321 patients with a distal tibial fracture were randomized to fixation with either an intramedullary nail (IMN) or a locking plate (LP). The purpose of this study was to compare cost-effectiveness of an intrmaedullary nail to a locking plate based on 12-month follow-up. Cost data demonstrated lower total societal cost and National Health Service (NHS) cost in the IMN group compared to the LP group, with similar gain in quality-adjusted life years between groups. Resulting probabilities of IMN fixation being cost-effective relative to LP fixation were above 90% at each willingness-to-pay threshold of £15,000, £20,000, and £30,000.