Objective To explore the clinical efficacy and postoperative complication rates of open reduction and intramedullary nail fixation for tibial shaft fractures, and to provide evidence-based evidence for optimizing the surgical plan. Methods A prospective randomized controlled trial design was adopted. A total of 116 patients with tibial shaft fractures admitted from January 2023 to June 2024 were initially screened, and 80 patients were finally enrolled. They were randomly divided into control group (receiving minimally invasive percutaneous plate internal fixation) and observation group (receiving intramedullary nail fixation), with 40 cases in each group. The study indicators included perioperative parameters, postoperative rehabilitation indicators, Johner-Wruhs functional score at 6 months follow-up, and the occurrence of complications. Results The operation time of the observation group was significantly longer than that of the control group (P < 0.05), the intraoperative blood loss was significantly less than that of the control group (P < 0.05), the number of fluoroscopic examinations was significantly more than that of the control group (P < 0.05), and the time for bone callus formation, the clinical fracture healing period, and the postoperative hospital stay were all significantly shorter than those of the control group (all P < 0.05). The visual analogue scale (VAS) score at 3 days after surgery was significantly lower than that of the control group (P < 0.05). The clinical follow-up data at 6 months after surgery showed that the excellent and good rate of Johner-Wruhs score in the observation group was significantly higher than that in the control group (P < 0.05). There was a statistically significant difference in the incidence of complications between the two groups (χ2 = 5.165, P = 0.023). Conclusion The intramedullary nail fixation has significant advantages in promoting fracture healing and improving functional prognosis. Although there are technical limitations such as prolonged operation time, its clinical value in reducing intraoperative trauma and optimizing the rehabilitation process is worthy of promotion.