Background: Distal third tibial fractures are challenging to treat due to the limited soft tissue coverage and the proximity to the ankle joint. This study aimed to compare the clinical, functional, and radiological outcomes of intramedullary nailing (IMN) and minimally invasive percutaneous plate osteosynthesis (MIPPO) for distal third tibial fractures. Methods: A prospective, randomized controlled trial was conducted, including 36 patients with distal third tibial fractures (AO/OTA 43-A1, A2, A3). Patients were randomly allocated to either the IMN group (n=18) or the MIPPO group (n=18) and followed up for 12 months. The primary outcome was time to union, and secondary outcomes included functional scores (AOFAS and OMAS), complications, and radiographic parameters. Results: The mean time to union was significantly shorter in the IMN group compared to the MIPPO group (16.2 ± 3.4 weeks vs 18.6 ± 4.1 weeks, p=0.042). There were no significant differences in functional scores, complications, or radiographic outcomes between the groups. Subgroup analysis based on fracture classification showed no significant differences between the groups. Multivariate analysis identified smoking status, fracture severity, and treatment group as significant factors influencing time to union. Conclusion: IMN was associated with a shorter time to union compared to MIPPO in the treatment of distal third tibial fractures, with similar functional outcomes and complication rates. These findings suggest that IMN may be the preferred treatment option, especially in non-smokers and less severe fracture types. Future research should focus on larger, multicenter trials with longer follow-up periods to confirm these findings and assess long-term outcomes.