Intramedullary nailing is often the treatment of choice in the management of fractures in the tibial diaphysis. One of the most frequent complications of tibial nailing is fracture malalignment leading to angulatory or rotational deformities. Access to the proximal tibia for intramedullary nailing of the tibial shaft fractures may be via a patallar tendon splitting or paratendinous exposure. Although the tendon splitting approach is more direct, the incidence of knee pain is significantly higher when this technique is used. In addition, several cases of heterotopic ossification have been reported following tendon splitting approaches. For these reasons an incision medial to the tendon is generally chosen. We reviewed 140 cases(131 patients) of tibial shaft fractures who were treated by use of the intramedullary nailing from 1994 to 1997 and made a comparison between the medial parapatellar approach and the patellar tendon splitting approach about degree of malalignment. We have noticed that there was significant difference in the number of tibias that were malaligned after tibial nailing with the medial parapatellar access and the tendon splitting approach. With the medial parapatellar approach, malalignment was seen in 13/42 tibiae(31.0%) of the fractures of tibial shaft, 11/12 tibiae of the proximal third fractures and 2/10 tibiae of the distal third fractures respectively. With the patellar tendon splitting approach, malalignment was seen in 8/98 tibiae(8.2%) of the fractures of the tibial shaft, 4/15 tibiae of the proximal third fractures, 1/45 of the middle third fractures and 3/38 tibiae of the distal third fractures respectively. We conclude that the tendon splitting approach may be better for intramedullary nailing of the proximal fractures of the tibia and the medial parapatellar approach may be chosen for the treatment of the middle and distal shaft fractures of the tibia.