157 patients with tibial fracture and undergoing intramedullary nail fixation were randomized to have the distal locking screw insertion assisted by electromagnetic navigation (E-navigation), or placement via conventional methods. Conventional methods of screw insertion included either the free-hand technique or the radiolucent drill technique. The purpose of the study was to compare the screw insertion time and fluoroscopy time between groups. Screw insertion with the radiolucent drill technique was significantly longer than that with either E-navigation or the free-hand technique, with no significant difference between the E-navigation and free-hand groups. Fluoroscopy time was significantly lower in the E-navigation group compared to either conventional method. Within the conventional group, fluorsocopy time was significantly lower in the free-hand versus the radiolucent drill method.