BACKGROUND The treatment of distal metaphyseal tibial fractures remains controversial. This study was performed to evaluate the results of intramedullary nailing of distal tibial fractures located within 5 cm of the ankle joint. METHODS Over a sixteen-month period at two institutions, thirty-six tibial fractures that involved the distal 5 cm of the tibia were treated with reamed intramedullary nailing with use of either two or three distal interlocking screws. Ten fractures with articular extension were treated with supplementary screw fixation prior to the intramedullary nailing. Radiographs were reviewed to determine the immediate and final alignments and fracture-healing. The Short Form-36 (SF-36) and Musculoskeletal Function Assessment (MFA) questionnaires were used to evaluate functional outcome. RESULTS Acceptable radiographic alignment, defined as <5 degrees of angulation in any plane, was obtained in thirty-three patients (92%). No patient had any change in alignment between the immediate postoperative and the final radiographic evaluation. Complications included one deep infection and one iatrogenic fracture at the time of the intramedullary nailing. Six patients could not be followed. The remaining thirty fractures united at an average of 23.5 weeks. Three patients with associated traumatic bone loss underwent a staged autograft procedure, and they had fracture-healing at an average of 44.3 weeks. The functional outcome was determined at a minimum of one year for nineteen patients and at a minimum of two years (average, 4.5 years) for fifteen patients. At one year, there were significant limitations in several domains despite fracture union and maintenance of alignment, but there was improvement in the MFA scores with time. CONCLUSIONS Intramedullary nailing is an effective alternative for the treatment of distal metaphyseal tibial fractures. Simple articular extension of the fracture is not a contraindication to intramedullary fixation. Functional outcomes improve with time.