OBJECTIVE To determine outcomes in the treatment of distal tibial fractures treated with intramedullary nails. METHODS Retrospective analysis. METHODS Level I trauma center with follow-up in a private orthopaedic practice. METHODS Radiographic determination of alignment, nonunion, and malunion, clinical outcome (range of motion, and implant-associated complaints), wound complications, and fibular fixation. METHODS A total of 105 patients with OTA/AO type A and C tibial fractures (<11 cm from the joint line) treated with intramedullary nailing. RESULTS Distance of the fracture from the joint line averaged 6.1 cm (range, 0-11). Mean follow-up was 25.6 months (range, 12-74). Nonunion occurred in 20 (19%) fractures and were significantly associated with open fractures (P = 0.012), wound complications (P < 0.001), and the need for fibular fixation (P = 0.007). Sagittal plane alignment averaged 2.5 degrees (±4.4) valgus. Malunion occurred in 25 (23.8%) fractures and again were significantly associated with open fractures (P = 0.045). Fifty (47.6%) patients had implant-related pain, which resolved in 27 (54.0%) after removal. CONCLUSIONS Intramedullary nailing of distal tibial fractures is a suitable treatment option. Acceptable alignment and range of motion can be achieved. Both nonunions and malunions were significantly associated with open fractures, wound complications, and fibular fixation. Implant removal was needed in 25% of cases. METHODS Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.