BACKGROUND: Current literature on ultra-distal tibial fractures (UDTF) is relatively limited, particularly regarding the outcomes and complications of different treatment strategies, with data being notably scarce. This study aimed to compare the clinical outcomes of intramedullary nailing (IMN) and distal tibial plate (DTP) fixation in the treatment of UDTF. METHODS: A total of 48 eligible patients were retrospectively reviewed and divided into two matched groups based on age, gender, injury severity score, and fracture type. The IMN group comprised 21 patients, and the DTP group included 27 patients. All patients were followed up to assess both clinical and radiological outcomes. RESULTS: The IMN group demonstrated significantly shorter surgery time (P = 0.043) and fracture healing time (P = 0.002) compared with the DTP group. However, no significant differences were found between the two groups in terms of time from fracture to admission (P = 0.740), preoperative hospital stay (P = 0.310), postoperative hospital stay (P = 0.379), infection rates (P = 1.000), or rates of nonunion (P = 0.822). Postoperative malalignment occurred in three patients in the IMN group and one patient in the DTP group (P = 0.430). The mean postoperative angulation in both groups was similar in the coronal plane (P = 0.101) and sagittal plane (P = 0.334). The mean Olerud-Molander Ankle Score (OMAS) was 88.62 ± 5.24 in the IMN group and 85.85 ± 8.39 in the DTP group (P = 0.169). CONCLUSION: Both implants are effective in treating UDTF. However, IMN offers advantages in reducing surgical time, accelerating fracture healing, and promoting early recovery. Therefore, IMN may represent a superior surgical option for managing UDTF.