Intramedullary nailing technique is currently the preferred treatment option for unstable tibial stem fractures, which are the most common stem fractures with an annual incidence of approximately 6/100,000. Studies have shown that intramedullary nailing of the tibia can achieve high fracture healing rates, acceptable limb axis and fewer complications. As the intramedullary nailing technique has become more sophisticated, it has begun to be used in a wider range of applications, such as open tibial fractures and proximal or distal tibial metaphyseal fractures. The current standard tibial intramedullary nailing technique is usually performed in extreme flexion of the knee (120-130 degrees), which was first used by Kuntscher in 1940, with both trans-patellar and parapatellar approaches for intramedullary nailing in extreme flexion of the knee. Although the tibial intramedullary nailing technique is now well established, it still presents challenges. With the traditional intramedullary nailing technique, for proximal tibial quarter fractures, the knee is extremely flexed during nailing placement, making it difficult to maintain fracture repositioning and maintain a good tibial alignment angle during surgery; although there are no specific findings reported in the literature, some patients experience persistent pain during knee flexion after tibial intramedullary nailing; it is difficult to obtain a satisfactory fluoroscopic position when the knee is placed in flexion, and may require intraoperative additional fixation or incision to assist in repositioning fixation. The hemi-extension tibial intramedullary nail was first used by Tornetta et al. for proximal tibial 1/4 fractures, and its use has subsequently become widespread. More authors have concluded that the semi-extension position of the knee has more advantages than the traditional surgical approach. Maintaining the knee in a semi-extended position during surgery provides better access for fracture repositioning, intraoperative fluoroscopy, and alignment of the tibial axis. Currently, there are many surgical approaches to the knee in a semi-extended position, including lateral or medial knee arthrotomy, suprapatellar intramedullary nail insertion, and extra-articular parapatellar approach. This article summarizes each approach, focusing on the position of the approach, intraoperative counteracting of fracture-deforming stresses, assisted repositioning, and intraoperative imaging fluoroscopic methods. The patient is placed in a supine position on an x-ray-transparent surgical bed. The C-arm machine is placed on the opposite side, and the ball tube is oriented perpendicular or parallel to the tibia. In conclusion, the extra-articular tibial intramedullary nailing technique in the semi-extended knee position has more technical advantages than the flexed knee tibial intramedullary nailing technique: better intraoperative control of the knee axis; easier disposal of combined injuries in ipsilateral patients; less time for intraoperative fluoroscopy, etc.