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The optimal fixation strategy for unstable pediatric tibia fractures is unclear with some favoring elastic intramedullary nails (EIN) and others favoring plate and screws [open reduction internal fixation (ORIF)]. The purpose of this study was to compare outcomes and complications of skeletally immature patients undergoing surgical stabilization of the tibia with either EIN or ORIF.A retrospective review was performed on all patients undergoing EIN or ORIF of a diaphyseal fracture at a single pediatric level I trauma center between 2010 and 2016. Patients were included if they had open growth plates, no intra-articular or physeal involvement, and radiographic follow-up until union. Patient demographic, injury, radiographic, and surgical data were recorded. Outcome measures included achievement of union, time to healing, residual deformity, complications, need for additional procedures, and return to sport. Statistical analysis was performed with alpha set at P<0.05.A total of 70 patients met inclusion, 44 underwent EIN and 26 underwent ORIF. There were no significant differences between demographics or injury variables between groups other than ORIF patients having more distal fractures (44% vs. 32%; P=0.006). At a mean follow-up of 1.4 years, 97% of fractures healed and there was no difference in healing rates between groups. The mean time to union was 15 weeks. ORIF patients had a shorter cast duration (7 vs. 10 wk; P<0.001), less angular deformities >5 degrees (15% vs. 41%; P=0.03), and lower rates of subsequent surgery (35% vs. 91%; P<0.001), but trended toward longer operating room times (69 vs. 59 min; P=0.06), and higher rates of wound complications (23% vs. 9%; P=0.10). Regardless of surgical technique, nearly all patients returned to full activities with no significant deficits.Surgical stabilization of unstable pediatric tibia fractures with ORIF or EIN constructs lead to predictable healing in the majority of patients. Complications can occur and differ based on surgical approach. ORIF led to more anatomic reductions and lower rates of second surgeries, but trended toward higher rates of wound-related complications and slightly longer operating room times.Level III—therapeutic study.