Reply: We agree that with continued interest in the treatment of patients with polytrauma, thorough understanding of the data in our manuscript2 is of paramount importance and is necessary to draw meaningful conclusions. We will attempt to respond to the points that you have outlined. As Papakostidis et al identified, the purpose of our manuscript was not to support or dispute early or delayed operative treatment of femoral shaft fractures, but to show a higher mortality not predicted by the Injury Severity Scores (ISS) in this group of patients with bilateral femur fractures. Papakostidis et al correctly identify that multiple intramedullary nailing procedures for bilateral femur fractures may comprise a risk factor for respiratory complications. That was one of the reasons our retrospective analysis was done, and is one of the a priori hypotheses. From our data, it was impossible to conclude whether it is the injury or the treatment that is associated with the complications observed in this patient population. Papakostidis et al also correctly identifed that several patients were operated on after a significant delay from the time of their initial presentation. In fact, 8% of all the patients reviewed had a delay greater than 48 hours, with many of these patients having a delay beyond the fourth day after injury. The reason for delays are multifactorial and likely are the combination of heightened awareness of the potential dangers of femoral intramedullary nailing between 2 to 5 days after injury, improved understanding of the potential systemic complications associated with patients with severe trauma who are stabilized during this time, and the presence of multiple associated injuries, such as head, chest, or abdominal trauma, which prevented early operative intervention by our general surgical and neurosurgical colleagues. Also, our study involved a treatment period between 1989 and 1997, which was a transitional time in our and our colleagues’ understanding of the treatment of patients with polytrauma. Although we think that early treatment of long bone fractures in the patient with polytrauma reduces mortality, we also understand that there is potentially a subpopulation of patients who may be better served with a delay in treatment, especially if their initial skeletal stabilizations cannot be done within 24 hours because of associated injuries. In a study from our hospital, Brundage et al1 confirmed this previously identified institutional concern: specifically, that stabilization of some patients between Days 2 and 5 after injury is associated with increased complications. This is consistent with other results in other publications regarding damage control orthopaedics and its relevance to the patient with polytrauma.3,4 The original goal of our study was to identify and emphasize the increased mortality and acute complications observed in patients with bilateral femur fractures, despite a similar ISS, which is assumed to be predictive of mortality. Our study confirmed that the ISS underestimates the severity of multiple extremity injuries and their contributions to morbidity and mortality. However, despite a review of more than 750 patients with femoral shaft fractures that were treated with reamed intramedullary nailing, the number of patients stabilized after 4 days was not large enough to draw any conclusions regarding the impact of an associated chest injury or head injury. Our study was designed to allow comparison between patients with a similar ISS (and age), with the intent of comparing similarly injured patients based on their total ISS (including chest, head, and other injuries). Because the relevant data set contracts significantly when we compare individual Abbreviated Injury Score (AIS) subsets, no conclusions should be drawn. We initially treat all adult patients with femoral shaft fractures with distal femoral traction which is applied in the emergency room. We agree that early fracture stabilization tailored to each patient is appropriate.