Proximal tibia fractures can be treated with intramedullary nail or locked plating, but it is unclear if one treatment is preferable. The authors randomized 108 adult patients with A1-3 or C1 proximal tibia fractures to undergoing intramedullary nail (n = 52) or locked plating (n = 47). Follow-up was performed to 1 year. Compartment syndrome was more common in the nail group (OR 4.0). There were no significant differences in terms of operative time, malalignment rates, walking ability, stair climbing, pain, use of supports, range of motion, the Short Musculoskeletal Funciton Assessment, bother index, or the Euroqol-5D. Non-union and adverse event rates were also similar between the two groups. Overall, only compartment syndrome was found to be significantly different between the two groups at any time point.