Background: Distal tibial fractures remain a therapeutic challenge because of a compromised soft tissue envelope, poor bone stock, comminution, and difficulty in achieving rigid fixation. Management strategies range from conservative treatment to intramedullary nailing, plating, and hybrid external fixation, each with its own advantages and limitations depending on fracture pattern, soft tissue condition, and patient factors. Objective: To evaluate and compare the clinical and functional outcomes of different treatment modalities used in the management of distal tibial fractures. Methods: This prospective analytical study was conducted in the Department of Orthopaedics, Saraswathi Institute of Medical Sciences, Hapur, from March 2024 to February 2026, after institutional ethical approval and written informed consent. Forty-eight patients aged 15–64 years with AO type 43-A distal tibial fractures, including open Gustilo–Anderson type 1, 2, 3A, and 3B injuries, were enrolled and allocated to four treatment groups of 12 patients each: Group I – conservative management, Group II – intramedullary nailing, Group III – hybrid external fixation, and Group IV – plate osteosynthesis. Patients were followed up clinically and radiologically at regular intervals, and functional outcome was assessed at six months using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle–hindfoot score. Data were analysed using ANOVA, with p < 0.05 considered statistically significant. Results: The majority of patients were male (32; 66.7%), and the highest incidence was in the 25–34 year age group (15; 31.3%). Road traffic accidents were the most common mode of injury (28; 58.3%), and AO type A3 was the most frequent fracture pattern (22; 45.8%); 35.4% of fractures were open and 64.6% closed. The mean duration of follow-up was 7.5 months (range 6–13 months). The highest mean AOFAS score was recorded in the plate osteosynthesis group (86.2 ± 6.5), followed by intramedullary nailing (78.3 ± 9.2), hybrid external fixation (73.1 ± 10.3), and conservative management (69.2 ± 11.7); the difference between groups was statistically highly significant (p < 0.001). Good to excellent outcomes were achieved in 72.7% of the plating group, 54.5% of the nailing group, 45.5% of the hybrid fixator group, and 36.4% of the conservative group, with no poor outcome in the plating group. Complications occurred in nine patients, including non-union (2), malunion (1), ankle stiffness (3), and infection (3); no case of deep vein thrombosis, pulmonary embolism, or mortality was recorded. Conclusion: Both intramedullary nailing and plate osteosynthesis offer satisfactory functional outcomes in distal tibial fractures, with plate osteosynthesis achieving the highest AOFAS scores in this series. Hybrid external fixation remains a valuable option in open and comminuted fractures with severe soft tissue injury, though it carries a higher complication rate, while conservative treatment retains a role in selected low-risk patients. An individualised approach based on fracture pattern, soft tissue status, and surgeon expertise is essential for optimising outcomes.