Forty-nine acute displaced tibial fractures (31 closed, 18 open: 5 Grade I, 7 Grade II, 4 Grade IIIA, and 2 Grade IIIB) were treated in 1 community with a standard operative protocol using a distractor without a fracture table, and an unreamed interlocked tibial nail. Forty-six fractures healed (94%). Complications included 3 nonunions (6%), 2 deep infections (4%), 9 delayed unions (18%), 4 angular malunions (8%), 2 rotatory malunions (4%), and 12 interlocking screws bent or broke (24%). Twenty-eight patients (57%) required at least 1 additional operation to obtain union, most commonly dynamization of a statically locked nail. The authors conclude that unreamed tibial nails provide adequate stabilization of displaced tibial fractures and can be used in the management of most open or closed tibial fractures. However, static locking is required in axially unstable fractures. Early dynamization or exchange nailing and bone grafting should be considered to hasten union and avoid screw failure. The distractor is an excellent adjunctive technique for reduction and alignment of tibial shaft fractures during intramedullary nailing.