BACKGROUND Medial parapatellar or transpatellar ligament approaches are commonly used for nail osteosynthesis in tibia shaft fractures. The lower leg is normally in a hanging position to allow guide wire insertion and reaming of the tibia. However, this position complicates fracture reduction and retention, as well as image intensification throughout the procedure. A lateral parapatellar approach with the lower leg in a semi-extended, horizontal position has been previously described for proximal tibial fracture fixation. The purpose of the presented study was to share the lateral parapatellar approach technique used in our institution and to analyse its feasibility for tibia shaft fracture fixation when compared to a medial parapatellar and transpatellar incision technique. METHODS All patients with tibial shaft fractures treated at our institution between 2009 and 2012 by intramedullary nailing through either a transpatellar, a medial parapatellar or a lateral parapatellar approach were reviewed. Demographics, injury pattern and the operative procedure, especially operation and fluoroscopy time, were analysed. RESULTS 73 patients were enrolled into the study. Twenty-six patients were treated by use of a lateral parapatellar approach, whilst a transpatellar or a medial parapatellar approach was chosen in 29 and 18 cases, respectively. Patients' characteristics were similar regarding gender and body mass index. When compared to the transpatellar (126 ± 30 min) or the medial parapatellar approach (105 ± 29 min), surgical time was significantly shorter in the lateral parapatellar approach group (96 ± 29 min). Likewise, shorter image intensifier time was documented when a lateral parapatellar approach was chosen (211 ± 189 s) compared to the transpatellar (347 ± 204 s) or the medial parapatellar approach (241 ± 222 s). CONCLUSIONS The extra-articular semi-extended tibial nailing technique using a lateral parapatellar approach was associated with a significant decrease in time of surgery, while fluoroscopy time was shorter but not significantly different between the three groups.