This systematic review and meta-analysis included 20 randomized controlled trials (RCTs) with a total of 1,528 patients with extra-articular distal tibia fractures. The study compared intramedullary nail (IMN) fixation versus plate fixation. Pooled outcomes of interest included surgery time, union time, weight-bearing time, wound infection rates, malunion rates, anterior knee pain, secondary procedures, and functional assessment scores. IMN was associated with shorter surgery time, faster union, and earlier full weight-bearing compared to plate fixation. Additionally, IMN significantly reduced the risk of wound infection and secondary procedures. However, IMN had a higher risk of malunion and anterior knee pain. Functional assessment scores and rates of nonunion and delayed union were comparable between both groups. These findings suggest that while IMN is preferable due to its advantages in faster recovery and fewer complications, the risk of malunion and knee pain should be carefully considered when selecting a surgical approach.