Summary:Shaft fractures of the femur or tibia or both are frequent components of multiple trauma. Besides the local fracture impact, they induce considerable systemic distress to remote organs because of pain, blood loss, necrotic or hypoperfused tissues, and mediator release. Additionally, unstable skeletal conditions (particularly of the lower extremities) impede optimal intensive care of these patients. Therefore in a polytrauma setup, primary operative stabilization of the femur is mandatory and generally accepted, whereas the optimal fixation procedure is still a source of controversies. The fracture per se and the manipulation of fragments may cause additional release of mediators and pulmonary embolism of microaggregates. Related to this, there is striking clinical and experimental evidence that reaming of the intramedullary cavity and inserting a nail generates extremely high temperatures and pressures within the intramedullary canal and induces a critical amplification of the release and embolism phenomena described. Therefore, the multiply injured (with the endogenous defense systems already close to decompensation) should not additionally be endangered by undue medical procedures, and the biomechanically best fixation technique should not be used, in favor of alternative procedures with a lower systemic distress level. We describe a treatment algorithm that appeared to be successful in a number of multitrauma situations.