems, and anatomic plate and screws can restore alignment better than intramedullary nails. It can be concluded from this study that intramedullary nails are recommended for fractures associated with soft-tissue damage of Tscherne C2 or higher. In other cases, the authors think that either treatment modality can yield expected results.