One of the most common questions I get from patients with a broken shinbone (tibia) is, “Doctor, how long do I have to be in a plaster cast?”The answer often surprises them: You might not need one at all.While casts were the standard for generations, modern orthopedic trauma care has evolved. For many tibial shaft fractures, I prefer a procedure called Intramedullary (IM) Nailing. I often describe it to my patients as “keyhole surgery” for the leg because it allows me to fix the bone internally without the trauma of a large open operation.Here is exactly what this procedure is, how I perform it, and why I believe it is often the best choice for recovery.It’s an Internal SplintWhen I perform this surgery, my goal is to stabilize your bone so it can heal while allowing you to move. Instead of putting a heavy cast on the outside of your leg, I insert a titanium rod down the inside—specifically, into the hollow canal of the tibia.Think of it as an internal splint. It holds the alignment perfectly from the inside out, sharing the load so the bone can heal securely.How I Perform the ProcedureThe “keyhole” aspect is crucial here. To put a metal plate on a bone, I would have to make a long incision and strip away the muscle, which can slow down healing. With nailing, I can be much less invasive.Alignment: First, I use traction to line up the broken bone pieces. I verify this using a real-time X-ray machine (fluoroscopy) to ensure the alignment is perfect before I even make an incision.Insertion: I make a small incision (usually just a few centimeters) near the knee. Through this small opening, I slide a guide wire down the hollow center of the bone, crossing the fracture site.The Nail: I then slide the titanium nail over that wire.Locking: Finally, I place small screws through the bone and the nail at the top (near the knee) and bottom (near the ankle). These “interlocking screws” are vital—they prevent the bone from twisting or shortening while it heals.Why I Prefer Nailing Over PlatingThere is a specific biological reason I prefer this method: It preserves the fracture hematoma.When you break a bone, your body immediately forms a blood clot around the break. This clot is packed with your own stem cells and growth factors—it is essentially your body’s “healing starter kit.” Because I don’t open up the fracture site directly, I leave that hematoma undisturbed. This biological advantage usually leads to faster and more reliable bone union.The Recovery: Why Patients Prefer ItThe biggest advantage for you, the patient, is mobility.Because the titanium nail shares the weight-bearing load with the bone, I don’t need to keep you completely immobilized. In many cases, I can encourage my patients to start moving their knee and ankle almost immediately after surgery. Depending on the fracture pattern, many patients are walking (with support) within days, rather than waiting months in a cast.It is still a major injury, and you will have some pain near the knee where the nail was inserted, but the trade-off is a faster return to your normal life and a much lower risk of joint stiffness